What is the position of patient to undergo d&c?

Prone

The prone or ventral decubitus position (Fig. 34.15) is primarily used for surgical access to the posterior fossa of the skull, the posterior spine, the buttocks and perirectal area, and the posterior lower extremities. The patient may receive either monitored anesthesia care or general anesthesia depending on the type of surgery and the patient’s body habitus and comorbidities. When general anesthesia is planned, the airway is usually secured via an endotracheal tube while the patient is still supine. Special attention should be paid to securing and taping the endotracheal tube to prevent dislodgement while the patient is prone or during changes in position. Placing an anesthetized patient in the prone position requires the coordination of the entire surgical staff. The anesthesiologist is primarily responsible for coordinating the move while maintaining inline stabilization of the cervical spine and monitoring the endotracheal tube. An exception might be the patient in whom rigid pin fixation is used when the surgeon often holds the pin frame. The endotracheal tube should be disconnected from the circuit during the move from supine to prone in order to prevent dislodgement. Which, and how many, monitors and lines are disconnected during the move is up to the clinical judgement of the anesthesiologist for an individual patient. Lines and monitors connected to the inside arm (the arm moving the least during the move) can often be easily maintained without disconnecting. Ventilation and monitoring should be reestablished as rapidly as possible.

Prone head position is critical. For patients under sedation, the head may be turned to the side if neck mobility is adequate. During general anesthesia, the head is usually kept neutral using a surgical pillow, horseshoe headrest, or head pins. Weight should be on the bony facial prominences and not soft tissue and especially not on the eyes. The face is not always visible. Mirror systems are available to facilitate intermittent visual confirmation that the eyes are not compressed, although direct visualization or tactile confirmation is prudent (Fig. 34.16). Several commercially available pillows are specially designed for the prone position. Most pillows support theforehead, malar regions, and chin, with a cutout for the eyes, nose, and mouth (seeFig. 34.15). The forehead and malar regions are supported by the horseshoe headrest and allow for reasonable access to the airway (Figs. 34.17 and 34.18). Pin fixation, which is most used in cranial and cervical surgery, is advantageous because there is no direct pressure on the face (Fig. 34.19). Patient movement must be prevented when the head is held in pins; movement in pins can result in scalp lacerations or a cervical spine injury. Both horseshoe and pin headrests attach to the operating room table with adjustable articulating supports. All articulating supports must be fully locked as failure of this bracketing device may lead to complications if the head suddenly drops.

19 How might upper extremity neuropathies be prevented through careful positioning?

Arm abduction should be limited to 90 degrees in supine patients. Protective padding is essential to avoid upper extremity neuropathies but does not guarantee against them. The ulnar groove should be padded, and pronation avoided since this places the ulnar nerve in its most vulnerable position. When arms are tucked at the side, a neutral position is preferable. Flexion at the elbow may increase the risk of ulnar neuropathy. Pressure on the spiral groove of the humerus may result in radial neuropathy. Range limitation is not uncommon at the elbow, and overextension may place the median nerve at risk. Properly functioning automated blood pressure cuffs do not alter the risk of upper extremity neuropathy.

KEY POINTS:

Patient Positioning

A conscientious attitude toward positioning is required to facilitate the surgical procedure, prevent physiologic embarrassment, and prevent injury to the patient.

Postoperative blindness is increasing in frequency, but it is unclear exactly which patients are at risk. Although not a guarantee to prevent this complication, during lengthy spine procedures in the prone position maintain intravascular volume, hematocrit, and perfusion pressure.

The most common postoperative nerve injury is ulnar neuropathy. It is most commonly found in men older than 50 years, is delayed in presentation, is not invariably prevented by padding, and is multifactorial in origin.

In order of decreasing sensitivity, monitors for detection of VAE are transesophageal echocardiography and Doppler ultrasound > increases in end-tidal nitrogen fraction > decreases in end-tidal carbon dioxide > increases in right atrial pressure > esophageal stethoscope. It should be noted that, of all these monitors, only the right atrial catheter can treat a recognized air embolism.

Intraoperative Patient Positioning and Preparation

A safety checklist (Box 44.3) should be incorporated into the surgical workflow that is utilized prior to commencing surgery and during the procedure and for a postprocedure debriefing.99,100

The patient is positioned supine with the head elevated 10 to 20 degrees or in the beach position. This position reduces the MAP and central venous pressure and can reduce mucosal bleeding.80,81,101 The table should be positioned 90 or 180 degrees away from the anesthesia machine, which also provides additional space for placement of endoscopic monitors and image-guidance machinery. A throat pack is not necessary.102 Theoretically, pharyngeal packs have been used to prevent aspiration and postoperative nausea and vomiting. However, pharyngeal packs have been associated with complications, including throat pain, aspiration, and death. A recent randomized control trial was conducted on 46 patients undergoing ESS, with patients blinded to intervention.102 No significant difference in mean throat pain at 4 hours following surgery (P = .860) was noted, but after 24 hours patients without pharyngeal packing experienced more pain than those who had a throat pack placed (P = .002). There was no significant difference in the level of nausea at 4 hours after surgery (P = .315) or at 24 hours after surgery (P = .315). The authors recommended against the routine use of placing pharyngeal packs during FESS.102 If placed, care should be taken to have one end come out through the mouth, and the safety checklist should include removal of the throat pack prior to extubation. The oral cavity and stomach must always be suctioned with an orogastric tube prior to extubation; this minimizes risk of aspiration and postoperative nausea. If the patient is under general anesthesia, the eyes should be lubricated and taped in a vertical fashion with the medial part of the eye kept clear for observation.50 A transparent tape may be used to cover the entire eyelids alternatively. A preoperative dose of an antibiotic that covers common sinus pathogens should be considered, particularly in the presence of an active infection. If intraoperative navigation is utilized, the navigation headsets are donned, and the system is appropriately calibrated. The surgeon then scrubs and dresses for surgery. Draping is accomplished either with a head drape (e.g., Memorial) or by triangulation of the nose with surgical towels. The eyes are included within the surgical field. With the positioned patient thus prepared, and topical pledgets placed, this is a good time to carefully review the CT scan before surgery is begun (Video 44.1

Positioning

Positioning patients in the reverse Trendelenburg position can optimize respiratory function. However, lying in one position for prolonged periods increases the risk of pressure sore formation. Pressure ulcers result from prolonged pressure on soft tissue or compression of the skin between a bony prominence or hard surface (e.g., bed sides). Pressure-induced injury ranges from nonblanching, erythematous (but intact) skin to deep ulcers down to the bone. The risk of pressure sores in critically ill patients is reduced by repositioning patients regularly [39]. When positioning patients, it is important not to occlude blood flow, which could increase the risk of VTE.

Positional Therapy

Positional OSA (POSA) is characterized by breathing events happening exclusively or the majority of time when in the supine posture. Three classification systems are used for POSA: Cartwright, Bignold, andAmsterdam Positional OSA Classification (APOC). The Cartwright definition stipulates that POSA requires a 50% or more AHI difference between supine and nonsupine positions.14 The Bignold criteria require “an overall AHI ≥15, supine AHI at least twice the nonsupine AHI; ≥20 min of sleep in supine and non-supine postures and non-supine AHI <15.”15 The APOC criteria focus on likelihood of benefit from positional therapy by defining three classes of POSA severity dependent on the relationship between the best and worst sleep position (on the basis of the AHI). All APOC classifications require at least 10% of sleep time in the best and worst sleep positions.16 Patients classified as APOC I have an AHI lower than 5 in their best sleep position. APOC II allows for an AHI of 5 or more in the best sleep position, which should be in a lower AHI severity category than the overall AHI. APOC III is defined by an overall AHI higher than 40 and a 25% decrease from the overall AHI in the best sleep position.16

Population-based epidemiologic studies suggest a prevalence of POSA of 75% in middle-aged and older adults with OSA, and exclusively (sleep apnea present inonly the supine position) in slightly more than one-third of patients with OSA, findings highlighting the importance of this entity.17 Although POSA can be treated with PAP or oral appliances, positional therapy is effective and an excellent first-line treatment. Adherence to positional therapy has historically been unmeasurable and presumed to be low because of the challenge of remaining nonsupine duringthe unconscious state of sleep; adherence is improved with more recent innovations to create low-profile, comfortable devices that alert users to undesirable positioning.18 Newer-generation approaches involve attaching a small device to the neck or chest that delivers a subtle vibrating stimulus to serve as negative reinforcement for supine positioning. These devices are associated with high short-term adherence compared with 10% self-reported adherence with the traditional approach of tennis balls sewn into the back of a shirt or use of bulky attachments that prevent rolling onto the back.18 In addition to nonsupine sleeping, even modest (7.5-degree) head-of-bed elevation is another positional therapy that may result in mild improvements in the AHI irrespective of lateral, prone, or supine position.19 Head-of-bed elevation may also alleviate gastroesophageal reflux disease symptoms and thereby improve sleep architecture.

Patient Positioning

Patient positioning is critical to the success of most surgeries and RRP in particular. RRP can be performed by both the transperitoneal and extraperitoneal approaches. For the former approach, it requires a steep Trendelenburg position for most of the procedure, and adequate padding and support are mandatory. It is primarily the responsibility of the PSS to ensure correct patient positioning and padding. This is particularly true at the beginning of a robotic program because, although the console surgeon and the PSS may have received training for the procedure, attendant staff and anesthetists are unlikely to have done so. The steep Trendelenburg position is rarely used in open surgery and would be familiar only to a team regularly exposed to laparoscopic radical prostatectomy or cystectomy.

Patient positioning

Patient positioning in free flap surgery is an important issue that needs to be well considered preoperatively. It is the aim to avoid repositioning of the patient intraoperatively in order to save operating time. Therefore, the defect location determines the positioning of the patient. Flap choice and recipient arteries are determined by this. Anterior defects favor the use of “anterior free flaps,” e.g. anterolateral thigh flap, gracilis flap, rectus flap, radial forearm flap. Lateral positioning favors “lateral free flaps,” e.g. scapular flap, latissimus dorsi flap.

Patient Positioning

Patient positioning is paramount to a successful laparoscopic liver resection. Left lateral, left median segment, and caudate lesions are best performed with the patient in a supine position with the arms out6,7 (Fig. 34-1). This allows for uncomplicated and safe division of the left triangular and coronary, falciform, and gastrohepatic ligaments. Lesions involving the right lobe (segments 5, 6, 7, and 8) are best laparoscopically approached with the patient in a left decubitus position with the operative bed in full flexion (Fig. 34-2).

Patient Positioning and Intraoperative Precautions

Patient positioning depends on the area or areas that need to be treated, other procedures the patient will be undergoing, the patient's body habitus/BMI, and surgeon preference. If the patient is scheduled to undergo liposuction of the abdominal flap as well as the lumbar area, then both prone and supine positioning is usually recommended. Some surgeons prefer using the left and right lateral decubitus positions instead of a combination of prone and supine.

One caveat with regard to patient positioning is that it is better to have sufficient and efficient positioning and achieve the optimum aesthetic result during the initial surgery than to have to return to the operating room for revisions and correction of contour irregularities. With that said, we believe that the prone and supine positioning offers the best opportunity to achieve symmetry by simultaneously evaluating the left and right sides of all body areas, and reduces the need for revision. Certain areas, such as the lateral trunk, hips, and thighs, may be amenable to supine-only positioning, but we prefer to ensure symmetry and perform these procedures with the patient in both the prone and the supine positions, allowing better contouring of the areas from several access points and from different directions. It is import-ant to keep the patient well padded at all pressure points and safely positioned. In addition, placing lower extremity compression devices, keeping the patient warm, and placing a urinary catheter when appropriate should all be on the preoperative checklist before surgery can proceed.

Positioning

Patient positioning is critically important and should be performed by someone who is adequately trained and experienced—ideally the surgeon himself. Traditionally, an exaggerated lithotomy position that places the perineum parallel with the floor is used (Fig. 7-1). However, such positioning, as well as the use of “candy cane” stirrups may increase the risk of lower-extremity neuropraxia. More recent experience has demonstrated that this operation can be successfully performed in a less exaggerated lithotomy position with decreased rates of this complication (Fig. 7-2). Allen stirrups are commonly used and ample padding is applied to all pressure points. The posterior scrotum and perineum are then shaved and a sterile skin preparation is applied from the umbilicus to the buttocks to include the inner thighs. Sterile drapes are applied leaving the genitalia and perineum exposed. A sterile towel is then fastened over the anus in such a way as to allow access to the rectum later during the operation. Positioning should further ensure that there is enough space to secure a perineal retractor device.