position

1. Positioning in anaesthesia
Dr. S. Parthasarathy
MD., DA., DNB, MD (Acu),
Dip. Diab. DCA, Dip. Software statistics
PhD (physio)

2. Goals
• Avoid pressure on the chest cavity
• To maintain circulation
• To prevent nerve damage
• To maintain patient’s airway
• To provide adequate exposure of the
operative site
• To provide comfort and safety to the patient

3. Positions – common
• Patient is not aware of the damage and he
cant tell that my eye is getting compressed
• supine,
• lithotomy,
• sitting,
• head-down,
• prone,
• lateral decubitus

4. Supine

5. Supine
• We spent most of our life like this
• Be careful
• patients with morbid obesity,
• mediastinal masses,
• poor cardiac function and
• term parturients prone to aortocaval
compression
• .

6. Supine

7. Step off effect

8. Supine
• prolonged contact of the back of the head
may result in alopecia
• ulnar neuropathy is the most common- males
• 0.25 % may be delayed upto 3 days
• Brachial plexus, femoral cutaneous nerves are
next common.
• Brachial or ulnar ??

9. Head rotation
putting brachial
plexus under
traction
Excess abduction of
upper limb
Forearm pronation
putting pressure on
ulnar nerve in ulnar
groove

10. CVS in supine
• MAP, heart rate (HR),venous return rises
peripheral vascular resistance decrease
• cardiac output and stroke volume increase.
• Offset anaesthetic action

11. RS
• cephalad movement of the abdominal contents.
• The main complications are airway obstruction
and decreased tidal volumes
• The resulting reduction in functional residual
capacity (FRC) is detrimental to gas exchange
• increase in ventilation–perfusion mismatching
and decrease in pulmonary compliance.

12. • loss of the natural lumbar lordosis
• associated with postoperative low back pain.
• The occiput, sacrum and heel are at risk of
developing pressure sores

13. Supine with pads and arms by the side
with pads

14. Lawn Chair Position

15. Lawn Chair Position
• modification of the standard supine position
• the lower and upper halves of the body are
slightly elevated in relationship to the hips
• Better venous drainage , better muscle
relaxation

16. beach chair position

17. beach chair position
• beach chair position is associated with the
risk for cerebral underperfusion.
• Blood pressure must be maintained at a level
that guarantees a perfusion pressure of 60 to
70 mm Hg measured at the level of the
foramen magnum

18. Trendelenburg

19. Trendelenburg
• Central blood volume increase by 1 litre.
swelling of the face, conjunctiva, larynx, and
tongue ?? postoperative upper airway
obstruction.
• The cephalic movement of abdominal viscera
against the diaphragm also decreases
functional residual capacity and pulmonary
compliance.

20. 5 March 2017 20
Effects of Trendelenberg’ s position
• ↑ CVP
• ↑ ICP
• ↑ IOP
• ↑ myocardial work
• ↑ pulmonary venous pressure
• ↓ pulmonary compliance
• ↓ FRC
• Swelling of face, eyelids, conjunctiva & tongue
observed in long surgeries

21. Trendelenburg
• The stomach also lies above the glottis
• Visualize the larynx before extubation.

22. Reverse trendelenburg

23. Reverse Trendelenburg position(head-
up tilt)
• to facilitate upper abdominal surgery by
shifting the abdominal contents caudad.
• This position is popular because of the
growing number of laparoscopic surgeries.
• slipping on the table,
• monitoring of arterial blood pressure.

24. Reverse Trendelenburg position
• hypotension and increased risk of venous air
embolism (VAE).
• the position of the head above the heart
reduces perfusion pressure to the brain

25. Lithotomy
• This position is most often used for
• genitourinary, gynecologic, and colorectal
• Procedures.
• Hips flexed 100 deg 30-40 deg. abduction at
the hips
• . Knees 90 approx 30 deg

26. ARMS – side and tucked in

27. Martin and Warner have proposed a
standardized classification
• low,
standard,
• high,
• hemi,
• exaggerated,
• tilted
• Martin JT, Warner MA (Eds): Positioning in
Anesthesia and Surgery, 3rd edition. Philadelphia,
WB Saunders, 1997

28. Low and standard

29. High and hemi

30. Exaggerated and tilted

31. Various lower limb fixations

32. Lithotomy
• coordinated positioning of the lower
extremities by two assistants to avoid torsion
of the lumbar spine.
• Both legs should be raised together, flexing
the hips and knees simultaneously.
• Slow removal
• Hands beware

33. lithotomy from the supine position
• Unanticipated stimulation of the carina with
bronchospasm or endobronchial intubation
may result.
• In the lithotomy position, calf compression is
almost inevitable and this predisposes to
venous thrombo embolism and compartment
syndrome ( surgery > 5 hours)

34. MAP at various levels

35. Lithotomy
• Lower extremity compartment syndrome is a
rare complication associated with the
lithotomy position.
• perfusion to an extremity is inadequate,
resulting in ischemia, edema
extensive rhabdomyolysis from increased
tissue pressure within a fascial compartment

36. Nerve injuries
• injury to the common peroneal nerve was
the most common lower extremity motor
neuropathy, representing 78% of nerve
injuries.
• A potential cause of the injury was the
compression of the nerve between the lateral
head of the fibula and the bar holding the
legs.

37. Nerve injuries in lithotomy

38. Exaggerated Lithotomy
• Extreme flexion of the hip
joints can cause
• neural damage by stretch
(sciatic and obturator
nerves)
• direct pressure
(compression of the
femoral nerve as it is
passes under the inguinal
ligament)

39. Hemodynamics and RS
• preload increases, transient increase in
cardiac output
• Cerebral venous and intracranial pressure in
otherwise healthy patients.
• causes the abdominal viscera to displace the
diaphragm cephalad, reducing lung
compliance and potentially resulting in a
decreased tidal volume

40. The frog-leg position
• hips and knees are flexed
• hips are externally rotated with the soles of
the feet facing each other,
• allows access to the perineum, medial thighs,
genitalia, and rectum.
• Care must be taken to minimize stress and
postoperative pain in the hips and prevent
dislocation by supporting the knees
appropriately

41. The prone or ventral decubitus
position
• used primarily for surgical access to the
posterior fossa of the skull,
• the posterior spine,
• the buttocks and
• perirectal area,
• and the lower
• extremities.

42. Prone position
Minimal neck
flexion
Face in
soft
headring
with
no
pressure
on eyes
and nose
Elbow
padded
No pressure in
axilla
Abdomen
free
anterior
flexion,
abducted
and
externally
rotated
g
e
n
i
t
a
l
n
i
p
p
l
e

43. Abdomen pressure in prone
• inferior vena caval compression,
• reduced venous return and subsequent poor
cardiac output.
• Associated pulmonary problems are caused by
an increase in transdiaphragmatic pressure
leading to reduced thoracic compliance.

44. RS – better
• An increase in FRC, changes in diaphragmatic
excursions and improved ventilation–
perfusion matching can significantly improve
oxygenation in the prone position.
• for treatment of refractory hypoxaemia and in
early ARDS
• 70–80% of patients turned prone initially
benefit from improved oxygenation

45. Prone position
• Complete obstruction of the contralateral
• vertebral blood flow with rotation of the head
>80
• Beware in old CVAs
• ‘Concorde’ position with the neck flexed and
the chin approximately one finger-breadth
from the sternum

46. Prone position with Wilson frame

47. Mirror type

48. Horse shoe adapter , may field head
pins

49. Relton-Hall frame

50. Wilson laminectomy frame

51. Park bench position- 3 quarter prone

52. The prone jackknife position

53. The prone jackknife position
• is often used for anorectal surgery.
• is first placed prone, and all pressure
• points are padded.
• The patient is situated on the table such that
when the table is anteflexed the apex of the
inverted “V” is at the patient’s inguinal
region.

54. Knee chest position
• sigmoidoscopies or
lumbar laminectomies
Severe hypotension is
seen due to pooling of
blood in the legs

55. The Andrews kneeling frame with
Wiltse's thoracic jack in use

56. Watson jones ortho table

57. Watson jones ortho table
• Brachial plexus injury
– Due to > than 90* extension of the upper limb
• Lower extremity compartment syndrome
– Due to long surgeries & compression
• Pudendal nerve injury
– Due to pressure of the perineal post

58. This table also !!

59. The lateral decubitus position
• surgery involving the thorax,
• retroperitoneal structures,
• hip.

60. The lateral decubitus position

61. The lateral decubitus position

62. The lateral decubitus position

63. The lateral decubitus position
• V/Q mismatch
• Maximal ocular complications
• BP check up especially in kidney position
• Nerve injuries

64. Sitting
• Not frequently used
• Craniotomy
• Venous return decrease and cardiac output
decrease
• HR no change
• Venous air embolism

65. Sitting

66. Sitting
• overall increase in ventilation with increased
VC and FRC.

67. Pressure points

68. Nerve injuries- overall
• ulnar neuropathy has been found in as many
as 26% of patients undergoing open-heart
surgery
• lower extremity neuropathy occurred in
1.5% of patients in the lithotomy position.
• The incidence of ulnar neuropathy is
estimated at 0.46% after noncardiac surgery

69. Overall mechanism of nerve injuries
• (i) stretch,
• (ii) compression,
• (iii) generalized ischaemia,
• (iv) metabolic derangement.

70. all predispose to perioperative nerve
injury
• Peripheral vascular disease,
• diabetes,
• hereditary neuropathy, and
• anatomic variation (eg, cervical rib),

71. Brachial plexus

72. Ulnar nerve in flexion

73. Suprascapular nerve stretch

75. Wedge in pregnant
• A rare complication of this positioning is
sciatic neuropathy, suggesting that time in
this position should be minimized
• Early intervention within 48 hours with EMG
studies
• no significant difference in the incidence of
ulnar neuropathy in patients undergoing
general anaesthesia, regional anaesthesia or
sedation.

76. Double crush phenomenon

77. Effects of Positioning - Obese
Patients
• 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

78. Ocular injuries
• The frequency of eye injury during anaesthesia
and surgery is very low (<0.1% of anaesthetics),
• As little as 10 min
• Corneal abrasions, periorbital,and conjunctival
edema, ocular hemorrhage,
• vitreous loss, retinal detachment,
• central retinal artery occlusion,
• ischemic optic neuropathy

79. Causes
• Patient movement,
• chemical irritation from prep solutions,
• direct trauma from face mask,
• pressure from the laryngoscopic blade,
• pressure effects on the globe from lateral
• and prone positioning, (duration )
• intraoperative hypotension, and anemia

80. Contributing patient comorbid
conditions
• hypertension, diabetes,
• obesity, smoking history,
hypercholesterolemia,
• alcohol abuse, atherosclerosis,
• anemia, Graves disease,
• and renal transplantation
• Tape ok !!! Ointment ??

81. Don’t Forget:
• Good positioning starts with an assessment
• Prevent surgical team members from leaning
• Arm board pads should be level with table pads
• Cushioning of all pressure points is a priority -
• Procedures longer than 2 ½ to 3 ??
• During a longer procedure, shifting the patient,
adjusting the table, or adding/removing a positioning
device
• assess extremities at regular intervals for signs of
circulatory compromise
• Documentation of the positioning process- accurate
and complete

82. Summary
• Change – check all
• Cardiac
• Respiratory
• Nerve injuries
• Pressure sores
• Visual loss
• Follow up for some days

83. Comfortable position

84. Uncomfortable position

85. Uncomfortable position but happy

86. Thank you all