Using a saline-filled bag as a shoulder roll, as we suggested in this morning's Tip of the Day, is not recommended because it could harm patients, according to guidance from AORN and an article in JAMA Surgery that details how an improvised shoulder roll badly burned a patient during an electrosurgical procedure.

The potential danger is explained in a 2009 article published in JAMA Surgery, which documented the case of a 47-year-old woman who suffered severe electrical burns when a small leak developed in a saline bag that was being used as a shoulder roll to extend her neck during a thyroid procedure.

Citing the same article, AORN also recommends against the practice, adding that "[e]quipment used for patient positioning during surgery should be specifically designed for positioning and should be used according to the manufacturer's recommendations."

"This practice puts the patient in jeopardy. Not only does the IV bag not re-distribute pressure, but it is not normothermic," says Debra L Fawcett PhD, RN, manager of infection prevention and control at Eskenazi Health in Indianapolis, Ind. "Not re-distributing pressure puts the nerves and skin blood flow at risk, could lead to nerve damage and even the beginnings of a pressure ulcer or at the least skin damage."

To vividly illustrate the dangers involved, one reader, Robert Kotler, MD, FACS, said he'd learned of the danger the hard way. He provided photos of a patient who'd been severely burned in 2012, apparently by the saline bag used by an anesthesia provider for positioning during a facelift he performed.

In addition to the burn danger, others have pointed out that because IV bags don't re-distribute pressure and aren't normothermic, they could lead to nerve or skin damage and pressure ulcers.

Readers were quick to reply to our Tip of the Day e-mail blast. "Bite the bullet and invest in some gel positioning rolls. You won't break the bank and they wipe down with disinfectant just fine," says one. "This was a great idea 40 years ago, when it was first done during the transition from glass IV bottles to plastic bags," says another.

To learn more about the important principles of patient positioning, we recommend this video.

Jim Burger