The importance of correct patient positioning in theatres and implications of mal-positioning

Impact of Surgical Table Orientation on Flow Disruptions and Movement Patterns during Pediatric Outpatient Surgeries

(1) Background: The surgical table within a typical ambulatory surgery operating room is frequently rotated and placed in different orientations to facilitate surgery or in response to surgeon preferences. However, different surgical table orientations can impact access to different work zones, areas and equipment in the OR, potentially impacting workflow of surgical team members and creating patient safety risks; (2) Methods: This quantitative observational study used a convenience sample of 38 video recordings of the intraoperative phase of pediatric outpatient surgeries to study the impacts of surgical table orientation on flow disruptions (FDs), number of contacts between team members and distance traveled; (3) Results: This study found that the orientation of the surgical table significantly influenced staff workflow and movement in the OR with an angled surgical table orientation being least disruptive to surgical work. The anesthesia provider, scrub nurse and circulating nurse experienced more FDs compared to the surgeon; (4) Conclusions: The orientation of the surgical table matters, and clinicians and architects must consider different design and operational strategies to support optimal table orientation in the OR.

Anesthetic considerations in patients with implantable devices and chronic pain surgery

The use of advanced invasive techniques for the control of chronic pain in patients with multiple comorbidities is becoming increasingly common. Neuromodulation offers a new management alternative involving the infusion of one or more drugs into the epidural or intrathecal space through a fully implantable infusion pump. It also involves spinal stimulation, a minimally invasive technique in which electrodes are positioned in the epidural space and connected to a pulse generator that is implanted subcutaneously and generates pulses designed to suppress the noxious stimulus. This article will describe the anesthetic considerations in cases of implantable drug delivery systems, and spinal and peripheral nerve stimulation devices. Additionally, patients with electrical or drug neuromodulation devices may present to anesthetic practice for surgical indications unrelated to their chronic pain pathology. Hence the importance of being familiar with the basic components of these devices, how they work, what drugs they use and the potential associated complications in the perioperative context, in order to ensure proper management and patient safety.

Perioperative management of positioning in gynecological cancersurgery: a national NOGGO-AGO intergroup survey

INTRODUCTION

The daily clinical routine in the operating room includes patient positioning. The number of perioperative positioning-related complications is growing, along with the legal proceedings concerning this topic, and only a few guidelines exist to provide specific recommendations. The aim of this survey was to assess perioperative positioning and associated adverse events during gynecological cancer surgery in Germany.

METHODS

A total of 633 gynecological departments of primary, secondary, and maximum healthcare hospitals in Germany were invited to participate in this multiple-choice online questionnaire. The survey was conducted anonymously for a period of six months. The survey was divided into five different sections: descriptive information about the respondent department, pre- and postoperative management, management of positioning in the operating room based on two fictional case examples, and quality management.

RESULTS

The response rate of our survey was 29.1 % (184/633). Nearly half of the departments (46.7 %) reported to have had one to five patients with positioning-related complications during the prior 12 months, and 29.1 % had experienced a legal dispute due to positioning-related complications. Departments with more than 50 gynecologic-oncological surgeries per year more often reported positioning-related complications (p=0.003). Standard operating procedures exist in almost every department for laparoscopic (97 %) and open surgery (95.1 %), respectively.

DISCUSSION

The high number of positioning-related complications throughout all departments of different healthcare levels underlines the relevance of this issue and supports the need for a prospective European registry for further analysis. Training and education for all staff members should be routinely implemented to reduce and prevent positioning-related complications.

Perioperative teamwork for the patient with a shared airway: a case study

Teamwork is an essential element of perioperative care. Shared airway surgery requires additional considerations for the perioperative team. This article analyses a case study of a patient undergoing thyroid surgery. Whilst the anaesthetic team is responsible for maintaining the patient's airway, the theatre and surgical teams have their own individual roles to assist in airway management and surgical care.

Evaluation of operating room reverse Trendelenburg positioning and its effect on postoperative hypoxemia, aspiration, and length of stay: a retrospective study of consecutive patients

Background

In 2014, this group published an investigation of surgical patients from 2012 who had substantial rates of postoperative hypoxemia (POH) and perioperative pulmonary aspiration (POPA). Therefore, we investigated whether intraoperative reverse Trendelenburg positioning (RTP) decreases POH and POPA rates.

Methods

Consecutive ASA I–IV surgical patients who had preoperative pulmonary stability requiring general anesthesia with endotracheal intubation were evaluated. Using pulse oximetry, hypoxemia was documented intraoperatively and during the 48 h following PACU discharge. POPA was the presence of a pulmonary infiltrate with hypoxemia. In early 2015, a multifaceted effort was undertaken to enhance anesthesiologist and operating nurse awareness of RTP to potentially decrease POH and POPA rates. Analyses included (1) combining 2012 and 2015 cohorts to assess risk conditions, (2) comparing post-campaign 2015 (increased RTP) and 2012 cohorts, and (3) comparing 2015 patients with audit-documented RTP during surgery to the other 2015 patients.

Results

Combining the 500 patients in 2012 with the 1000 in 2015 showed that POH had increased mortality (2.3%), compared to no POH (0.2%; p = 0.0004). POH had increased postoperative length of stay (LOS) (4.6 days), compared to no POH (2.0 days; p < 0.0001). POPA had increased mortality (7.7%) and LOS (8.8 days), compared to no POPA (0.4%; p = 0.0004; 2.3 days; p < 0.0001). Open aortic, cranial, laparotomy, and neck procedures had greater POH (41.3%) and LOS (4.0 days), compared to other procedures (16.3%; p < 0.0001; 2.2 days; p < 0.0001). Glycopyrrolate on induction had lower POH (17.4%) and LOS (1.9 days), compared to no glycopyrrolate (21.6%; p = 0.0849; 2.7 days; p < 0.0001). POH was lower (18.1%) in 2015, than in 2012 (25.6%; p = 0.0007). POPA was lower with RTP in 2015 (0.6%), than in 2012 (4.8%; p = 0.0088). For the 2015 patients, LOS was lower with audit-documented RTP (2.2 days), compared to other patients (2.7 days; p = 0.0246).

Conclusions

These findings are only hypothesis-generating. A randomized clinical trial is needed to confirm whether RTP has an inverse association with POH and POPA, and if RTP and glycopyrrolate are associated with improved outcomes.

Trial registration

ClinicalTrials.gov, NCT02984657

Retrospective review of predisposing factors for intraoperative pressure ulcer development

STUDY OBJECTIVE

To evaluate the comorbidities and surgical factors involved in the genesis of intraoperative pressure ulcers.

DESIGN

Retrospective chart review.

SETTING

Anesthesiology department of a university medical center.

MEASUREMENTS

The charts of 222 patients with varying illness, who underwent an operation of at least two hours' duration, were analyzed retrospectively. Data on surgery type, case length, comorbidities, intraoperative surgical position, and area of ulceration were recorded.

MAIN RESULTS

Risk factors for intraoperative pressure ulcer development include surgical times of 4 hours or longer; comorbidities affecting tissue perfusion (namely, diabetes, hypertension, and nonspecific cardiac issues); supine placement during surgery; and abdominal, noncardiac thoracic, and orthopedic operations. Regions of the body most at risk for ulceration include the coccygeal/sacral region, the buttocks, genitalia, and heels.

CONCLUSIONS

Pressure ulcers are a costly, debilitating, and avoidable complication of surgery.

Perioperative hypoxemia is common with horizontal positioning during general anesthesia and is associated with major adverse outcomes: a retrospective study of consecutive patients

Background

Reported perioperative pulmonary aspiration (POPA) rates have substantial variation. Perioperative hypoxemia (POH), a manifestation of POPA, has been infrequently studied beyond the PACU, for patients undergoing a diverse array of surgical procedures.

Methods

Consecutive adult patients with ASA I-IV and pre-operative pulmonary stability who underwent a surgical procedure requiring general anesthesia were investigated. Using pulse oximetry, POH was documented in the operating room and during the 48 hours following PACU discharge. POPA was the presence of an acute pulmonary infiltrate with POH.

Results

The 500 consecutive, eligible patients had operative body-positions of prone 13%, decubitus 8%, sitting 1%, and supine/lithotomy 78%, with standard practice of horizontal recumbency. POH was found in 150 (30%) patients. Post-operative stay with POH was 3.7 ± 4.7 days and without POH was 1.7 ± 2.3 days (p < 0.0001). POH rate varied from 14% to 58% among 11 of 12 operative procedure-categories. Conditions independently associated with POH (p < 0.05) were acute trauma, BMI, ASA level, glycopyrrolate administration, and duration of surgery. POPA occurred in 24 (4.8%) patients with higher mortality (8.3%), when compared to no POPA (0.2%; p = 0.0065). Post-operative stay was greater with POPA (7.7 ± 5.7 days), when compared to no POPA (2.0 ± 2.9 days; p = 0.0001). Conditions independently associated with POPA (p < 0.05) were cranial procedure, ASA level, and duration of surgery. POPA, acute trauma, duration of surgery, and inability to extubate in the OR were independently associated with post-operative stay (p < 0.05). POH, gastric dysmotility, acute trauma, cranial procedure, emergency procedure, and duration of surgery had independent correlations with post-operative length of stay (p < 0.05).

Conclusions

Adult surgical patients undergoing general anesthesia with horizontal recumbency have substantial POH and POPA rates. Hospital mortality was greater with POPA and post-operative stay was increased for POH and POPA. POH rates were noteworthy for virtually all categories of operative procedures and POH and POPA were independent predictors of post-operative length of stay. A study is needed to determine if modest reverse-Trendelenburg positioning during general anesthesia has a relationship with reduced POH and POPA rates.

Prone positioning for surgery

The role of the registered perioperative practitioner (Operating Department Practitioner or Registered Nurse) includes the responsibility for safely positioning patients for surgery. The prone position is in common use for a variety of surgical procedures. The formal term for this surgical position is ventral decubitus (meaning laying face down).

Anterior thigh compartment syndrome after prone positioning for lumbosacral fixation

We report a case of a patient who developed anterior thigh compartment syndrome after being positioned prone for instrumented lumbar spine surgery. Although rare, clinicians should be aware that compartment syndrome is a possible complication of spinal surgery.