Overview
Definition:
Operating room positioning injuries are iatrogenic injuries that occur due to improper patient positioning during surgical procedures
These can range from superficial skin damage and nerve palsies to more severe complications like compartment syndrome or rhabdomyolysis.
Epidemiology:
The incidence of positioning injuries varies widely, reported between 0.02% and 33%, with higher rates associated with longer duration of surgery, extreme positions, and specific patient factors such as obesity or pre-existing neuropathies
Nerve injuries are the most common type, affecting approximately 1-10% of patients
Risk is increased in procedures lasting over 5-6 hours.
Clinical Significance:
These injuries can lead to significant patient morbidity, prolonged hospital stays, increased healthcare costs, and potential legal ramifications
Understanding and implementing preventive measures is crucial for all surgical teams to ensure optimal patient outcomes and maintain professional standards, a key focus for DNB and NEET SS preparation.
Types Of Injuries
Nerve Injuries:
Direct nerve compression or stretching is common
Examples include ulnar neuropathy (most frequent), brachial plexus injury, peroneal nerve palsy, and sciatic nerve injury
These can result in motor deficits, sensory loss, or pain
Factors include direct pressure on bony prominences, excessive limb traction, or pressure from equipment.
Skin Injuries:
Pressure sores, shear injuries, and burns can occur
Pressure sores are caused by prolonged pressure on soft tissues over bony areas, leading to ischemia and tissue breakdown
Shear injuries happen when skin layers move in opposite directions
Burns can result from electrosurgical devices or warming blankets.
Musculoskeletal Injuries:
Joint dislocations, ligamentous injuries, and muscle strains can occur due to extreme joint flexion or extension, or excessive manipulation
Compartment syndrome, a surgical emergency, can develop due to prolonged compression and edema within a fascial compartment, leading to muscle and nerve damage.
Other Injuries:
Ocular injuries (corneal abrasions, retinal ischemia), rhabdomyolysis from prolonged pressure and ischemia, and hypothermia can also be consequences of improper positioning and patient management during surgery.
Risk Factors
Patient Factors:
Obesity
advanced age
cachexia
diabetes mellitus
peripheral neuropathy
pre-existing musculoskeletal or neurological conditions
smoking
malnutrition
prolonged immobility before surgery.
Anesthetic Factors:
General anesthesia with loss of sensation and muscle tone
prolonged duration of anesthesia
use of muscle relaxants reducing patient’s ability to reposition
hemodynamic instability requiring careful monitoring and potentially specific positions.
Surgical Factors:
Long operative times (> 5-6 hours)
extreme patient positions (e.g., prone, lithotomy, Trendelenburg)
use of specialized equipment (e.g., arm boards, stirrups, beanbags)
repeated repositioning during surgery
inexperienced surgical team.
Equipment Related Factors:
Hard, uneven surfaces of the OR table
improper padding
incorrect use of restraints and positioning devices
malfunctioning equipment that applies undue pressure.
Prevention Strategies
Preoperative Assessment:
Thorough patient assessment including neurological status, skin integrity, and mobility
Identifying high-risk patients allows for tailored positioning plans and increased vigilance
Review of previous surgical records for prior positioning issues is also beneficial.
Team Communication And Planning:
A multidisciplinary approach involving the surgeon, anesthesiologist, and nursing staff
Clear communication of the planned position, duration, and potential risks is essential
Pre-operative huddles and checklists can reinforce safety protocols.
Proper Padding And Support:
Use of adequate padding on all bony prominences (e.g., heels, elbows, sacrum, occiput) and pressure points
Specialized gel pads, egg-crate foam, and positioning devices should be utilized appropriately
Avoid direct pressure on nerves, especially superficial ones like the ulnar nerve at the elbow
Ensure limbs are not hyperextended or hyperflexed.
Careful Limb Positioning:
Limbs should be positioned in a neutral alignment to prevent nerve stretch or compression
Avoid excessive traction on limbs
Ensure arm boards are not placed too high or low, and that the ulnar nerve is protected
Use padding and avoid pressure on the fibular head for the peroneal nerve.
Monitoring During Surgery:
Regularly check for pressure points, skin integrity, and peripheral pulses
Assess for signs of nerve compromise or venous stasis
In prolonged cases or high-risk patients, consider intermittent repositioning or specialized pressure-relieving devices
Vigilance is paramount even in routine cases.
Postoperative Assessment:
Immediate and thorough post-operative examination of skin and neurological function
Educate the patient about potential symptoms and encourage reporting any new sensory or motor deficits
Prompt investigation and management of any suspected injury.
Management Of Positioning Injuries
Initial Steps:
Immediate cessation of pressure or manipulation causing the injury
Document the event thoroughly
Perform a detailed neurological and dermatological examination
Assess for signs of compartment syndrome or vascular compromise.
Nerve Injuries Management:
Conservative management with physiotherapy, splinting, and pain control is the mainstay
Occupational therapy for functional recovery
If no improvement within 3-6 months, surgical exploration for nerve decompression or grafting may be considered
Electrodiagnostic studies (EMG/NCS) are crucial for diagnosis and monitoring.
Skin Injuries Management:
Pressure sores require wound care protocols, including debridement, dressing changes, and pressure relief
Advanced cases may require surgical reconstruction (e.g., flap surgery)
Prevention of infection is critical
Burns need appropriate burn management protocols.
Musculoskeletal Injuries Management:
Treatment depends on the specific injury
Dislocations require reduction
Ligamentous injuries may need immobilization or surgical repair
Compartment syndrome is a surgical emergency requiring fasciotomy
Rhabdomyolysis requires aggressive hydration and monitoring for renal failure.
Key Points
Exam Focus:
DNB and NEET SS exams frequently test knowledge on patient safety
Positioning injuries, though preventable, are important causes of morbidity
Focus on risk factors, common injuries (ulnar, peroneal nerve), and the multi-faceted prevention strategy.
Clinical Pearls:
Think of positioning injuries whenever a patient develops new neurological deficits or skin breakdown post-operatively, especially after long or complex procedures
Always assess the "B.A.C.O." mnemonic: Bony prominences, Arms, Chest, Occiput for pressure points
Never assume a deficit is pre-existing without thorough documentation.
Common Mistakes:
Underestimating the risk in shorter procedures
inadequate padding of bony prominences
neglecting to protect superficial nerves
poor communication within the surgical team
failing to document meticulous pre-operative assessments and positioning details.