A patient becomes increasingly dependent on those around them during the perioperative period. Anesthesia prevents patients from being able to protect themselves against danger. Correct patient positioning is essential for maximum surgical exposure whilst taking into consideration the patients safety and comfort. All members of the surgical team should be responsible for protecting the patient from injury during positioning.

Guidance should always be sought from appropriate team members to ensure specific needs are met when providing safe patient care.

It is important to realise if you do not ask for assistance when undertaking a difficult positioning task or are unsure you may be held negligent.

Factors that determine the position include:

The type of operation

The site of the injury or lesion

The surgical approach

The age, weight, height and general condition of the patient

Goals of patient positioning

◦To provide optimal exposure to the surgical site

◦To maintain good body alignment

◦To maintain circulatory and respiratory function

◦To protect nerve and skin integrity

Factors to consider when positioning:

◦All table fittings and accessories should be in theatre prior to commencement of surgery.

◦Evaluate the patient's skin condition and integrity. Pad all bony prominences to prevent any skin damage including head rings, gel heel pads.

◦No part of the patient should come in contact with the operating table or fittings.

◦Always gain the anesthetist's permission before positioning the patient.

◦Friction or pressure may cause patient injury. Patient circulation should not be obstructed by an awkward position, pressure on any part of the patients body may come from equipment resting against their body including such things as the mayo stand, lithotomy stirrups.

◦Ensure enough personnel are available before moving the patient.

◦Any abnormalities or defects are given special attention when positioning, for example; spinal injuries, previous hip surgery.

◦The arms should not be abducted more than 90 degrees; this can cause severe permanent nerve damage.

◦The patient should not be left in a pool of fluid, such as prep solution or blood as this area of skin becomes more vulnerable to pressure ulcers, or possible diathermy burns,

◦It may be necessary to modify a patient's position to suit the range of movement their body can accommodate.

Transferring an unconscious patient:

◦Ensure the patient's limbs are aligned with their body, and their neck and head is guarded from injury, the anaesthetist will support the patient's airway on transfer.

◦The patient's body should be lifted and turned in one smooth motion.

◦The pat slide should be used with a verbal count to ensure the team starts the patient transfer together.

◦Check that all drains catheters, infusion lines are in view and moved with the patient,

◦Ensure enough help is available prior to moving the patient.

The most common positions used for operative procedures include the patient lying on their back (supine), on their abdomen (prone) or on their side (lateral) Less commonly a sitting position (fowler) is used.

Supine Position:

The patient lies flat on their back in the supine (dorsal) position with arms either at their side, placed on armboards, or folded on their chest. It is the most common position for surgery and is the position most patients will be anaesthetised in. Access to major body organs is allowed in this position.

Sometimes the patient's legs need to be flexed into a 'frog-like' position to provide access to the groin, the thighs are externally rotated and knees are flexed with a pillow to support each leg. This position may be used to harvest a vein graft for coronary bypass surgery.

The patients blood supply may be compromised in this position due to many factors. Pregnant women and obese patients may suffer from the extra weight they are carrying. When positioning a patient for a cesarean section, a wedge should be placed under the patient's right side to tilt them ensuring pressure is taken off the patient major blood vessel to their heart (Vena Cava).

Vulnerable areas to pressure ulcers would include; the back of the head (occiput), shoulder (scapular), elbow (olecranon), tailbone (sacrum and coccyx) and heel (calcaneus).

Variations of this procedure include:

1.Lateral tilt.

2.Trendelenberg for pelvic operations, and reverse trendelenberg for thyroid surgery.

3.Lithotomy for vaginal and rectal operations, abdominoperitioneal resection, and laparoscopic procedures.

Lithotomy Position:

This position is used for a variety of surgical procedures including urological, gynaecological, and rectal operations. The patient is moved from a supine position and slid down the bed, the legs are raised and abducted (rotated outwards) to expose the perineal region. The legs are held in place with the use of stirrups.

The stirrups/lithotomy poles should be checked before use to ensure they will be able to be securely fastened to the operating table. If the stirrups were to slip nerve and muscle injury or bone fractures may occur.

The stirrups should be symmetrically placed on the OR table.

Both legs should be raised simultaneously to prevent any strain on the patient's lower back. Two people are required to lift both legs, the foot should be held by one hand and the calf held close to the knee with the other. Legs should be raised and flexed in a gentle, slow motion.

Once the legs have been secured into the stirrups, the mattress and lower part of the bed needs to be removed. The buttocks should be even with the lip of the OR table this reduces any risk of damage to the patients lower back area.

Extreme caution should be taken to prevent fingers being caught in the brake of the bed, and also when the lower section of the bed is elevated back into the horizontal position. The

patient's arms should be placed at their side, placed on armboards or placed across their abdomen.

Pressure on the nerve may cause footdrop and other long term problems; padding should be used to prevent this. The surgeon should be consulted if you are unsure of this position.

When returning the patient's leg to their horizontal position, they need to be lowered simultaneously to prevent any strain on the lower back. The legs should be moved slowly to allow time for the blood circulation to adjust to the change in position.

Prone Position:

In this position the patient is lying on their abdomen. It is used specifically for operations to the back, and rectal areas.

The patient is anaesthetised on their bed in the supine position. Turning the patient safely onto the prone position can be achieved safely by using enough people to aid in the transfer; four or more people may use the 'log-roll' technique. The OR table and patients bed should have their brakes on. One person should be on either side of the beds, the anesthetist should take the head and neck area and on other person supporting the patient's legs.

The arms should either be secured by the patient's side, or placed on arm boards. Extra padding should be available to prevent damage and pressure. The arms should not be allowed to hang over the side of the table as the radial nerve may be compressed by leaning on the operating bedside rails. The head should be turned and positioned in a way that keeps the neck in alignment, a foam pillow may be used.

Occasionally a laminectomy frame may be used. This type of device allows the diaphragm to move more freely and the lungs to expand, female breasts and male genitalia should be

checked to ensure there is not pressure on them. A cushion should be placed under the ankles to prevent any pressure on the toes. A specific operating table may be used with the addition of a hip/leg supports. Returning the patient back to a supine position requires four people to adequately support the patient back onto their bed using the log roll manoeuvre. The patients skin should be checked on all pressure points.

Lateral Position:

In this position the patient lies on their non-operative side. The patient's lower arm needs to be extended, slightly flexed on an armboard. The upper arm is either placed on an arm rest support on a pillow across their chest. Depending on the type of surgery, the lower leg will either be flexed or straight and the other leg the opposite. A pillow between the knees will help relieve any pressure. Extra supports may be attached to secure the patient into position; a safety strap/wide tape may be used around the patient's hips and under the operating table. Pressure points should be protected with padding. This position is used for operations on the thorax, kidneys and ureters.