Surgical services professionals who believe patient positioning is merely aimed at improving surgeon access to the surgical site are ignoring some of its primary benefits – and, as a result, could be jeopardizing patient safety and quality outcomes.

While it’s true that patient positioning allows for optimal exposure to the surgical site and better access to IVs and monitoring devices, that’s only one piece of the overall picture. Attention must also be given to the patient’s comfort and safety, while also taking into careful consideration circulatory, musculoskeletal and neurological structures.

“The procedure, surgeon preference and patient condition determine equipment used for positioning. Working as a member of the team, the perioperative nurse can minimize the risk of perioperative complications related to positioning,” notes the Association of periOperative Registered Nurses, in its “Recommended Practices for Positioning the Patient in the Perioperative Practice Setting.”

The absence of proper positioning can leave the patient vulnerable to a number of serious health complications – including a decrease in respiratory function due to the mechanical restriction of the rib cage from certain positions (such as prone, lateral and lithotomy), redistribution and congestion of blood supply from lithotomy and Trendelenburg positions, and impaired circulatory responses that may lead to vasodilatation, hypertension and decreased cardiac output. Nerve and muscle trauma may also stem from stretching or compression when upper extremities are abducted at greater than 90 degrees to the body, hips are placed in excessive external rotation, and/or the head and neck is hyperextended.

And the risks don’t end there. Indwelling catheters, tubes, or cannulas may be dislodged without proper support, and intraoperative skin injuries may also result from unrelieved or extended pressure – particularly in surgical procedures lasting longer than two-and-a-half to three hours, studies show. In fact, the incidence of pressure ulcers presenting as a result of surgery may be as high as 66 percent. Skin shearing and friction also contribute to the pressure ulcer and skin breakdown risks, and both high pressure for a short-duration procedure and low pressure for extended duration are also risk factors for tissue breakdown.

Alleviating Pressure, Risks
While the market is brimming with a wide variety of surgical-positioning devices, surgical services professionals must understand that not all products are created equal.

Studies suggest that positioning devices, which come in a broad range of shapes, sizes and configurations to meet the unique requirements of the patient and procedure at hand, should maintain normal capillary interface pressure of 32 mm Hg or less. Foam pads are ineffective in reducing capillary interface pressure because they quickly compress under heavy body areas, whereas use of gel pads, which provide flexible support, or similar devices over the surgical bed can effectively decrease pressure at any given point by redistributing overall pressures across a larger surface area. Convoluted foam mattress overlays are effective in reducing pressure only if they are made of a thick and dense foam that resists compression, the AORN states, adding that pillows, blankets and molded foam devices may produce only a minimum of pressure reduction, and towels and sheet rolls fail to reduce pressure and may even contribute to friction injuries.

The AORN notes that pre-planning is essential for ensuring that the appropriate positioning devices and an adequate number of personnel are available to position the patient properly. Beyond that, it’s imperative that surgical staff are well-versed on positioning basics and possess a solid understanding of the physiologic effects and implications of the position in relation to the patient’s assessed status and limitations. It’s recommended that the perioperative nurse actively participate in patient positioning and that specific patient needs be properly communicated to surgical team members.

Surgical staff must be sure to protect the patient’s head with proper pillows and headrests – such as “donuts” for patients in the supine or Trendelenberg position. The buttocks, which can be prone to pressure ulcers due to prolonged contact with the surgical table, must also be protected, particularly for patients undergoing lengthier procedures. Additionally, hip and leg alignment is critical for relieving pressure on the lower back and hip joints. This is particularly vital in orthopedic procedures where the hips can be subjected to lumbar plexus damage due to excessive strain. If possible, the patient’s knees should remain flexed, with additional support underneath and minimal rotation to the sides.

Another common problem is brachial plexus injury, which may stem from hyperextension of the arms, particularly in patients undergoing procedures in the supine position. To help prevent this condition, the patient’s arms must not be extended to more than a 90-degree angle.

Once the patient is positioned, the process shouldn’t end there. Prior to the start of the procedure, staff should reevaluate body alignment and tissue integrity, taking care to check the ulnar bone and the lumbar area, which are especially vulnerable. Tubes and lines should be carefully checked throughout the procedure. A postoperative assessment should also be performed, using care to examine any and all areas that were under direct pressure. Skin assessments should be conducted to check for reddened skin and other potential signs of tissue damage. When the patient is alert and able to communicate, they should be asked if they’re experiencing any numbness or tingling in the extremities. Comprehensive documentation of nursing assessments and the type, location and placement of positioning devices – along with the names of surgical staff involved in positioning the patient – should also be performed, the AORN recommends.