PRINCIPLES OF

PATIENT POSITIONING
MH/AG/SG
 Proper patient positioning
Often overlooked
Critical step in surgical preparation
Responsibility of surgeon and anesthesiologist
Balancing surgical comfort vs risks related to
position
Improper positioning : morbidity and area of
litigation if complication happen (eg
peripheral nerve lesion)
 Overview
One must be aware of the anatomic and physiologic
changes associated with anesthesia, patient positioning,
and the procedure.
The following criteria should be met to prevent injury
from pressure, obstruction, or stretching:
No interference with respiration
No interference with circulation
No pressure on peripheral nerves
Minimal skin pressure
Accessibility to operative site
Accessibility for anesthetic administration
No undue musculoskeletal discomfort
Maintenance of individual requirements
Goals of Proper Positioning
To maintain patients airway and avoid
constriction or pressure on the chest cavity
To maintain circulation
To prevent nerve damage
To provide adequate exposure of the operative
site
To provide comfort and safety to the patient
 Assessment
The team should assess the following prior to
positioning of the patient:
Procedure length
Surgeons preference of position
Required position for procedure
Anesthesia to be administered
Patients risk factors
age, weight, skin condition, mobility/limitations,
pre-existing conditions, etc.
Patients privacy and medical needs
Basics of anatomy & physiology
 Team Responsibilities
Surgeon :
-Optimal procedural exposure
Anesthesia :
-Physiologic requirements (A-B-Cs)
-Position timing
Nursing:
-Safe transfer using adequate
personnel
-Use of adequate padding and
positioning aids
-Provide an ongoing assessment
 POSITION DEVICES
Patient-positioning devices can be divided
into two categories
One which are primarily geared toward
pressure-relief
Ones which are designed to provide
better access to the surgical site
TABLE ACCESSORIES
AND ATTACHMENTS
 TABLE FEATURES AND ATTACHMENTS

ELEVATED
ARM REST LATERAL SUPPORT STIRRUPS

BREAKABLE
HEAD REST
DETACHABLE
FOOT REST

SLIDING
BARS METAL SOCKET
ARM BOARD

HYDRAULIC
WHEELED BASE
MANUAL
STAND
LEVER

OTHERS PILLOWS, HEAD RING, SANDBAGS, ROLL SUPPORT, SOFT PADS, MATTRESS
 Surgical Positions
Four basic Variations include:
surgical positions Trendelenburg
include: Reverse
Supine trendelenburg
Prone Fowlers
Lateral Jackknife
Lithotomy High lithotomy
Low lithotomy
 Supine
Most common with the least amount of harm
Placed on back with legs extended and uncrossed at the ankles
Arms either on arm boards abducted <90* with palms up or
tucked (not touching metal or constricted)
Spinal column should be in alignment with legs parallel to the OR
bed
Head in line with the spine and the face is upward
Hips are parallel to the spine
Padding is placed under the head, arms, and heels with a pillow
placed under the knees
Safety belt placed 2 above the knees while not impeding
circulation
ARM TUCKING IN SUPINE
POSITION

TO PREVENT BRACHIAL PLEXUS

INJURY
Potential pressure points
 PRECAUTIONS POTENTIAL COMPLICATIONS

Head not Hyperextended Backache resulted from

unsupported lumbosacral
To ensure that arms are
curvature
not abducted < 90
Armboard is padded Paralysis of arm and hand due
to over abduction
Hand in prone position
Radial or Ulnar nerve palsy due
Arms do not overlap or to arm or elbow hanging or
hang over table edge tight strapping
Patient protected from
Continuous pressure on the
metal contact
calves may caused venous stasis
Bony prominences are resulting thrombosis which can
protected (occiput, scapulae, lead to Pulmonary Embolisms
thoracic vertebrae, olecranaon,
sacrum and coccyx, calcaneus)
 Supine Concerns
Greatest concerns are circulation and
pressure points
Most Common Nerve Damage:
Brachial Plexus: positioning the arm >90*
Radial and Ulnar: compression against the OR bed,
metal attachments, or when team members lean
against the arms during the procedure
Peroneal and Tibial: Crossing of feet and plantar
flexion of ankles and feet
Vulnerable Bony Prominences:
(due to rubbing and sustained pressure)
Occiput, spine, scapula, Olecranon, Sacrum,
Calcaneous
 PRONE POSITION

PRONE POSITION

The patient lying with abdomen on table surface

Arms are placed above the head
Pillows are placed under the shoulders, hips and feet
Access for all surgeries involving posterior back
(cervical spine, back, rectal area and dorsal extremities)
 PRECAUTIONS POTENTIAL COMPLICATIONS

Pillow or towel under Lower neck and upper back

shoulders and hip pain resulting from
facilitate chest expansion, hyperextension of head
reduce abdominal
Radial and ulnar nerve palsy
pressure and venous
due to arm restrainer
oozing at operation site
Hypotension resulted from
Head not hyperextended, pressure on inferior vena cava
placed on side and kept and pooling of blood in lower
supported limbs
Pressure point are well Shoulder dislocation during arm
protected with pad (cheek, positioning
ear, acromion process,
breast, genitalia, patella, Brachial plexus injury due to
dorsum of feet, toes) over extension of arm < 90
Potential pressure points
 Lateral
Anesthetized supine prior to turning
Shoulder & hips turned simultaneously to prevent torsion of the
spine & great vessels
Lower leg is flexed at the hip; upper leg is straight
Head must be in cervical alignment with the spine
Breasts and genitalia to be free from torsion and pressure
Axillary roll placed caudal to axilla of the downside arm (to
protect brachial plexus)
Padding placed under lower leg, to ankle and foot of upper leg,
and to lower arm (palm up) and upper arm
Pillow placed lengthwise
between legs and between
arms (if lateral arm holder is
not used)
Stabilize patient with
safety strap and silk tape,
if needed
Lateral
 Lateral Concerns
Greatest concerns are respiratory,
circulatory, and pressure points
Most Common Nerve Damage:
Brachial, radial, median, ulnar, peroneal
Vulnerable Bony Prominences:
Temporal, acromion, olecranon, iliac,
greater trochanter
Vulnerable Vessels:
Carotid, axillary, brachial, aorta,
vena cava, saphenous
 TRENDELENBURG POSITION

Patient lying in supine

position with knees
over lower break of
the table TRENDELENBURG POSITION
Head tilted down to 15 or according to the surgeon
preferences
Arms may placed on the chest or armboard
Common position for laparoscopic surgeries in pelvic or
lower abdominal region
Using of shoulder or knee braces may benefit patient
from sliding
 PRECAUTIONS
Head not hyperextended and arm
not abducted beyond 90
Hands on padded armboards are
supinated
Arms not overlap the table edge or
hang over
Patient is protected from metal
contact
Bony prominences are well
protected (occiput, scapulae,
thoracic vertebrae, olecranon,
sacrum and coccyx and
calcaneus)
Returning leg first to reverse
venous stasis
POTENTIAL COMPLICATIONS
A 30 Trendelenburg
position may caused
changes in blood pressure,
cerebral edema, congestion
of face and neck
A too steep position may
result in cyanosis due to
alteration on diaphragmatic
extension and lung
expansion
Shearing of skin may
occurred during
positioning
 FRACTURE TABLE POSITION
Patient positioned in
supine with the pelvis
stabilized against well
padded vertical perineal
post
Traction of operative leg is achieved either by boot-
shaped cuff or devices with restraining straps
Unaffected leg may be rested on well padded,
elevated leg holder
Common position for ORIF of hip or closed femoral
nailing
ORTHOPAEDIC FRACTURE TABLE
 PRECAUTIONS
Patient usually brought into
theatre with hospital bed and
traction applied
Ensure patient is anaesthetized
before transfer onto OT table
Operating table are and
attachments are ready according
to surgeon preferences or
standard manual
Cautions and extra care regarding peroneal or femoral
shear force injuries,
musculoskeletal and nervous
system during transfer
Bony prominences protected
POTENTIAL COMPLICATIONS
Pressure due to perineal
post may injured genital
structure
Fecal incontinence and
loss of perineal sensation
may occurred as a result of
pressure injury to perineal
and pudendal nerve
Tight strap may resulted
obturator nerve damage
resulting in foot drop
 SEMI-FOWLERS AND FOWLERS
POSITION
SEMI-FOWLERS AND
The patient positioned in FOWLERS POSITION
supine with the upper body
part is flexed to 45 or 90
and the knees slightly
flexed and legs lowered
Arms may be placed over
the laps or armboard
A footrest is used to prevent
footdrop and head spike to stabilized head
Useful position for craniotomies, shoulder or
breast reconstruction and ENTS
 PRECAUTIONS
The cervical, thoracic and
lumbar section of spine must
be aligned once position
established
Extra padding are requires
over bony prominences
(coccyx, ischial tuberosities,
calcaneus, elbows, knees and
scapulae)
The use of anti-embolism
stocking may necessary to
assist venous return
Reposition after surgery must
be done gently and slowly
POTENTIAL COMPLICATIONS
Orthostatic hypotension due
to blood pooling at lower
extremities
Risk of venous thrombosis
and embolisms as a result of
impended venous return
High risk of development of
skin pressure over affected
bony prominences
Alteration on chest
movement due to restriction
from rested arms or tight
straps
Potential pressure points
 Effects of Positioning - Obese Patients
Supine:
Normal blood flow may be impeded due to compression of vena cava
and aorta by abdominal contents
Impairs diaphragmatic movement and reduces lung capacity
Trendelenburg:
Tolerated less well than supine
Added weight of abdominal contents on the diaphragm may lead to
atelectasis and hypoxemia
Prone:
Problematic
Requires additional support and monitoring of the patient and
pressure on the abdomen
Ventilation may be markedly more difficult
Lateral:
Well tolerated
Correct sizing and placement of axillary roll is important
Ensure that pendulous abdomen does not hang over side of OR bed
Head-Up: (Reverse Trendelenburg/Semi-recumbent)
Most safe
Weight of abdominal contents unloaded from diaphragm
Use of well-padded footboard to prevent sliding
 Key Points
Use safe body mechanics during transfers and
positioning ensure adequate assistance is
used
Maintain stretcher/bed in a locked position
prior to patient transfers and positioning
Verify weight limit on OR table to be used
Ensure that the patient is adequately secured
to the OR table
One strap placed across the patients thighs
and the second across the lower legs
Extra care must be taken to ensure that loose
skin is protected (ie lithotomy position)
POSITIONING OF ELDERLY PATIENT

FRAGILE SKIN SURFACES

ARTHRITIC JOINTS
LIMITED RANGE OF MOTION
PARALYSIS
LIFTING RATHER THAN SLIDING OR
DRAGGING
AVOID OF ADHESIVE TAPE FOR STRAPPING
ADEQUATE PADDING FOR BONY
PROMINENCES
ALLOW PATIENT TO POSITIONING BEFORE
ANAESTHETIZED
 POSITIONING OF PAEDIATRIC
PATIENT
Think of appropriate size
Right size for bed and attachments
May necessary to use safety strap
Never overextended limbs or keep in one
position for longer periods
Due to small size, children are prone to and
has greater risk of physiologically
compromised
Appropriate positioning and observation are
essential
 Safety
Considerations
 Supine
Risk #1: Safety
Pressure points: Considerations:
occiput;scapulae;thoracic Padding to heels, elbows,
vertebrae;olecranon knees
process;sacrum/coccyx; Spine, head alignment with
hips
calcaneae;knees
Legs parallel, uncrossed at
ankles
Risk #2: Safety
Neural injuries of Consideration:
extremities, brachial Arm board at less than 90
plexus, ulna, radial nerves degrees
Head in neutral position
Arm board pads level with
OR bed
 Prone
Risk #1: Safety Consideration:
Maintain cervical neck
Head, eyes, nose alignment
Protection of forehead,
eyes, chin
Padded headrest to provide
airway
Safety Consideration:
Risk #2:
Chest rolls to allow chest
Chest compression, movement and decrease
iliac crest, breast, abdominal pressure
male genitalia Breasts and genitalia free
from torsion
Risk #3: Safety Consideration:
Knees Padded with pillows
Risk #4: Safety Consideration:
Padded footboard
Feet
 Lateral
Safety Consideration:
Risk #1:
Axillary roll for
Bony prominences and pressure points on dependent
dependent axilla side
Lower leg flexed at hip
Upper leg straight with
pillow between legs
Padding between knees,
Risk #2: ankles and feet
Spinal alignment Safety Consideration:
Maintain spinal alignment
during turning
Padded support to
prevent lateral neck
flexion
 Dont Forget:
Good positioning starts with an assessment
Prevent surgical team members from leaning against patients
Arm board pads should be level with table pads
Cushioning of all pressure points is a priority - the correct use of
padding can protect the patient
Procedures longer than 2 to 3 hours significantly increase the
risk of pressure ulcer formation
During a longer procedure, you should assist with shifting the
patient, adjusting the table, or adding/removing a positioning
device
The nurse must assess extremities at regular intervals for signs
of circulatory compromise
Documentation of the positioning process should be performed
accurately and completely
 One last note
Positioning problems can result in
significant injuries and
successful lawsuits.
Knee Surgery
 Positioning considerations
Move patient to end of table
Allows better access
Consider a bump under hip so patella is straight up
Tourniquet high on thigh, snug but not tight
Avoid venous tourniquet effect
Protect other leg
SCD
Heels, peroneal nerves free of compression
 Knee Positioning
Drape off tourniquet with steridrape or equivalent
Consider a bump for foot to hold knee flexed at 70-
90 degrees
For arthroscopy, place lateral post at mid-thigh
 Knee Prepping
Suspend leg using curved leg holder and a
stirrup
Prep from knee outward to thigh and ankle
Hip Surgery
 Patient Positioning
Patient placed in lateral decubitus position
Operative side placed up
Used for anterolateral and posterior hip approaches
Stullberg positions or hip rests used to stabilize patient
Axillary roll placed under down axilla to prevent
compression of brachial plexus
Axillary roll
Stullberg positioner for anterior pelvis
Stullberg positioner, lumbar spine
 Patient Positioning
Pad boney prominences with foam padding
Particularly peroneal nerve of down leg!
Proper
positioning on
the operating
room table
insures that the
patients
operative hip is
aligned with the
ipsalateral
shoulder
Up arm is positioned
on an arm rest with
padding under elbow
and wrist, digits are
left free

Down arm is placed

on an arm board
with padding
beneath the elbow
and wrist
Foley tubing and other
wires are safe tucked
at head of table to
prevent trip hazard

Foot pads are placed at

sides of operating room
table for surgeon comfort
Shoulder Surgery
 Shoulder surgery
Beach chair position
Most common
Open and arthroscopy
Lateral position
Arthroscopy: instability
Unusual cases
 Positioning considerations
Neutral neck position
Varies by patient
Kyphosis common in elderly
Protect uninvolved arm
Ulnar nerve free of compression
Neutral wrist position (slightly dorsiflexed)
Protect legs
SCDs
Heels, peroneal nerves free of compression
 Beach chair position
Position on table with trochanters at flex point
Flex knees over leg support cushion
 Beach chair position
Place head supports and sit up 50-70 degrees
Adjust to achieve neutral neck position for
that patient, careful with kyphosis
 Lateral position
Position on bean bag slightly
tipped back, axillary roll goes
under upper chest (not in axilla)
Secure with wide tape to prevent
loss of position
Neck in neutral position with
blankets
Down leg protected (peroneal
nerve)
Pillow between legs