Operative Positioning and Intraoperative-Acquired Pressure Injury: A Retrospective Cohort Study.

OBJECTIVE: To comprehensively assess the association between operative positioning with intraoperative-acquired pressure injury (IAPI) development. METHODS: This retrospective cohort study included 455 patients who underwent surgery between October 2020 and January 2021. The authors grouped patients by operative positioning into the prone position and nonprone position groups. They used propensity-score matching at a 1:2 ratio to control for preoperative confounders, applied multiple logistic regression models to analyze the effects between positioning and IAPI, and assessed interactions of positioning and intraoperative factors on IAPI. RESULTS: The final enrollment was 92 cases in the prone position group and 181 in the nonprone position group. Multivariable logistic analysis suggested that the prone position had a 2.92 times higher risk of IAPI than the nonprone position (odds ratio, 2.92; 95% CI, 1.13-7.57; P = .026). Subgroup analysis showed a significant multiplicative interaction between positioning and foam dressing on IAPI (P < .05), which was not observed in other intraoperative factors (P > .05). CONCLUSIONS: This study provides evidence that prone operative positioning can increase IAPI risk. Patients in the prone position may particularly benefit from using dressings in Chinese populations. Further large-sample longitudinal studies are required to confirm these findings.

Changes in the corrected carotid flow time can predict spinal anesthesia-induced hypotension in patients undergoing cesarean delivery: an observational study.

PURPOSE: Spinal anesthesia is a standard technique for cesarean delivery; however, it possesses a risk of hypotension. We hypothesised that the changes in the corrected flow time induced by the Trendelenburg position could predict the incidence of hypotension after spinal anesthesia for cesarean delivery. METHODS: Patients undergoing elective cesarean delivery under spinal anesthesia were enrolled. Before anesthesia induction, corrected flow time was measured in the supine and Trendelenburg positions (FTc-1 and FTc-2, respectively). Additionally, a percent change in corrected flow time induced by the Trendelenburg position was defined as ΔFTc. The primary endpoint was to investigate the ability of ΔFTc to predict the incidence of spinal anesthesia-induced hypotension until delivery. The receiver operating characteristics curves to assess the ability of FTc-1, FTc-2, and ΔFTc to predict the incidence of hypotension were generated. RESULTS: Finally, 40 patients were included, and of those, 26 (65%) developed spinal anesthesia-induced hypotension. The areas under the curve for FTc-1, FTc-2, and ΔFTc were 0.591 (95% CI: 0.424 to 0.743) (P = 0.380), 0.742 (95% CI: 0.579 to 0.867) (P = 0.004), and 0.882 (95% CI: 0.740 to 0.962) (P < 0.001) respectively, indicating ΔFTc as the best predictor among these three parameters. The best threshold for ΔFTc was 6.4% (sensitivity: 80.8% (95% CI: 53.8 to 96.2), specificity: 85.7% (95% CI: 42.9 to 100.0)). CONCLUSIONS: This study demonstrated that changes in the corrected carotid flow time induced by the Trendelenburg position could serve as a good predictor of spinal anesthesia-induced hypotension for cesarean delivery.

Extended prone positioning for intubated ARDS: a review.

During the COVID-19 pandemic, several centers had independently reported extending prone positioning beyond 24 h. Most of these centers reported maintaining patients in prone position until significant clinical improvement was achieved. One center reported extending prone positioning for organizational reasons relying on a predetermined fixed duration. A recent study argued that a clinically driven extension of prone positioning beyond 24 h could be associated with reduced mortality. On a patient level, the main benefit of extending prone positioning beyond 24 h is to maintain a more homogenous distribution of the gas-tissue ratio, thus delaying the increase in overdistention observed when patients are returned to the supine position. On an organizational level, extending prone positioning reduces the workload for both doctors and nurses, which might significantly enhance the quality of care in an epidemic. It might also reduce the incidence of accidental catheter and tracheal tube removal, thereby convincing intensive care units with low incidence of ARDS to prone patients more systematically. The main risk associated with extended prone positioning is an increased incidence of pressure injuries. Up until now, retrospective studies are reassuring, but prospective evaluation is needed.

Guidelines in Practice: Positioning the Patient.

Positioning the patient is an important perioperative task; the recently updated AORN "Guideline for positioning the patient" provides perioperative personnel with background information and evidence-based best practices for perioperative patient positioning and focuses on maintaining patient and staff member safety. The revised guideline includes recommendations for placing patients safely in a variety of positions and avoiding positioning injuries, such as postoperative vision loss. This article provides an overview of positioning recommendations for assessing patients' risk for injury, implementing safe positioning practices, placing patients in the Trendelenburg position, and preventing intraocular injuries. It also includes a patient-focused scenario on preventing adverse events associated with the Trendelenburg position that aligns with information discussed in the article. Perioperative nurses should review the guideline in its entirety and implement appropriate recommendations for positioning patients during procedures.

Factors associated with complications after percutaneous nephrolithotomy: an analysis of 1,066 cases.

OBJECTIVE: The aim of this study was to identify predictive factors for complications after percutaneous nephrolithotomy. METHODS: We prospectively analyzed patients who underwent percutaneous nephrolithotomy from June 2011 to October 2018. The association of preoperative and intraoperative factors with the presence of complications was assessed using univariate and multivariate analyses. The significance level was set at p<0.05. RESULTS: A total of 1,066 surgeries were evaluated, and the overall complication rate was 14.9%. In all, 105 (9.8%) surgeries were performed in the prone position, and 961 (90.2%) were performed in the supine position. Univariate analysis demonstrated that surgical position, upper pole puncture, surgical time, number of tracts, and Guys Stone Score were associated with complications. In multivariate analyses, prone position (odds ratio [OR] 2.10; p=0.003), surgical time ≥90 min (OR 1.76; p=0.014), upper pole puncture (OR 2.48; p<0.001), and Guys Stone Score 3 or 4 (OR 1.90; p=0.033) were independent predictive factors for complications after percutaneous nephrolithotomy. CONCLUSION: Performing percutaneous nephrolithotomy in the supine position, in under 90 min, and avoiding upper pole punctures may reduce complications during the treatment of large kidney stones.

Spinal cord ischemia as intraoperatory complication in shoulder surgery positioned in beach chair: case report.

Spinal cord infarction is an uncommon phenomenon, which can be caused by different etiologies, constituting a real diagnostic challenge which can lead to devastating consequences. General anesthesia in beach chair positioning with intraoperative hypotension in order to avoid surgical bleeding are associated with hypoperfusion and potential neurological ischemia-related complications. We present a case of spinal cord ischemia in the context of shoulder surgery in a beach chair position.

Resection of posterior fossa tumors in the semi-sitting position in children younger than 4 years of age.

PURPOSE: The semi-sitting position for resection of posterior fossa tumors is a matter of ongoing debate. Here we report about our experience with this approach in children younger than 4 years of age. METHODS: We retrospectively analyzed data of children younger than 4 years of age operated on in our institution in the semi-sitting position over a 15-year period. Patients were intraoperatively monitored for venous air embolism (VAE) by transthoracic Doppler (TTD) or transesophageal echocardiography (TEE). The severity of VAE was classified according to the Tübingen grading scale. Intraoperative incidents of VAE were recorded and the patients' course was followed postoperatively with a special focus on possible complications. RESULTS: Twenty-four children (18 boys, 6 girls) were operated on in the semi-sitting position (26 operations). Mean age was 2.2 years (± 1.0), range between 0.4 and 3.9 years. External ventricular drains were inserted in 18 children with hydrocephalus preoperatively. VAE was detected in 6 instances during surgery (6/26 (23.1%)). In 3 patients with grade 1 VAE, no additional treatment was necessary. In one patient with grade 2 VAE, intracardiac air suction via the central venous catheter was performed, and in two patients with grade 4 VAE, additional cathecholamine-infusion was administered. No major intraoperative complications occurred. Postoperative CT images showed pneumocephalus in all children. In two children, small asymptomatic impression skull fractures at the site of the Mayfield pin occurred. Revision surgery was necessary in one child with a suboccipital CSF fistula. CONCLUSION: The semi-sitting position for resection of tumors in the posterior fossa in children younger than 4 years of age can be safely performed in experienced centers taking special caution to detect and treat potential complications in an interdisciplinary setting.

An appraisal of the methodology and quality of evidence of systematic reviews on the efficacy of prone positional ventilation in adult patients with acute respiratory distress syndrome: an umbrella review.

The objective of the study was to evaluate all available systematic reviews on the use of prone positional ventilation in adult patients with acute respiratory distress syndrome (ARDS). An umbrella review on the efficacy of prone positional ventilation in adult patients ventilation in adult patients with acute respiratory distress syndrome was conducted. We performed a systematic search in the database of Medline (Pubmed), Scopus, Cochrane Library, Web of Science, and Epistemonikos. The ROBIS tools and GRADE methodology were used to assess the risk of bias and certainty of evidence. We estimated the necessary number of patients to be treated to have benefit. For the synthesis of the result, we selected the review with the lowest risk of bias. Sixteen systematic reviews including 64 randomized clinical trials and evaluating the effect of prone positional ventilation, with or without other ventilation strategies were included. Aoyama 2019 observed prone positioning, without complementary ventilation strategies, leading to a reduction in the 28-day mortality only when compared to high-frequency oscillatory ventilation (RR 0.61; 95% CI 0.39-0.95) and lung-protective ventilation in the supine position (RR 0.69; 95% CI 0.48-0.98), with an ARR of 9.32% and 14.94%, an NNTB of 5.89 and 8.04, and a low and moderate certainty of evidence, respectively. Most reviews had severe methodological flaws that led to results with very low certainty of evidence. The review with the lowest risk of bias presented results in favor of prone positional ventilation compared with high-frequency oscillatory ventilation and lung-protective ventilation. There is a need to update the available reviews to obtain more accurate results.

Spinal cord ischemia as intraoperatory complication in shoulder surgery positioned in beach chair: case report

Abstract Spinal cord infarction is an uncommon phenomenon, which can be caused by different etiologies, constituting a real diagnostic challenge which can lead to devastating consequences. General anesthesia in beach chair positioning with intraoperative hypotension in order to avoid surgical bleeding are associated with hypoperfusion and potential neurological ischemia-related complications. We present a case of spinal cord ischemia in the context of shoulder surgery in a beach chair position.

Psychological Stress Induced by Prone Positioning among Adults with Severe Cerebral Palsy.

The purpose of this study was to investigate the psychological impact of various positionings in subjects with cerebral palsy (CP). The participants were 17 individuals with severe motor and intellectual disability due to CP. They began in a sitting position in their wheelchair, and were placed consecutively in prone or supine positions, with no intervals between placements. Physiological observations were made in each position, and included salivary α-amylase activity, pulse, percutaneous oxygen saturation, respiratory rate, learance or not of airway secretions, and occurrence or not of adverse events. Salivary α-amylase activity values were higher in the prone position than in the baseline and supine positions (p<0.05). Clearance of airway secretions was significantly more prevalent in the prone position than in the baseline and supine positions (p <0.05). The participants' pulse was significantly lower in the supine and prone positions than in the baseline position (p<0.05). Greater prevalence of airway secretion clearance and significantly higher stress levels as indicated by saliva amylase were observed in the prone position than in the other two positions. Therefore, when such patients are placed in a prone position, close attention to airway management and the potential for psychological stress may be necessary.

Value of Evoked Potential Changes Associated with Neck Extension Prior to Cervical Spine Surgery.

Background: Multimodal intraoperative monitoring (MIOM) is a useful tool to warn surgeons to intervene for intraoperative spinal cord injury in cervical spine surgery. However, the value of MIOM remains controversial before cervical spine surgery. Objective: To explore the value of MIOM in early detecting spinal cord injury associated with neck extension before cervical spine surgery. Methods and Materials: Data of 191 patients receiving cervical spine surgery with the MIOM were enrolled from June 2014 to June 2020. The subjects were divided into a group of evoked potentials (EP) changes and a group of no EP changes for analysis according to the monitoring alerts or not. Results: Five (2.62%) patients showed EP changes associated with neck extension during intubation or positioning. After early different interventions, such as repositioning and timely surgical decompression, none or transient postoperative neurological deficits were observed in four cases, and only one case was with permanent neurological deficits. The average preoperative Japanese Orthopaedic Association (JOA) scores of the group with EP changes were lower than those of the group with no EP changes (P = 0.037 < 0.05). There was no statistical significance in gender, average age, mean Pavlov ratio, and the minimum Palov ratio between the two groups (P > 0.05). Conclusions: The MIOM could identify spinal cord injury associated with neck extension before cervical spine surgery. Active and effective interventions could prevent or reduce permanent postoperative neurological deficits. Severe spinal cord compression might be a risk factor for EP changes.

Risco para lesões por posicionamento cirúrgico decorrentes da posição supina / Riesgo de lesiones de posicionamiento quirúrgicoderivadas de la posición supina / Risk for surgical position injuries arising from the supine position

Objetivo: relacionar o escore de risco de lesões por posicionamento cirúrgico decorrentes da posição supina com aspectos sociodemográficos, clínicos, cirúrgicos e ocorrência de complicações. Método: estudo observacional longitudinal realizado com 89 pacientes em decúbito dorsal. Aplicadas variáveis ​​sociodemográficas e clínicas e a Escala de Risco para Desenvolvimento de Lesões por Posicionamento Cirúrgico. Adotadas análises descritivas, bivariadas e de regressão logística, considerando-se um nível de significância de α=0,05. Resultados: a idade aumentou em 1,11 vezes (p<0,001) e a obesidade em 13,77 vezes (p=0,01) a chance de aumento do risco de lesões. A proporção de dor (34,1%) e lesão por pressão na região sacrococcígea (91,7%) destacou-se nos pacientes de maior risco (p=0,05). Conclusão: obesos e idosos apresentaram maior risco de lesões. Dor e ocorrência de lesão por pressão na região sacrococcígea foram as complicações predominantes nos pacientes de maior risco (AU)

Objective:to relate the risk score for injuries due to surgical positioning resulting from the supine position with sociodemographic, clinical, surgical aspects and the occurrence of complications. Method: longitudinal observational study carried out with 89 patientsin the supine position. Sociodemographic and clinical variables and the Risk Scale for the Development of Surgical Positioning Injuries were applied. Descriptive, bivariate and logistic regression analyzes were adopted, considering a significance level ofα=0.05. Results: age increased by 1.11 times (p<0.001) and obesity by 13.77 times (p=0.01) the chance of increased risk of injury. The proportion of pain (34.1%) and pressure injury in the sacrococcygeal region (91.7%) stood out in patients at higher risk(p=0.05). Conclusion:obese and elderly people had a higher risk of injury. Pain and occurrence of pressure injury in the sacrococcygeal region were the predominant complications in patients at higher risk (AU)

Objetivo:relacionar el puntaje de riesgo de lesiones por posicionamiento quirúrgico derivado de la posición supina con aspectos sociodemográficos, clínicos, quirúrgicos y la ocurrencia de complicaciones. Método:estudio observacional longitudinal realizado con 89 pacientes en decúbito supino. Se aplicaron variables sociodemográficas, clínicas y la Escala de Riesgo para el Desarrollo de Lesiones de Posicionamiento Quirúrgico. Fueron adoptados análisis descriptivos, bivariados y de regresión logística, considerando un nivel de significancia de α=0,05. Resultados:La edad aumentó en 1,11 veces (p<0,001) y la obesidad en 13,77 veces (p=0,01) la probabilidad de mayor riesgo de lesión. La proporción de dolor (34,1%) y lesión por presión en la región sacrococcígea (91,7%) sedestacó en los pacientes de mayor riesgo (p=0,05).Conclusión:Las personas obesas y ancianas tenían mayor riesgo de lesiones. El dolor y la aparición de lesión por presión en la región sacrococcígea fueron las complicaciones predominantes en los pacientes de mayor riesgo (AU)

[Meralgia paraesthetica as complication of patient positioning : A not fully controllable risk]. / Meralgia paraesthetica als Lagerungsschaden : Kein voll beherrschbares Risiko.

Meralgia paraesthetica (MP) is the consequence of an entrapment or stretch injury of the lateral femoral cutaneous nerve at the crossing region with the inguinal ligament where the nerve exits the pelvis. It results in temporary or permanent sensory loss, paraesthesia and pain in the anterolateral region of the thigh. Idiopathic forms are known for example as seat belt syndrome or jeans syndrome. An MP can also occur as a complication of surgical or intensive care patient positioning. In focus are the lithotomy position, prone position and beach chair position.We analyzed 21 complaints about MP occurring for the first time postoperatively, which had been submitted to the expert committee for medical treatment errors at the North Rhine Medical Association over the past 10 years. Among these, six cases could be identified as positioning damage after a lithotomy position. In three cases MP occurred after supine positioning but the etiology could not be clarified with certainty. In 12 cases MP was recognized as a direct surgical complication.The pathophysiology, incidence and course as well as legal implications of position-related MP are discussed. Pressure damage to the nerve at its intersection with the inguinal ligament is assumed to be the main pathomechanism. Although all the cases presented here occurred after lithotomy positioning, the complication also appears to occur with other types of positioning according to the literature data, the most common being prone positioning. This also explains the increasingly published case reports of MP after prone positioning in COVID-19 patients for respiratory treatment. Safe avoidance of the positioning-related complication does not appear to be possible due to the anatomical variability of the course of the nerve and the unclear pathomechanisms.

Acute compartment syndrome of the contralateral thigh following reconstructive shoulder surgery done for multidirectional shoulder instability in lateral decubitus position.

A man in his early 40s had revision reconstructive surgery on his left shoulder while in a right lateral decubitus position. The prolonged surgery (7 hours) caused acute compartment syndrome (ACS) in the contralateral (right) thigh. Moderate pain and swelling of the contralateral thigh ('well limb') was first noted in the recovery room. After progression to severe swelling and numbness in his right toes, fasciotomies of the right thigh were performed, confirming ACS. Thirteen months later he returned to his prior work without lower extremity discomfort or limitations, and he reported a good result from the revision shoulder surgery. Non-traumatic ACS of a well limb is a rare complication of surgery performed in the lateral decubitus position. We suggest that moving the patient temporarily, or to a new position (eg, beach chair), should be considered when the duration of surgery approaches 4.5 hours.

Does surgical position affect infective complications in percutaneous nephrolithotomy?

The downward orientation of the access sheath during supine percutaneous nephrolithotomy (PCNL) allows the faster evacuation of fluids and stone fragments. It theoretically can contribute to the reduction of the high intrarenal pressure-associated complications. We aimed to investigate whether there is a difference between prone and supine PCNL in terms of infective complications. This retrospective study includes 182 patients who underwent supine and prone PCNL due to kidney stones in our clinic between April 2020 and May 2022. Demographic (age, sex, body mass index, comorbidities), radiological (cumulative stone burden, stone density, number of stones, stone localization, stone laterality, presence of hydronephrosis), clinical (previous stone surgery, previous urinary tract) and perioperative (prone or supine position, surgery duration, hospitalization, success, non-infective and infective complications) data of all patients were evaluated. All patients were divided into two groups, the prone position group, and the supine position group. These two groups were compared in terms of pre and postoperative data above. Infective complications were observed in 16 (18%) patients in the prone position group and in 7 (7.5%) patients in the supine position group, and this difference was statistically significant (p = 0.034). Surgery duration (OR = 1.041; 95% CI 1.021-1.061; p < 0.001), number of stones (OR = 4.09; 95% CI 1.093-7.309; p = 0.036), previous urinary tract infection (OR = 6.272; 95% CI 1.936-9.317; p = 0.002) and prone position (OR = 4.511; 95% CI 1.265-7.087; p = 0.02) were found as independent risk factors for infective complications. Prone position was proved as an independent predictor of postoperative infectious events. Supine PCNL will be further adopted as the standard PCNL approach by a continuously growing proportion of endourologists.

Sudden arrhythmia in the prone position during spinal surgery: A case report.

RATIONALE: The prone position is the most commonly required position during spinal surgery. Decreasing lumbar lordosis is necessary to facilitate the accessibility of the surgical field. And this can affect the hemodynamic circulation of the patients. The Jackson spine table is one of the most preferred methods, known to have minimal effects on cardiac function. PATIENT CONCERNS: We report a case of sudden arrhythmia that developed during the prone position using a Jackson spine table. It occurred 30 minutes after the positional change. DIAGNOSES: Arrhythmia showed bizarre P and QRS waves. Ectopic P, bundle branch block, or both was suspected. INTERVENTIONS: Because it was difficult to define the exact type or cause of this sudden arrhythmia and considering that other vital signs remained stable, we decided to keep close observation during the operation rather than applying uncertain antiarrhythmic medication. OUTCOMES: Arrhythmia spontaneously developed and subsided repeatedly. And it recovered to normal sinus rhythm immediately after the positional change to the supine position. Therefore, increased intrathoracic pressure caused by the prone position was highly suspected to be the cause of this event. LESSONS: Although the Jackson spine table is known to have the least effect on cardiac function, the patient experienced arrhythmia in our case. Hence, to achieve better clinical outcomes, an understanding of physiological alterations and possible complications caused by the prone position is necessary for earlier diagnosis and management.

Preventing patient positioning injuries in the nonoperating room setting.

PURPOSE OF REVIEW: Postprocedural positioning injuries are an under-appreciated source of morbidity for patients. These injuries may not present until days after anesthesia and may be missed for multiple reasons including the distracting injury of the procedural site, illness of the patient, lack of follow-up, and insufficient awareness of this type of injury. Risks for these adverse events are exacerbated in the nonoperating room anesthesia (NORA) population for several reasons. These patients tend to be older and sicker than patients presenting to the operating room, increasing the risk of an injury. Proceduralists and anesthesia providers are usually consultants, not the primary care team, so may have limited patient follow-up. This review will discuss the risk factors for position-related injuries and how to prevent them with proper positioning and padding. RECENT FINDINGS: The mainstay of preventing periprocedural positioning injuries is careful positioning of the patient and proper padding of pressure points. This may be particularly challenging because of physical constraints and positioning requirements for NORA procedures, as well as preference for radiolucent positioning materials. Recent studies have shown the potential benefit of monitoring somatosensory evoked potentials (SSEP) in high-risk patients. SUMMARY: Careful consideration of patient positioning and thorough understanding of peripheral nerve and pressure injuries is essential for anesthesia providers to avoid positioning injuries during NORA procedures. VIDEO ABSTRACT: http://links.lww.com/COAN/A87.

Pressure Injuries Due to Prone Positioning in Patients with COVID-19.

Preemptive interventions are needed to prevent pressure injuries in patients with COVID-19 who are placed in the prone position.Risk factors for pressure injuries in these patients include severe obesity, a long duration of prone positioning, male sex, a high D-dimer level, and the use of commercial endotracheal tube holders.

Respiratory decompensation with proning - when prone positioning can worsen respiratory mechanics.

Prone positioning recently gain- ed more popularity from its use in COVID-19 management. It is gene--rally considered to improve respiratory mechanics via increased lung compliance. In surgery, prone positioning is typically encountered when it is a necessity to access certain posterior anatomic structures. Though certain post-operative complications from prone positioning are well known (e.g., postoperative vision loss), the potential intraoperative complications that it can have for respiratory com-pliance and O2 saturation, in the setting of general anaesthesia, are perhaps less familiar, as only a few studies showed improved respiratory mechanics in the setting of ge-neral anaesthesia [1-3] and one study showed that prone positioning led to a 30-35% drop in respiratory compliance under general anaesthesia [4]. As the following case illustrates, proning is a critical point in the intraoperative course as it can sometimes lead to negative respiratory sequelae disrupting homeostasis.

Masseter muscle pressure injury: First report of a prone position complication in patients with COVID-19.

We report the case of a 59-year-old, obese woman who underwent prolonged prone position during the medical management of an acute respiratory distress syndrome induced by SARS-CoV-2 infection, complicated by a masseter muscle pressure injury. Such side effect may be underestimate in intensive care units and should be prevent by prophylactic dressings on facial weight-bearing sites. The understanding of facial deep tissue injury is essential to guide clinical detection and management of such a complication in COVID-19 patients.