Positioning (Pressure Injury Prevention and Tourniquet Safety)

Guidelines:

• Positioning patients is one of the most important tasks and is the responsibility of all members of the surgical team.
• Goals of patient positioning:
  • Providing exposure of the surgical site
  • Maintaining patient’s comfort and privacy
  • Providing access to intravenous lines and monitoring equipment
  •  Allowing for optimal ventilation by maintaining a patent airway and avoiding constriction or pressure on the chest or
    abdomen
  •  Maintaining circulation and protecting muscles, nerves, and bony prominences, joints, skin, eyes, and vital organs from injury
  •  Observing and protecting fingers, toes, and genitals
  •  Stabilizing to prevent unintended shifting or movement
• Goals of pneumatic tourniquet:
  • Obtain a near bloodless field during extremity surgeries
  •  Confine a bolus of intravenous regional anesthesia in an extremity

Considerations:

• Proper positioning and body alignment to prevent pressure injuries:
  • SUPINE: the patient’s knees should be flexed approximately 5-10 degrees. The patient’s heels should be elevated off the underlying surface using a heel suspension device or a wide, pressure redistributing surface
    • Prevents popliteal vein compression and reduces risk for DVT
    • Don’t place pressure on Achilles tendon with heel-suspension
  • TRENDELENBURG: Supine variation. Shortest time possible, minimize the degree of Trendelenburg position as much as possible
    • Decreases the potential for complications or patient injury
    • Retinal detachment and blindness may result from prolonged use of steep Trendelenburg position
  • LITHOTOMY: shortest time possible, repositioned at established intervals during procedures
    • The longer the patient’s legs are maintained in lithotomy, the greater the potential for developing neuropathy, neurovascular complication, or compartment syndrome
  • PRONE: Shortest time possible. Patients in prone position should be positioned 5-10 degree reverse Trendelenburg, if possible.
    •  Intraocular pressure increases in the anesthetized patient in the prone position
    • The magnitude of this increase is related to the amount of time spent in the prone position
    •  Positioning surgical patients with the head above the heart helps reduce venous congestion in the eye and orbit and decrease intraocular and intraorbital pressure
• Pneumatic Tourniquet
  • Some patient conditions increase risk for complications associated with pneumatic tourniquet use
    • Diabetic neuropathy
    • Previous revascularization
    •  Sickle cell anemia
    • Severe infection
    • History or current VTE
    • High BMI
    • Low preop Hemoglobin
    • AV grafts or fistulas
    • Peripheral vascular disease (PVD)
    • Malignancy
    • Open fracture
    • Severe crushing injuries
    • Severe scar tissue at cuff location
• IFU may specify contraindications for tourniquet use
• Assessment/Diagnosis/Outcome Identification
  • Conduct preoperative, intraoperative, and postoperative nursing assessments specific to patient positioning
  • Understand the physiologic changes that occur during operative and invasive procedures
  • Evaluating the patient’s risk for injury based on an assessment of identified needs and the planned operative or invasive procedure
  • Anticipating the surgeon’s requirement for surgical access (site, laterality, etc)
  • Respecting the patient’s individual positioning limitations
• Planning/Implementation/Evaluation
  • Identify, select, use, and maintain positioning equipment and devices
  • Use neurophysiological monitoring to identify and prevent potential positioning injuries
  • Implement interventions to provide for patient’s comfort and safety and to protect the patient’s circulatory, respiratory, musculoskeletal, neurological, and integumentary structures
  • Prophylactic dressing may be applied to bony prominences (heels, sacrum) or other areas subjected to pressure, friction, and shear
  • Support the activities of the anesthesia professional
  • Implement safe practices for positioning patients in the supine, Trendelenburg, prone, reverse Trendelenburg, lithotomy, sitting and semi-sitting, and lateral positions and modifications of these position
  • Documenting patient positioning and positioning-related activities
  • Include in team communication
• Follow manufacturer’s IFU and organization policies/procedures related to positioning and pneumatic tourniquet use in the OR
•  Document care and be specific about positioning, padding, repositioning, evaluation, etc.
• Communicate positioning clearly and frequently to the interprofessional team. Include relevant information in handover reports. Include in briefing, time-out, debriefing as warranted.
•  Report device or positioning related injuries

Pitfalls:

• Incorrect positioning and tourniquet application can result in serious injury
•  Primary cause of pressure injuries is sustained cell and tissue deformation
•  Surgical patients are at increased risk for positioning injury because of the effects of anesthesia and the lack of normal perception and protective reflexes
• Frequent re-evaluation and team communication is key to patient safety

Examples:

• Da Vinci’s Vitruvian Man

Linchpins (Key Points):

• The risk for injury is multifactorial and may be related to the patient’s condition as well as the position
•  Many positioning injuries are associated with prolonged procedures
• Surgical positioning creates a risk for skin breakdown and pressure injury development
• Nursing interventions can prevent positioning injuries