CRUCIAL CONSIDERATION Proper positioning with the right attachments can make or break a procedure.

Ask any surgeon and he'll tell you excellent outcomes depend on optimal access. Perhaps that's why OR teams sometimes spend more time positioning patients for surgery than surgeons do completing procedures.

The latest protective pads and table accessories give your surgeons the access they want, help protect your patients from skin and nerve damage, and turn OR tables into versatile surfaces your facility needs to keep pace with evolving surgical care.

Cutting-edge exposure
Outpatient total joints are one of surgery's hottest specialties with more patients seeking out facilities with the equipment and expertise to send them home soon after surgery. The anterior approach to the hip joint spares the muscle at the pelvis and femur, shortens recoveries and prepares patients for same-day discharge. This single-incision technique, which requires one leg to stay in a normal position while other is hyperextended to where the foot is on or just above the floor, has traditionally required a specialty table that's both large and relatively expensive, as much as $150,000 or more.

Enter innovative leg positioners that attach to any standard operating room table to provide surgeons with the access they need to perform anterior hip replacements. The attachments represent a significant recent breakthrough in advanced patient positioning, according to John Masonis, MD, a hip and knee surgeon at OrthoCarolina in Charlotte, N.C.

Spine procedures, which are also beginning to gain traction in the outpatient setting, rely on stable access to the vertebrae or posterior pelvic region. Surgeons must minimize muscle damage and potential pain, and manage bleeding, says John C. Liu, MD, co-director of the Spine Surgery Center at Keck Medicine of USC in Los Angeles, Calif.

"During lumbar spine surgery, it's about maximizing exposure and spine alignment and decreasing abdominal compression," says Dr. Liu. "That's how you keep intraoperative blood loss to a minimum."

Radiolucent tables are critical both clinically and in terms of efficiency, because patients' extremities, once positioned, don't have to be moved to produce clear images. The Wilson frame, says Dr. Liu, not only provides 360 degrees of radiolucency, it "allows the abdomen to be free and not compressed, which decreases intra-abdominal pressure and thereby venous engorgement and blood loss." Specially designed tables that allow ideal spine alignment for fusions, along with easy access for imaging, navigation and robotics access are also game-changers, says Dr. Liu.

STAYING PUT A special underbody pad absorbs perspiration, which helps keep patients in the Trendelenburg position from sliding.

Added versatility
Some newer attachments have advanced to where they enable budget-conscious, multi-specialty centers to transform basic surgical surfaces into OR centerpieces that match the performance of expensive specialty tables. That cost-effective versatility can accommodate various positioning requirements multi-specialty facilities must have to host a variety of procedures that are often performed in the same operating room on different days, points out Dr. Masonis. "Surgery centers may struggle to justify the kind of capital expense needed for more complex tables and usually have some space restrictions," he says.

Versatile attachments encase the feet in individual "ski boots," and allow the patient's legs to be adjusted and rigidly fixed in exactly the position the surgeon needs. "Whether you're doing orthopedic surgery, Ob-gyn, or urologic procedures — any scenario where you're trying to manipulate extremities and you may need to move them independently of one another and lock them there — these kinds of accessories can certainly be an advantage," says Dr. Masonis.

Not only are the attachments considerably less expensive than full-sized tables, they're also very portable. "They can be moved from operating room to operating room, and from surgery center to surgery center," he says.

There was a time that surgeons had to depend on help from OR staff to secure retractors during surgery. Newer attachments that do the job instead not only free up staff to concentrate on other more important clinical responsibilities, they come in especially handy if you're short-staffed.

"A stable platform that can hold a retractor exactly where you want it held and without having another individual in the operating room, or the added expense of an assistant can be a big benefit," says Dr. Masonis.

First, do no harm
Positioning-related pressure ulcers and nerve injuries weren't an issue at the Women's Division of the Voorhees (N.J.) OR & Endoscopy Units, but Lis Digneo, BSN, RN, CNOR, the facility's nurse director, still decided to review the latest evidence-based recommendations to ensure their run of patient safety success continued.

"Our primary concern was inconsistency," says Ms. Digneo, the facility's nurse director. "Multiple surgeons and different circulators were using different positioning practices. Of course we also wanted to decrease the potential for having pressure ulcers develop during surgery." It wasn't something her staff had been having a problem with, and she wanted to keep it that way.

A team made up of RNs, surgical techs, nursing aides and a CRNA ended up recommending several changes to protect bony prominences and vulnerable pressure points:

Provide ankle support. The team realized that patients on their backs were vulnerable to pressure ulcers, because their ankles were being allowed to rest on OR tables and beds and weren't being elevated. "That was a change in practice," says Ms. Digneo. "We now have gel supports that we place under patients' ankles to take their feet off the bed."

Look out for lithotomy. Patients positioned in stirrups are potentially vulnerable in a couple of ways, the team found. One solution was to equip tables with larger boots that accommodate, support and protect the ankles and calves of larger patients placed in the stirrups, eliminating the potential for spillover that could result in pressure sores. Staff members were also reminded about the dangers of hyperextension and nerve injuries.

Prevent slippage. The team also noted that patient warming sometimes caused patients to perspire, which made them more likely to slide when in the Trendelenburg position and potentially experience shearing. Plenty of pads, restraints and bolsters are designed to secure patients in Trendelenburg, including an underbody pad that Ms. Digneo says helps absorb perspiration and keep patients from slipping and sliding.

SOFT TOUCH Using gel pads to support a patient's heels and ankles can prevent pressure ulcers on a vulnerable part of the body.

Avoid friction injuries. The team also decided against using foam egg crates, except to protect patients' arms under certain specific circumstances — the concern being that "where egg crates are touching the body can cause breakdowns in the skin and pressure ulcers," says Ms. Digneo.

Skin in the game
Surgeons must take responsibility to show their OR teams exactly how they like patients placed for each procedure, but once surgery is underway, the entire surgical team needs to constantly monitor the patient to ensure pressure points are free of excessive forces that can cause skin injuries or nerve damage.

For example, during ACL repairs, the knee must be positioned in such a way that surgeons have access to the lateral meniscus and the medial meniscus, while obtaining enough flexion to place the drill at the correct angle.

Positioning patients for shoulder procedures is also difficult, because surgeons are working within tight spaces next to the patient's head and airway. Obese patients can also be a challenge, because they have more soft tissue, which makes it harder to optimize joint access using positioning aids.

Ultimately, patient positioning can make or break any procedure. Along with providing the right instruments and accessories, remind your staff that focusing on proper patient positioning keeps patients safe and gives surgeons room to maneuver for successful outcomes. OSM