ARM SAFE FROM HARM Foam padding can prevent nerve injury, but make sure to protect bony prominences against pressure ulcers.

Once the sedative effects of anesthesia kick in, your patients are at heightened risk of nerve damage, pressure ulcers, shear forces, and other skin and deep-tissue injuries. Don't put your patients in harm's way when the following practical advice from a few experts we spoke to can prevent perioperative positioning injuries.

1. Know the risks
Patients are in jeopardy if they've been positioned with more thought given to clinical access than to ergonomic safety. General anesthesia and other hypotensive drugs also increase the hazard of improper positioning, as do chilly ORs and the possibility of hypothermia. The longer patients are on the table, the higher their risk of injury, especially as cases approach the 3-hour mark. Improper positioning on the OR table for a prolonged period of time adversely affects the integrity of the skin and causes compression of subcutaneous tissue and muscle. The damage to surface or underlying tissue presents over time as redness, bruising, blistering, sloughing or necrosis, and any time there is skin breakdown, the risk of infection is very high.

Intrinsic risks include, but are not limited to, a patient's age (with elderly patients more susceptible), lack of mobility, diabetes, recent weight loss, poor nutritional status (which is often exacerbated by pre-surgical NPO restrictions), and use of blood thinners.

Even though most patients who undergo surgery at outpatient facilities are in good overall health, they can face the same risks, and while the signs of positioning injuries may not appear for 2 to 4 days, they can originate from a single stay on the OR table.

LIGHTEN THE LOAD Low-friction lateral transfer devices can sidestep the shear forces that hurt patients' skin.

2. Assess the skin's condition
Check the skin condition of all surgical patients for intactness and risk of injury during the pre-op and post-op periods. Communicate the findings at patient handoffs using the Braden Scale for Predicting Pressure Sore Risk (osmag.net/9wAgQA).

Hold regularly scheduled in-services, at which a perioperative nurse champion and a wound-ostomy-continence nurse (who'll know about skin healing) can collaborate to remind nurses how to use evidence-based practices, for which there is a wealth of supporting literature. Try a case review of a patient who suffered a perioperative injury. Talking about what went wrong, and what could have prevented it, is an interactive and effective way to keep patients safe.

3. Soften the surface
Only in the past 10 years or so have pressure injuries received the preventive attention they deserve. The areas of chief concern are the bony prominences, in particular the sacrum, coccyx and buttocks (the anatomy most commonly affected by pressure injuries); the heels (often overlooked, but at risk among patients of all ages); and the back of the head (where damage can be concealed by the hair).

Use soft, silicone, multi-layered sacral dressings to protect patients against friction and shear during transfers and pressure while they're positioned for surgeries. The suspension of the heels is another critical intervention. While this can be accomplished through the use of stirrup boots and other devices, it doesn't require large investments in table accessories.

The National Pressure Ulcer Advisory Panel's clinical practice guideline on prevention and treatment (osmag.net/2PdGeQ) recommends placing pillows or foam cushions beneath the legs to "float the heels" and eliminate pressure on them entirely. This also creates a slight flexion in the legs and knees. Additionally, many inexpensive positioning devices — including gel-filled, donut-shaped cushions — can assist in redistributing pressure beneath the back of the head.

A supportive surface is of utmost importance in preventing perioperative injuries. Patient safety depends not just on how you position their arms and legs, but the surfaces they're placed on.

While the NPAUP's guideline doesn't name specific products, it recommends the use of pressure redistribution pads on OR tables. Redistribution, not reduction, is the key here. Consider, for example, foam padding. It's ideal for preventing nerve injury, but given that it bottoms out, it does not effectively protect skin against pressure injuries.

There's been significant improvement in table mattress construction in recent years. The latest versions are made from memory foam or gel-and-foam layers, allowing the body to sink into them but still remaining supportive. This immersion factor is what you're looking for in pressure redistribution. Also, they're covered with material that features 4-way stretch. Traditional foam-and-vinyl mattresses don't offer nearly as much support or give.

Layering linens on top of a table can reduce the effectiveness of its padding by creating a hammock effect. Using sheets that give, such as those made from jersey instead of stiff cotton, can help, as can minimizing the layers you put down. Also, placing high-absorbency disposable underpads beneath surgical patients can wick away the perspiration, irrigation and other moisture that leave skin vulnerable to moisture. And always reach for low-friction lateral transfer devices to lift and not drag patients when moving them onto or off of the table.