Contents:

• Introduction
   
• Intubation
  
• Obstetrics
• Morbid obesity
• Lithotomy
• The sitting position
  
• Miscellany

Introduction

Correct positioning of the surgical patient facilitates comfortable surgical access to the operative site, reduces bleeding (mostly by avoiding venous congestion), prevents pressure damage to skin, nerves, joints and muscles, minimises adverse cardiac and respiratory problems, and provides good access for the anaesthetist.

SurgicalTutor has a brief document about prevention of positioning-related injuries.

Intubation.

Flexion of the cervical spine and extension of the atlanto-occipital joint gets you the classical 'sniffing' position. On a normal bed, the patients chest wall sinks into the mattress, flexing the neck to some degree, even if no pillow is used. A single standard pillow will usually prove too thin when used on a much firmer operating table. Grogono's GasNet tip was to use more than one pillow. Michael Bookallil uses one pillow folded in half. I use a foam rest over a standard pillow.

Laminectomy.

Usually prone, with risk of eye, ulnar nerve, neck and brachial plexus injury. A GasNet tip suggested that extubation while prone has advantages and another emphasises the importance of ETT fixation when prone. Always securely close the eyelids to avoid corneal abrasions, and avoid pressure on the globe and hypotension. Pads over the eyes will only increase pressure on the eye if any exists.

Obstetrics.

The WFSA summary of physiological changes in pregnancy includes brief comments on positioning for anaesthesia; another provides specifics of lateral tilt during caesarean section. Another details the influence of patient position during injection for spinal anaesthesia.

The morbidly obese.

Make sure the table is able to take the weight. Get lots of assistance with movement.

Lithotomy & Laparotomy.

Take care not to compress the calves if the patient is steeply head down (pressure in the muscle compartment can exceed perfusion pressure). Reduced lung volume leading to atelectasis is common. See Nick Robson's notes on gynaecologic surgery.

Sitting position for neurosurgery.

This GasNet abstract discusses use of PEEP to reduce venous air embolism in the sitting position. Hypotension due to venous pooling in dependent limbs and neuropraxias need to be carefully managed. SNACC Web has this extensive bibliography.

Miscellaneous:

• A review of complications of hysteroscopy, including positioning-related issues.
• WFSA position for cannulation of the subclavian vein
• Neurological complications of regional anaesthesia in obstetrics - many can be positioning related
• The Frontier group (UK) are experts in pressure area care.