ANESTHESIA POSITIONS

INTRODUCTION
 Positioning is the joint responsibility of the surgeon
&anesthesiologist.

 Ideal pt. positioning involves balancing surgical comfort, against

the risks related to the pt. position.

 Pt. positioning & postural limitation should be considered during

the PAC.

OVERVIEW
One must be aware of the anatomic and physiologic changes
associated with anesthesia, patient positioning, and the
procedure.

 The following criteria should be met to prevent injury from

pressure, obstruction, or stretching:

 No interference with respiration

 No interference with circulation
 No pressure on peripheral nerves
 Minimal skin pressure
 Accessibility to operative site
 Accessibility for anesthetic administration
 No undue musculoskeletal discomfort
 Maintenance of individual requirements

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 ASSESSMENT
 The team should assess the following prior to
positioning of the patient:

 Procedure length

 Surgeon's preference of position

 Required position for procedure

 Anesthesia to be administered

 Patient's risk factors

 age, weight, skin condition, mobility/limitations,

pre- existing conditions, airway etc.

 Patient's privacy and medical needs

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 GENERAL PHYSIOLOGICAL CONCERNS
CVS CONCERNS

In an awake patient postural changes doesn't cause

change in SBP

In anaesthesitised patient:

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 PULMONARY CONCERNS

 Any position which limits movements of

abdomen, chest wall or diaphragm increase
atelectasis and intrapulmonary shunt

 Change from standing to supine - decrease FRC

due to cephalad displacement of the diaphragm

BYBGICAL PQSITIONS
Four basic surgical
Variations include
positions include
1.Supine 1.Trendelenburg
2.Lateral 2.Reverse trendelenburg
3.Prone 3.Fowler's/semifowler
4.Lithotomy 4.Beach chair position
5.Wattson jone position
6.Position for robotic
surgeries

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 SUPINE
Most common with the least amount of harm

Placed on back with legs extended and uncrossed at the

ankles

Arms either on arm boards abducted <90* with palms up or

tucked (not touching metal or constricted(

Spinal column should be in alignment with legs parallel to

the OR bed

 Head in line with the spine and the face is upward

 Hips are parallel to the spine

Padding is placed under the head, arms, and heels with a

pillow placed under the knees

Safety belt placed 2" above the knees while not impeding
circulation

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 SUPINE CONCERNS
 Greatest concerns are circulation and pressure points

 Most Common Nerve Damage:

 Brachial Plexus: positioning the arm >90*

 Radial and Ulnar: compression against the OR bed,

metal attachments, or when team members lean
against the arms during the procedure

 Peroneal and Tibial: Crossing of feet and plantar

flexion of ankles and feet

 Vulnerable Bony Prominences: (due to rubbing and

sustained pressure(

 Occiput,spine, scapula, Olecranon, Sacrum,

Calcaneous

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 TRENDELENBURG POSITION AND
REVERSE TRENDELENBURG
POSITION

TRENDELENBURG
The patient is placed in the supine position while the OR bed
is modified to a head-down tilt of 35 to 45 degrees resulting
in the head being lower than the pelvis

Arms are in a comfortable position either at the side or on

bilateral arm boards

The foot of the OR bed is lowered to a desired angle

ADVANTAGES
 To increase V.R after spinal anesthesia

 To increase central venous volume / prevent air embolism

/ facilitate central cannulation

 To minimise aspiration during regurgitation

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 TRENDELENBURG CONCERNS
 CVP
 ICP
 IOP

 myocardial work

 pulmonary venous pressure

 pulmonary compliance

 FRC

 Swelling of face, eyelids, conjunctiva , tongue, laryngeal edema observed in

long surgeries

REVERSE TRENDELENRURG

 The entire OR bed is tilted so the head is higher than the feet

 Used for head and neck, laproscopic procedures

 Facilitates exposure, aids in breathing and decreases blood supply to the

area

 A padded footboard is used to prevent the patient from sliding toward the
foot

 Reduces venous return therefore hypotension

 Laproscopic cholecystectomy : reverse trendelenburg position with right up

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 SUPINE POSITION__COMPLICAIONS
 Pressure alopecia
 Back ache
 Peripheral nerve injuries/ ASA

LITHOTOMY POSITION

LITHOTOMY
 With the patient in the supine position, the hips are flexed to 80-100 ° from
the torso so that legs are parallel to it and legs are abducted by 30-45 ° to
expose the perineal region

 The patient's buttocks are even with the lower break in the OR bed (to
prevent lumbosacral strain(

 The legs and feet are placed in stirrups that support the lower extremities

 The legs are raised, positioned, and lowered slowly and simultaneously,
with the permission of the anesthesia care provider

 Adequate padding and support for the legs/feet should eliminate pressure
on joints and nerve plexus

 The position must be symmetrical

 The perineum should be in line with the longitudinal axis of the OR bed

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LITHOTOMY POSITION WITH "CANDY
CANE" SUPPORTS

PHYSIOLOGICAL CHANGES
 Preload increases, causing a transient increase in
CO, cerebral venous and intracranial pressure

 Reduce lung compliance

 If obesity or a large abdominal mass is present

(tumor, gravid uterus)- VR to heart might decrease

 Normal lordotic curvature of the lumbar

spine is lost potentially aggravating any previous
lower back pain

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 NERVE INJURIES IN LITHOTOMY POSITION

LATEBAL
 Anesthetized in supine prior to turning

 Shoulder & hips turned simultaneously to prevent torsion of the

spine great vessels

 Lower leg is flexed at the hip; upper leg is

straight

 Head must be in cervical alignment with the spine

 Breasts and genitalia to be free from torsion and pressure

 Axillary roll placed caudal to axilla of the downside arm (to protect
brachial plexus(

 Padding placed under lower leg, to ankle and foot of upper leg, and
to lower arm (pálm up) and upper arm

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 Pillow placed lengthwise between leg and
between arms (if lateral arm holder is not
used(

 Stabilize patient with safety strap and silk

tape, if needed

 Pulse should be monitored in the dependent

arm for early detection of compression to axillary neurovascular
structures.

 Low saturation reading in pulse oximetry may be an early warning

of compromised circulation.

 When a kidney rest is used, it must be properly placed under the

dependent iliac crest to prevent inadvertent compression of the
inferior vena cava

PRONE POSITION
Access to the posterior fossa of the skull, the posterior spine, the
buttocks and perirectal area, and the lower extremities

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Arms tucked in the neutral position /placed next to the
patient's head on arm boards-sometimes called the prone
"superman" position/Extra padding under the elbow -
prevent ulnar nerve

When GA is planned, the patient is intubated on the

stretcher/ i.v access is obtained/ETT is well secured/pt is
turned prone onto the OT table/disconnect blood pressure
cuffs and arterial and venous lines that are on the side to
avoid dislodgment

disconnection of pulse oximetry,arterial line, and tracheal

tube, leading to hypoventilation, desaturation, hemodynamic
instability, and altered anesthetic depth. Therefore its best to
keep pulse oximetry and arterial line connected

ETT position is reassessed immediately after the move

Head position

 Turned to the side(45 degrees) if neck mobility is fine.

 Check the dependent eye for external compression.

 Maintained by surgical pillow, horseshoe headrest, or

Mayfield head pins Mostly, including disposable foam
versions, support the forehead, malar regions, and the
chin, with a cutout for the eyes, nose, and mouth

 Mirror systems are available to facilitate intermittent

visual confirmation

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 SUPPORT DEVICES USED IN PRONE
POSITION HEAR
1.MIRROR SYSTEM

2.HORSESHOE REST

 Increased intra-abdominal pressure decreases

FRC, compliance and elevated VP of the
abdominal and spine vessels-increase bleeding
risk.

 Its imp that the abdomen hangs free and moves

with respiration- space of atleast 6 cms!

 Thorax: firm rolls or bolsters placed each side

from the clavicle to the iliac crest ( wilson frame,
jackson table, relton frame(

 Pendulous structures (e.g., Male genitalia and

female breasts) should be clear of compression

 Its essential to check the ETT position at a

required degree of flexion

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 HEMODYNAMICS AND VENTILATION
 Increases intraabdominal pressure, decreases VR
to the heart, and increases systemic and
pulmonary vascular resistance- HYPOTENSION

 Oxygenation and oxygen delivery, however, may

improve as

1.Perfusion of the entire lungs improves

2.Increase in intraabdominal pressure decreases

chest wall compliance, which under PPV,
improves ventilation of the dependent zones of the
lung

3.Previously atelectatic dorsal zones of lungs may

open.

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 SITTING

 This is actually a modified recumbent position as

the legs are kept as high as possible to promote
venous return.

 Arms must be supported to prevent shoulder

traction.

 Head holder support is preferably attached to the

back section of the table.

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 ADVANTAGE
 Excellent surgical exposure

 Reduced perioperative blood loss

 Superior access to the airway

 Reduced facial swelling

 Improved ventilation, particularly in obese

patients

 Modern monitoring- early indication of air

embolism

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 HEMODYNAMICS AND VENTILATION
 Increases intraabdominal pressure, decreases VR
to the heart, and increases systemic and
pulmonary vascular resistance- HYPOTENSION

 Oxygenation and oxygen delivery, however, may

improve as

1.Perfusion of the entire lungs improves

2.Increase in intraabdominal pressure decreases

chest wall compliance, which under PPV,
improves ventilation of the dependent zones of the
lung

3.Previously atelectatic dorsal zones of lungs may

open.

PROBLEMS
 Venous air embolism

 Hypotension (prevented by stocking(

 Arms if not supported well- brachial plexus injury

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