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Avoid These 5 Patient Positioning Disasters
From pressure ulcers to vision loss, don't let positioning problems happen on your watch.
Kendal Gapinski
Publish Date: March 31, 2015   |  Tags:   Patient Safety
prone position patient PRONE TO INJURY Prone position carries with it several potential complications, including perioperative vision loss.

Poor patient positioning can lead to devastating consequences. While some complications are unavoidable, there are plenty of ways to reduce your risk. Check out these 5 real-life patient positioning disasters and experts' advice on how to prevent them.

1. Pressure ulcers
A 78-year-old man — who was 6-foot-2 and 250 lbs. — with Parkinson's disease was placed in supine position for a cholecystectomy. His Parkinson's, along with his large and heavy legs, made movement difficult. After surgery, he developed blisters on his heels that progressed to full-thickness wounds. After a delayed discharge from the hospital, the man was sent to a wound care center for 4 months until the pressure ulcers healed.

heels in supine position AVOID DISASTERS Be sure to float a patient's heels in supine position to avoid pressure ulcers.

"The simple answer is his heels should have been elevated," says Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN-R, PLNC, a perioperative nursing specialist for AORN. But it often takes more than that to prevent pressure ulcers. Prevention requires a multi-factor approach, she says, including a skin assessment and proper use of positioning devices to prevent skin breakdown.

Brent Klev, MBA, BSN, RN, surgical services nurse manager for South Jordan Health Center at the University of Utah, says every patient at your facility — even those undergoing short procedures — should have a pre-op skin assessment. The assessment should use the Braden Scale and look at such risk factors as an age older than 70, vascular disease or diabetes, an operation longer than 4 hours, or a patient who is thin or malnourished.

If a patient is found to be at risk, Mr. Klev says staff should pad all bony surfaces, including floating the patient's heels. For those deemed high-risk, Mr. Klev suggests using a fluid mattress overlay on the OR bed and placing a foam sacral dressing on patients. Ms. Van Wicklin recommends using gel positioning devices, which distribute pressure better.

2. Perioperative vision loss
An obese man was scheduled to undergo back surgery. He was placed in the prone position and under general anesthesia for the procedure, which unexpectedly lasted 9 hours. When the man awoke from surgery, he had lost his vision. The man sued, eventually winning a $21.8 million verdict.

The most common cause of perioperative visual loss is ischemic optic neuropathy, which may be attributed to perioperative anemia, blood loss, hypotension, poor positioning, lack of monitoring and prolonged surgery, says William Landess, CRNA, MS, JD, corporate director of anesthesia services at Palmetto Health in Columbia, S.C.

While patients with glaucoma, diabetes or obesity may be at a higher risk for vision loss, there is currently no pre-operative screening test for ischemic optic neuropathy, since its causes are still largely unknown. Ms. Van Wicklin says it's not a common incident, but perioperative vision loss "is a risk—" especially in prone, beach chair and Trendelenburg positions.

Only use the prone position when it's necessary for a surgeon to obtain good exposure, the experts say. Mr. Klev notes that in the position, the patient's head must be kept in a neutral position, typically by using a foam headrest. Your staff must be diligent in using the headrest correctly, he says. If using a popular style that features a 'T' cutout, patients' eyes should be resting in the opening of the top of the 'T' to prevent pressure on the eyes.

Additionally, Mr. Klev notes you should limit the use of foam eye protector "goggles," which can shift during surgery in the prone position and place pressure on eyes. Your best bet, says Mr. Klev, is a headrest that uses a mirror attachment, so your anesthesia provider can conduct and record eye checks every 15 to 20 minutes.

3. Brachial plexus injury
After undergoing an open-heart procedure that lasted 5 hours, a man woke up to find his right hand and arm numb. Nurses documented that his right arm was bruised and swollen, and he was eventually diagnosed with a brachial plexus injury. While the hospital argued in court the injuries were caused internally during the procedure, experts believed the injuries occurred from improper or inadequate padding, or someone leaning against the patient's arm during surgery.

Brachial plexus injuries are some of the most common injuries associated with patient positioning, says Mr. Landess. The injury is common in nearly all positions, he says, but is especially "notorious" in supine and prone position. It's often caused by a stretching of the brachial plexus, a network of nerves that runs from the spine to the shoulders, arms and hands.

position the head firmly HEADREST Use tape to position the head firmly against the gel pad in the headrest.

One of the best ways to prevent the injury is to avoid stretching the arms in order to place them on arm boards flexed beyond 90 degrees away from the body, says Ms. Van Wicklin. She also says that during positioning, staff should avoid extreme rotation of the head and should ensure that all pressure points are properly padded, especially around the head, shoulders and elbows, to avoid a nerve injury.

Additionally, as may have been the case above, a staff member leaning on a patient can cause injury. That's more common than you think, says Mr. Landess, and can be easily prevented. Encourage OR staff to remain alert and speak up if they see something that's putting undue pressure on the patient. "Often it is a battle between the comfort of the surgeon and the comfort of the patient," says Mr. Landess. "With staff advocacy, the patient wins."

4. Skin and nerve injury in Trendelenburg position
A 65-year-old man underwent a robotic prostatectomy. The man was placed into lithotomy position and then tilted back into Trendelenburg position with his arms tucked to the side and hands insulated with foam pads. The surgery unexpectedly lasted for 6 hours. In PACU, his head and face were swollen. His arms had marks and blisters from the straps securing him and from the blood pressure cuff. He experienced long-term numbness and tingling in his arms and hands.

positioning non-operative extremities\ Positioning non-operative extremities is as important as the operative ones.

While Trendelenburg is a useful position, since it gives the surgeon better visualization and exposure, it is "very tricky," says Ms. Van Wicklin. The most common problem is patient sliding, she says, which can cause shearing or put undue pressure on extremities.

To help avoid this, positioning devices and tables can make a big difference. Mr. Klev's facility recently invested in a special Trendelenburg positioner "which has stopped all sliding issues." Look for new positioners made of material that molds to patients' bodies, helping them stay secure while reducing pressure on pressure points. If not using a special positioner, Ms. Van Wicklin says staff should check that straps or tape used to secure the patient, as well as BP cuffs, are tight enough to do their job without cutting into the patient's skin. "It's a fine balance," she says. Additionally, shoulder braces should not be used to secure patients, since they can cause brachial plexus injuries.

Mr. Landess notes that there are other complications with Trendelenburg besides sliding. Cardiovascular and pulmonary problems are common with the position, as well as perioperative vision loss. To help prevent these complications, consider regularly "flattening" the patient, or slowly elevating his head. This should be done as frequently as the surgeon and procedure allow, says Mr. Landess.

5. Beach chair position complications
A North Carolina man underwent a right shoulder arthroscopy and right open rotator cuff repair and was placed in the beach chair position. After surgery, he woke up and reported pain in his left arm, elbow and fingers believed to be from improper positioning and inadequate padding of the non-operative arm. He was eventually diagnosed with ulnar nerve neuropathy, which left him with permanent daily pain.

Positioning non-operative extremities is as important as the operative ones, says Mr. Klev. To prevent nerve injury, it's important that the patient's arms are secured in a neutral position, he says, and that padding is placed behind the non-operative shoulder to relieve stretching of the brachial plexus. Mr. Landess notes that the non-operative arm should be flexed at the elbow at 90 degrees, with the forearm in a neutral or slightly supine position. Additionally, there should be sufficient staff available to ensure that the patient's head isn't lifted too quickly.

Nerve injury isn't your only concern in beach chair, says Ms. Van Wicklin. Since the patient's head is elevated and feet are lowered, there is an increased risk for poor venous return. She suggests repositioning after 4 hours, if possible, and considering sequential compression devices for patients at risk for vascular complications. Mr. Klev notes that research has shown high blood pressure is also something to carefully monitor. "A patient is more likely to stroke in this position than have a nerve injury," he says.