Surgical positions

From Wikipedia, the free encyclopedia Surgical positioning is to facilitate the surgeon's technical approach while balancing risk factors. Surgical techniques have been expanded by the flexibility provided by anesthesia methodology, so that new areas of the body have become accessible and new positions have been developed. All surgical positions carry some degree of position-related risk; these risks are increased in the anesthetized patient, who cannot make the clinician aware of compromised positions. The goal of providing the best surgical exposure is always balanced by the need to minimize the risk to the patient. COMMON INTRAOPERATIVE POSITIONS There are five standard positions (ie, supine, prone, lateral, sitting, lithotomy) commonly used for surgical procedures. Often, these intraoperative positions are modified according to surgeons' preferences, surgical approaches, and patients' physiologic requirements. Supine. When positioned supine (ie, dorsal recumbent), the patient is placed on his or her back on the OR bed. The patient's arms are tucked at the sides with the palms facing inward or extended on padded arm boards with the palms facing upward (Figure 9). The patient's spinal column should be in a straight line with his or her legs parallel to the OR bed. Supine positioning is used for abdominal, cardiac, peripheral vascular, and some orthopedic extremity procedures. Variations of the supine position include * Trendelenburg's position (ie, patient supine with head lowered, feet up), * reverse Trendelenburg's position (ie, patient supine with head up, feet lowered), and * modified supine position on the fracture table (ie, patient supine with one leg extended in traction, one leg placed in stirrup device) (Figure 10). Possible injuries. Pressure points vulnerable to skin breakdown in the supine position include the occiput, scapulae, thoracic vertebrae, olecranon (ie, elbow), sacrum, coccyx, and calcaneous (ie, heel). Pressure injuries to the patient's genitalia may occur after positioning on a fracture table. Neural injuries common with prolonged supine positioning involve the extremities (eg, brachial plexus injury, wrist drop, ulnar neuropathy, foot drop, pudendal nerve injury). Changing the patient's position from supine to Trendelenburg's or reverse Trendelenburg's also may place the patient at risk for shear injuries.(27) Physiologic responses. Supine positioning has less adverse effect on the patient's circulatory system than other surgical positions. The patient's respiratory efforts, however, may be impeded by decreased diaphragmatic movements secondary to pressure from abdominal contents, especially in Trendelenburg's position. Trendelenburg's position may adversely affect the patient's cardiac output because of mechanical compression of the heart and increased venous return from the lower extremities. Prone. When positioned prone, the patient is placed face down on the OR bed. The arms are placed at the patient's side, palms up or extended outward and upward on padded arm boards,

palms down, with elbows flexed to prevent overextension of the shoulders (Figures 11 and 12). The patient most likely will be anesthetized in the supine position on a transportation vehicle (eg, stretcher, patient bed). After the patient is intubated, surgical team members must transfer the patient to a prone position quickly to avoid airway compromise. An adequate number of surgical team members is needed to support the patient's body alignment during transfer to the prone position because the patient must be turned as a single unit (ie, log rolled). Body rolls are placed anteriorly from the patient's shoulders to the pelvis to lift the chest off the OR bed to ensure adequate lung expansion during respiration. The patient's spinal column should be straight and in parallel alignment to the sides of the OR bed. Specialty beds or accessory equipment (eg, laminectomy frames) may be used to customize prone positions for different surgical approaches. Modifications to the prone position include the jackknife (ie, Kraske's) used for proctologic procedures (Figure 13) and the knee-chest and kneeling positions used for spinal procedures. Prone positioning is used for surgical procedures that require access to the cervical, thoracic, or lumbar spines (eg, lumbar laminectomy, spinal fusion, discectomy), reconstructive flap procedures, and proctologic procedures (eg, hemorrhoidectomy, sigmoidoscopy, fistula repair). Possible injuries. The prone position places the patient's face (ie, eyes, nose, ears, cheeks), clavicles, elbows, breasts, iliac crests, male genitalia, knees, and toes at risk for pressure injuries. Possible neural injuries result from neck hyperextension, foot drop, and brachial plexus insults. Other potential injuries are facial, head, neck, and conjunctival edema; alopecia; corneal abrasion; and retinal ischemia.(28) Physiologic responses. Prone positioning subjects the patient's cardiac and respiratory systems to unique and unfamiliar requirements (eg, decreased cardiac index and stroke volume, increased systemic and pulmonary vascular resistance). Respiratory excursion can be limited severely unless the patient is positioned in a manner that supports the chest and pelvis while allowing the weight of the abdomen to fall away from the diaphragm. Lateral The lateral position (ie, lateral recumbent, lateral decubitis, Sims's) is used for surgical procedures involving the upper chest, kidney, or upper areas of the ureter. The circulating nurse may place a bean bag device on the OR bed before the patient is transferred to the OR bed. The anesthesia care provider anesthetizes the patient in the supine position. A minimum of four surgical team members use a draw sheet to lift and turn the patient onto his or her nonsurgical side (ie, the anesthesia care provider controls the patient's head and neck, one person moves the lower extremities, one person lifts and supports the shoulders and chest, one person controls the pelvis). The circulating nurse ensures all movements are coordinated to prevent spinal injuries. In the right lateral position, the patient lies on his or her right side with the left side placed upward. In the left lateral position, the patient lies on his or her left side with the fight side placed upward. Lateral positioning is used for thoracotomy (eg, resection, lobectomy, repair of aortic aneurysms), gastroesophageal, orthopedic, neurosurgery, renal (eg, nephrectomy, pyelostomy, pyelolithotomy, adrenalectomy), and retroperitoneal procedures. Positioning for thoracotomy procedure. During lateral chest positioning, the patient lies on the unaffected side to expose the surgical chest wall or flank. The circulating nurse places a pillow between the patient's legs and inserts padding under the ankles and feet to maintain proper alignment. He or she places a safety strap across the patient's hip and may apply two-inch adhesive tape across the patient's upper hip and fasten the ends of the tape to the OR bed for stability. In most thoracotomy procedures, the patient's bottom leg is flexed for stability, and the

top leg remains straight, although the legs may be positioned in two other ways: both legs flexed or the upper leg flexed and the lower leg straight.(29) The patient's upper arm usually is placed on a padded overhead brace or an elevated arm board, flexed slightly at the elbow, and raised above the head at a 90-degree angle or less. The upper arm also may be flexed gently at the elbow and brought forward to rest near the patient's head on the OR bed (Figure 14) The lower arm is brought forward slightly, flexed, and positioned in front of the patient on a padded arm board. The circulating nurse places a small roll at the apex of the patient's scapula to relieve pressure on the dependent arm and allow chest movement with respirations. The anesthesia care provider uses a pillow to support and align the patient's head. Positioning for renal procedures. After the patient is anesthesized, surgical team members position the patient over the kidney elevator of the OR bed, so that the area between the twelfth rib and the iliac crest is elevated when the OR bed is flexed and the kidney elevator is raised. The circulating nurse may use padded kidney rests, pillows, sandbags, rolled blankets, and adhesive tape to maintain the patient in this position. He or she places the patient's upper arm on an elevated, padded arm board. The circulating nurse brings the lower shoulder slightly forward, flexes the elbow, and places the arm on a padded arm board or near the patient's head on the OR bed. He or she ensures the upper extremities are perpendicular to the patient's shoulder level to prevent shoulder injuries. The circulating nurse flexes the lower leg and extends the upper leg. He or she places one or two pillows between the patient's legs and supports the feet with a pillow. The circulating nurse applies a safety strap across the patient's thigh so that the strap does not interfere with the surgical site. He or she places a small roll or bolster under the lower axilla to facilitate lung expansion with respirations and to prevent compression of the scapula and brachial plexus. The anesthesia care provider flexes the OR bed to lower the patient's head and legs. The circulating nurse ensures the patient's body is in a straight horizontal line from the shoulder to the hip. Possible injuries. At all times, surgical team members take care to stabilize the patient's torso, avoid extreme flexion of the head, and maintain alignment of the spine. Areas susceptible to pressure injuries include the patient's dependent ear, eye, acromial process, iliac crest, anterior iliac spine, greater trochanter, medial and lateral condyles, and maleolus. Potential neural injuries may occur to the peroneal, sacral, tibial, ulnar, or suprascapular nerves and the brachial plexus. Additional injuries associated with lateral positioning include corneal abrasions and shear injuries, which may occur during flexion of the OR bed or initial positioning.(30) Sitting. In the sitting position (ie, modified Fowler's), the back of the OR bed is elevated to a vertical plane, a foot board is placed perpendicular to the bed to support the patient's feet, and the patient is placed over the break in the OR bed. The patient's head and back are elevated, the arms are secured on a pillow across the abdomen, die knees are flexed, and the legs are dependent. The sitting position is used for posterior cervical spine procedures (eg, posterior cervical laminectomy, removal of posterior spinal tumors) and posterior and lateral cranial procedures (eg, posterior fossa craniectomy, occipital and craniotomy procedures, transsphenoidal procedures). The sitting position usually involves the use of an over-bed frame that attaches to a skull pin fixation device. Occasionally, a surgical procedure that requires access to a patient's neck or shoulder will require a semisitting position (ie, "lawn chair" positioning) without the use of a skull pin device or overbed frame (Figure 15). Possible injuries. Areas that may be affected by pressure injuries include the patient's occiput (ie, in a semisitting position), scapulae, back of the knee, coccyx, ischial tuberosities, and

calcaneous. Positioning injuries can occur to the patient's supra-scapular, ulnar, sciatic, peroneal, and anterior tibial nerves as a result of inadequate padding and poor body alignment. Another potential sequela of the sitting position is the increased likelihood of air embolism due to negative venous pressure in the patient's head and neck. Air can enter through skull pin sites and through open venous channels and sinuses in the exposed brain. The anesthesia care provider and the surgeon monitor the patient for development of an air embolism via Doppler ultrasound readings and central venous line pressures.(31)" Physiologic responses. One advantage of the sitting position is the positive effect on the patient's respiratory system. Lung excursion and diaphragmatic activity are facilitated by the unrestricted movement of die thoracic cavity. Hemodynamics are adversely affected by the sitting position, as gravitational forces cause pooling of blood in the patient's lower extremities. Cerebral ischemia and hypotension are common complications found during surgical procedures that require sitting positions. Lithotomy. In the lithotomy position, the patient lies supine with his or her legs abducted and elevated in stirrup devices attached to the OR bed. The patient's buttocks are even with the lower break in the OR bed to prevent lumbosacral strain, and the arms are tucked at the sides or placed across the abdomen to prevent the patient's fingers from resting in the bed break (Figure 16). Lithotomy positioning is used for gynecologic (eg, vaginal hysterectomy, dilatation and curettage, cervical biopsy), obstetric, urologic, and rectal (eg, hemorrhoidectomy, sigmoidoscopy, repair of anal fistula) procedures and for radical resections of the groin, vulva, and rectal areas. Possible injuries. Pressure injury sites are the patient's occiput, scapulae, elbows, and the sacrum, where most of the patient's weight rests. Depending on the type of stirrup devices used (eg, ankle strap, boot, knee crutch), pressure injuries can occur to the patient's ankles, heels, plantar surfaces of the feet, and behind the knees and lower legs. The potential for injury to the patient's femoral, obturator, peroneal, sciatic, posterior tibial, and saphenous nerves during lithotomy positioning is significant. The most common injury is peroneal nerve damage on the lateral aspect of the patient's knee, which can result in foot drop.(32) Other possible dangers are hand injuries from fingers being trapped in hinges of the OR bed at the lower break point, deep vein thrombus formations, and nerve injury from severe external rotation or flexion of hip joints. The circulating nurse should apply antiembolism stockings and pneumatic compression sleeves (eg, intermittent, sequential, graduated) and attach the sleeves to a power unit before the start of surgery if the patient is to remain in the lithotomy position for more than two hours. This will decrease blood pooling in calf muscles and prevent deep vein thrombus formations. He or she also should warn surgical team members not to lean on the inner aspects of the patient's thighs to prevent drastic external hip rotations or flexions. A compartment syndrome (ie, increased internal pressure in the muscle compartment) in calf muscles also develops from lithotomy positions in which stirrup devices cause external pressure and prolong limb compressions. Knee crutch stirrups compress calf muscles and the popliteal fossa more severely than ankle strap stirrups and, therefore, are least desirable for extended lithotomy procedures.(33) Physiologic responses. Lithotomy positioning may result in respiratory and circulatory compromises. The extreme flexion of the patient's thighs impairs respiratory function by increasing intraabdominal pressure against the diaphragm, which results in pulmonary congestion and decreased tidal volumes. Circulatory compromise begins with the gravitational flow of blood from the elevated legs to the splanchnic area during the surgical procedure. Blood

loss may not be detected immediately during surgery because of increased splanchnic blood volume. Circulating blood volume may be depleted when the patient's legs are lowered to the OR bed at the end of the surgical procedure and blood is diverted quickly to the patient's peripheral circulation. Gravitational forces return 500 to 800 mL of blood to the patient's legs,(34) which depletes the circulating volume and decreases the patient's blood pressure. Slow, simultaneous positioning of the patient's legs at the beginning and end of the surgical procedure allows the body to adjust to shifting blood volumes. In addition, lowering and raising both legs simultaneously prevents possible hip dislocations or lumbar muscle strain. PERIOPERATIVE NURSING CONSIDERATIONS The safe positioning of patients for surgical procedures requires the cooperation of all surgical team members. Nurses implement appropriate perioperative nursing actions throughout all phases of patients' surgical experiences to prevent and minimize potential complications related to intraoperative surgical positioning. Preoperative patient care. During the preoperative interview and assessment, the preoperative nurse routinely notes the patient's age, weight, preexisting medical problems, prescribed medications, skin condition, laboratory test results, range of motion of all extremities, baseline vital signs, presence or absence of peripheral pulses, and mobility impairments. The preoperative nurse also notes the patient's level of consciousness and his or her ability to follow instructions at the time of this assessment. Preexisting health conditions. Notation of the patient's preexisting health conditions and medication history aids the nurse in anticipating medications needed by the anesthesia care provider. Preoperative knowledge of the patient's general state of health also allows the nurse to assess the patient's risk for respiratory or cardiac complications related to surgical positioning. Impaired skin integrity. During visual skin inspection, the preoperative nurse notes the patient's skin color and temperature and the presence of bruises, abrasions, or any other breaks in the skin's integrity. The nurse also questions the patient about the condition of his or her skin, specifically asking about skin areas that may be visually inaccessible during the interview because of wound dressings or privacy issues. He or she questions the patient about the presence of stomas, catheters, or implanted devices (eg, colostomy, urostomy, ileostomy, percutaneous nephrostomy catheters, gastrostomy tubes, pacemakers, joint prostheses). An abdominal stoma may be at risk for pressure injury from prone positioning and may require extra protection. External catheters, tubes, or drains may compress against the patient's skin and the OR bed surface and cause pressure injuries, or they may be removed or repositioned inadvertently as a consequence of improper positioning. Implanted devices also may cause pressure injuries if they are compressed against the surfaces of OR beds.

Fowler's position
From Wikipedia, the free encyclopedia In medicine, Fowler's position is a standard patient position. It is used to relax tension of the abdominal muscles, allowing for improved breathing in immobile patients as it alleviates compression of the chest due to gravity, and to increase comfort during eating and other activities. It is also used in postpartum women to improve uterine drainage. The patient is placed in a semi-upright sitting position (45-60 degrees) and may have knees either bent or straight.

Such a position is maintained during procedures that involve either the nasal or oral passageways as it prevents aspiration during the introduction of feeding tubes and also promotes a slight gravitational pull in peristalsis when swallowing. There are several types of Fowlers positions: low, semi-, high Fowler's, and Standard Fowlers (also known as simply "Fowler's"). High Fowler's position is when the patient's head is raised 80-90 degrees, whereas Semi-Fowler's position is when the patient's head is elevated 30-45 degrees. Low Fowler's position is when the head of bed is elevated 15-30 degrees, and finally Fowler's which is 45-60 degrees.

Trendelenburg position
From Wikipedia, the free encyclopedia

Old description of the Trendelenburg position.

In the Trendelenburg position the body is laid flat on the back (supine position) with the feet higher than the head by 15-30 degrees, in contrast to the reverse Trendelenburg position, where the body is tilted in the opposite direction. This is a standard position used in abdominal and gynecological surgery. It allows better access to the pelvic organs as gravity pulls the intestines away from the pelvis. It was named after the German surgeon Friedrich Trendelenburg.[1] It is not recommended for the treatment of hypovolaemic shock.[2]

Contents
[hide] 1 Uses 2 See also 3 References 4 External links

[edit] Uses
People with hypotension (low blood pressure) have historically been placed in the Trendelenburg position in hopes of increasing their cerebral perfusion pressure (the blood pressure to the brain). A 2005 literature review found the "Literature on the position was scarce, lacked strength, and seemed to be guided by 'expert opinion.'"[3] A 2008 meta-analysis found adverse consequences to the use of the Trendelenburg position and recommended it be avoided.[4] However, the passive leg raising test is a useful clinical guide to fluid resuscitation and can be used for effective autotransfusion.[5] The Trendelenburg position used to be the standard first aid position for shock.[6] The Trendelenburg position was used for injured scuba divers.[7] Many experienced divers still believe this position is appropriate, but current scuba first aid professionals no longer advocate elevating the feet higher than the head. The Trendelenburg position in this case increases regurgitation and airway problems, causes the brain to swell, increases breathing difficulty, and has not been proven to be of any value.[8] "Supine is fine" is a good, general rule for victims of submersion injuries unless they have fluid in the airway or are breathing, in which case they should be positioned on the side. Perhaps because of its effect on breathing difficulty and airway problems, the Trendelenburg position is used in waterboarding. The Trendelenburg position may be used in childbirth when a woman's cervix is too swollen and won't quite dilate to 10 centimeters, or during the incidence of a prolapsed umbilical cord to take pressure off the cord and get more oxygen to the fetus, or it can be used to help rotate a posterior fetus either during pregnancy or the birth itself. Trendelenburg position is helpful in surgical reduction of an abdominal hernia.[9] The Trendelenburg position is also used when placing a Central Venous Line. [10] Trendelenburg position uses gravity to assist in the filling and distension of the upper central veins when placing a central line in the internal jugular or subclavian veins. It is also used in the placement of an external jugular peripheral line for the same reason. It plays no role in the placement of a femoral central venous line.

High Fowlers position

From Wikipedia, the free encyclopedia This article does not cite any references or sources. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (November 2010)

The High Fowler's position is a position in which typically a patient in a hospital is placed when the head of the bed needs to be elevated as high as possible. The patient's upper half of their body is between 60 degrees and 90 degrees in relation to the lower half of their body. The legs of the patient may be straight or bent.

Contents
[hide] 1 Purposes 2 See also 3 References 4 External links

[edit] Purposes
This position is frequently used when feeding a patient (especially one on feeding precautions), radiology needing to take a specific type of x-ray at the bedside, (at times) when a breathing treatment being given to the patient, when the patient is having difficulty breathing, dependent drainage after abdominal surgery, grooming, etc.

High Fowlers position

From Wikipedia, the free encyclopedia This article does not cite any references or sources. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (November 2010)

The High Fowler's position is a position in which typically a patient in a hospital is placed when the head of the bed needs to be elevated as high as possible. The patient's upper half of their body is between 60 degrees and 90 degrees in relation to the lower half of their body. The legs of the patient may be straight or bent.

Contents
[hide] 1 Purposes 2 See also 3 References 4 External links

[edit] Purposes
This position is frequently used when feeding a patient (especially one on feeding precautions), radiology needing to take a specific type of x-ray at the bedside, (at times) when a breathing treatment being given to the patient, when the patient is having difficulty breathing, dependent drainage after abdominal surgery, grooming, etc.

Lithotomy position
From Wikipedia, the free encyclopedia

This article may contain inappropriate or misinterpreted citations that do not verify the text. Please help improve this article by checking for inaccuracies. (help, talk, get involved!) (July 2009) The lithotomy position is a medical term referring to a common position for surgical procedures and medical examinations involving the pelvis and lower abdomen, as well as a common position for childbirth in Western nations. The lithotomy position involves the positioning of an individual's feet above or at the same level as the hips (often in stirrups), with the perineum positioned at the edge of an examination table. References to the position have been found in some of the oldest known medical documents including versions of the Hippocratic oath (see lithotomy); the position is named after the ancient surgical procedure for removing kidney stones, gall stones and bladder stones via the perineum. The position is perhaps most recognizable as the 'often used' position for childbirth: the patient is laid on the back with knees bent, positioned above the hips, and spread apart through the use of stirrups. The position is frequently used and has many obvious benefits from the doctor's perspective. Most notably the position provides good visual and physical access to the perineal region. The position is used for procedures ranging from simple pelvic exams to surgeries and procedures involving, but not limited to reproductive organs, urology, and gastrointestinal systems. New observations and scientific findings, combined with a greater sensitivity to patient needs have raised awareness of the physical and psychological risks the position may pose for prolonged surgical procedures, pelvic examinations, and, most notably, childbirth.

Trendelenburg position
From Wikipedia, the free encyclopedia (Redirected from Reverse Trendelenburg position)

Old description of the Trendelenburg position.

In the Trendelenburg position the body is laid flat on the back (supine position) with the feet higher than the head by 15-30 degrees, in contrast to the reverse Trendelenburg position, where the body is tilted in the opposite direction. This is a standard position used in abdominal and gynecological surgery. It allows better access to the pelvic organs as gravity pulls the intestines away from the pelvis. It was named after the German surgeon Friedrich Trendelenburg.[1] It is not recommended for the treatment of hypovolaemic shock.[2]

Contents
[hide] 1 Uses 2 See also 3 References 4 External links

[edit] Uses
People with hypotension (low blood pressure) have historically been placed in the Trendelenburg position in hopes of increasing their cerebral perfusion pressure (the blood pressure to the brain). A 2005 literature review found the "Literature on the position was scarce, lacked strength, and seemed to be guided by 'expert opinion.'"[3] A 2008 meta-analysis found adverse consequences to the use of the Trendelenburg position and recommended it be avoided.[4] However, the passive leg raising test is a useful clinical guide to fluid resuscitation and can be used for effective autotransfusion.[5] The Trendelenburg position used to be the standard first aid position for shock.[6] The Trendelenburg position was used for injured scuba divers.[7] Many experienced divers still believe this position is appropriate, but current scuba first aid professionals no longer advocate elevating the feet higher than the head. The Trendelenburg position in this case increases regurgitation and airway problems, causes the brain to swell, increases breathing difficulty, and has not been proven to be of any value.[8] "Supine is fine" is a good, general rule for victims of submersion injuries unless they have fluid in the airway or are breathing, in which case they should be positioned on the side. Perhaps because of its effect on breathing difficulty and airway problems, the Trendelenburg position is used in waterboarding. The Trendelenburg position may be used in childbirth when a woman's cervix is too swollen and won't quite dilate to 10 centimeters, or during the incidence of a prolapsed umbilical cord to take pressure off the cord and get more oxygen to the fetus, or it can be used to help rotate a posterior fetus either during pregnancy or the birth itself. Trendelenburg position is helpful in surgical reduction of an abdominal hernia.[9] The Trendelenburg position is also used when placing a Central Venous Line. [10] Trendelenburg position uses gravity to assist in the filling and distension of

the upper central veins when placing a central line in the internal jugular or subclavian veins. It is also used in the placement of an external jugular peripheral line for the same reason. It plays no role in the placement of a femoral central venous line.

Sims' position
From Wikipedia, the free encyclopedia

The Sims' position, named after James Marion Sims is usually used for rectal examination, treatments and enemas. It is performed by having a patient lie on their left side, left hip and lower extremity straight, and right hip and knee bent.

[edit] Detailed description

The position is described as follows:
1. Patient lies on their left side. 2. Patient's left lower extremity is straightened 3. Patient's right lower extremity is flexed at the hip, and the leg is flexed at the knee. The bent knee, resting against bed surface or a pillow, provides stability.

Common uses
1. Post partum perineal examination

2.Supine position
3. From Wikipedia, the free encyclopedia

4. 5.

6. A man lying in the supine position /supan/) is a position of the body: lying down with the face up, as opposed to the prone position, which is face down, sometimes with the hands behind the head or neck. When used in surgical procedures, it allows access to the peritoneal, thoracic and pericardial regions; as well as the head, neck and extremities.[1] A study claims that people solve anagrams significantly faster when supine than when standing.[2] 8. Using terms defined in the anatomical position, the dorsal side is down, and the ventral side is up.
7. The supine position (