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April 25, 2024
Growing demand for anesthesia services at ASCs is being met with a dwindling supply of anesthesia providers....
FIRM HOLD Several restraints have been developed to keep patients from shifting or sliding while they're in a steep head-down tilt.The patient is intubated and in stirrups. Before you drape and tilt the table into Trendelenburg, remember that if a patient in tilt shifts or slides even a few centimeters on the OR table, a long list of serious injuries much more severe than sheared skin can occur. Some examples:
- Shoulder restraints can compress or stretch the brachial plexus, with subsequent palsy, which can be permanent.
- Stirrup posts can crush hands, pinch fingers, and bend wrists backward or forward.
- The head-down tilt can raise intraocular pressure and intensify glaucoma.
- Abdominal organs pushing toward the chest can lean so heavily on the lungs that they can't expand enough to oxygenate the blood, resulting in the so-called V/Q mismatch.
- And then there's "meat hooking," the new risk brought on by robotic-assisted laparoscopy. When a patient slides on the table while robotic arms are buried deep inside the trocars, the trocar sites act as meat hooks, restraining the patient by the abdominal wall against gravity's pull. This can cause painful incisional tears, hernias and necrosis at the camera port.
1. Shoulder bumps, not braces. Shoulder braces used to be the size of cinder blocks — and as unyielding. They were effective at keeping patients from sliding, but they'd often cause brachial plexus injuries because they'd force so much weight and pressure on the clavicle. Now they're called shoulder bumps. They're shorter and shaped like half moons, meant to stabilize the patient, not completely stop him and stretch out the brachial plexus. Bumps don't come all the way over the shoulders; you just tuck them under the shoulders. Another raised half-roll section of foam (resembling a speed bump) fits in the contour of the patient's neck, bumping up against the trapezius muscle.
ARM POSITIONING If you need to abduct the patient's arm for the case, do not exceed 90 degrees.2. Protect patients' hands. Be careful how you tuck the arms of patients in Trendelenburg (see "Tuck the Draw Sheet to Safely Secure Arms"). You can easily injure your patient's hands and arms — and an anesthetized patient can't tell you his hand's being crushed or his wrist is being bent backwards. If you put the arms on arm boards and the patient slides, that can put a lot of pressure on the brachial plexus and lead to neuromuscular injuries. Use arm boards at less than 90 degrees when possible to avoid hand and arm injuries.
When you tuck the arms, pad the hands and wrist and be sure to note the position of the hands under the drapes when you move the stirrups. If a patient is tilted to the right or left or starts to slide, his hands can become wedged between his outer thigh and the stirrup post, causing a crush injury. If sliding occurs in stirrups, be sure to alleviate pressure on the peroneal nerve.
TERRIBLE TILTS
No Need to Go MacGyver
A patient in Trendelenburg can inspire creative and curious positioning ploys at the OR table. There's so-called gift wrapping, when you cover patients in layers of eggcrate foam and yards of tape. Some ORs use Ace bandages to tie the patient's feet and lower leg into the stirrup boot. Others use belts, straps, bean bags and gel pads to secure patients — alone or in combination. Some say these efforts are only slightly better than the original method of keeping the patient in a tilted position: an assistant standing at the foot of the operating table with the patient's legs draped over his shoulders.
3. Less can be more. Trendelenburg is all about giving the surgeon better visualization and exposure. But some anatomy, like the rectum and the sigmoid, are independent of gravity, so a 40-degree tilt may be no more beneficial than 20 degrees. Some surgeons think the steeper the tilt, the better the exposure. That's not always the case with fixed anatomy. Fewer degrees of tilt can result in acceptable operative exposure with fewer negative consequences.
4. Respiration. Ventilating patients in Trendelenburg is challenging, because the gut is pushing against the diaphragm, making it difficult for people to breathe, especially obese patients. A complication known as V/Q mismatch is not uncommon. V/Q mismatch is a defect that occurs in the lungs whereby ventilation and perfusion are not evenly matched. The head-down tilt causes so much pressure on the lungs they can't expand enough to oxygenate the blood. If you hear anesthesia say, We've got to level back out. I can't ventilate very well, think V/Q mismatch."
5. Tilt test. Here's a quick step you can take before every Trendelenburg case to assure patient safety. I call it a "test run." Before you drape, bring the patient from supine into the full operative degree of Trendelenburg and hold for a 5-count to see if the restraint technology will prevent the patient from sliding. There's nothing worse than draping out the patient and getting him into Trendelenburg, only to realize that he's sliding. No sliding virtually guarantees safe positioning. OSM
SPEED-BUMP METHOD
How This Hospital Stopped Patients From Sliding
SECURE HOLD The speed-bump method of patient positioning uses a piece of foam that fits the contour of the patient's neck bumps up against the trapezius muscle.The OR team at the University of Michigan Health System tried everything to prevent its OB/GYN patients from sliding: eggcrate foam, gel pads, shoulder braces and bean bags as positioning devices. Nothing really worked.
"Despite our best efforts, we still experienced head movement in some patients," reports Jan Barber, BSN, RN, the University of Michigan Health System's service educator for gynecology/urology in a poster presentation. One patient, she said, slid 3 cm.
Their solution: the speed-bump method. Here's how it works. First, secure a frame covered with Velcro to the rails on the OR bed. Then, position the patient with 4 pieces of foam that attach to the frame. One of the pieces of foam has a raised half-roll section that resembles a speed bump. Place the speed bump in the contour of the patient's neck, bumping up against the trapezius muscle. Place another piece of foam under the patient's head to stabilize side-to-side movement. Place the last 2 pieces of foam lightly next to each shoulder at a 45-degree angle. "These function not as shoulder braces, but as lateral stabilizers," says Ms. Barber.
To increase the friction surface, Ms. Barber used the concavities of the patient's back. Shaped like half moons, these so-called speed bumps fit into the curves of the neck, lumbar spine and lower calves. They're covered with corrugated rubber so they interlock with the ribs of the underlying mattress, giving a cog-wheel effect.
"The steeper the tilt, the more firmly they'll hold," says Ms. Barber. "If you correctly place the bolsters, it's virtually impossible for a patient to slip in the maximum tilt of which most tables are capable — about 50 degrees."
During a 10-month period in which they performed 503 laparoscopic and gynecological cases with patients inclined to steep Trendelenburg at a 30- to 40-degree angle, "no patient slid on the OR bed and there have been no skin shearing or brachial plexus injuries," says Ms. Barber.
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