Why is Positioning so Important to CRNAs?
Nerve injury is the primary problem that develops during anesthesia due to poor patient position. Under anesthesia a patient cannot change position in response to pain due to position problems. The American Society of Anesthesiologists (ASA) database indicates that nerve injury is the 2nd most settled cause of malpractice claims (32%death, 16%nerve injury, 12% brain damage). Ulnar neuropathy at (28%) is the most common nerve injury, and occurs more often in men than women. The extent of nerve injury is dependent on the duration of pressure that the nerve undergoes. This compression injury can result in loss of conduction with delayed recovery and nerve degeneration. This is why proper positioning is so important as a CRNA. While you are a CRNA student you need to practice good positioning techniques that will carry over in you career. The best CRNA Schools offer extensive training in patient positioning to avoid injury.
Positioning the Patient for Surgery
Supine: Most common position used in surgery with the patient laying flat on their back. Patient’s arms can be placed in a few different positions depending on the type of surgery. You can place them to the patient’s side in a tucked position, or extending out to the side making sure they are angled less then 90 degrees to prevent nerve injury. This allows for great exposure for abdominal cases.
Contoured Supine: Also known as the “Lawn Chair” position, and it provides an anatomical neutral position for the hips and knees.
Frogleg Supine: This position is great for perineal exposure. It allows for access to the medial thighs and perineum. The thighs are flexed and rotated at the hip to keep heels together.
Lithotomy: Legs are placed up in stirrups and allows for access to the perineum. Most cystoscopy cases are done using this position.
Prone: The patient is in the face down position which allows access to the spine. The prone position requires special attention to eyes and face. Any pressure on eye can cause corneal abrasions, ocular edema, or blindness. Many different foam head and face supports with cut out portion are available to keep the eyes free from pressure.
Sitting: the sitting position is good because it takes pressure off the patient’s eyes, and makes diaphragmatic excursion easier which allows lowers airway pressures. Complications that can arise from this position include hypotension, ventilation problems, and venous air embolism.
Post-Op Assessment
Assessing the patient post operatively for any injuries that may have occurred from positioning is very important. Motor and sensory function of upper and lower extremities must be assessed by the CRNA.
Upper extremities: (especially after any procedure requiring extensive manipulation of arms)
Median: normal sensation on palmer surface on index finger
Ulnar: normal sensation of palmer surface of 5th finger.
Radial: ability to abduct thumb
Lower extremities: (especially after being in lithotomy position)
Sciatic: ability to flex leg at knee.
Peroneal: ability to dorsiflex great toe.
Tibial: ability to plantarflex great toe.
Femoral: ability to extend leg at knee.
Anterior Cutaneous: normal sensation on lateral surface of thigh.
Saphenous: normal sensation on medial surface of leg
Being a Safe CRNA
Being a CRNA is more important then just putting people to sleep. It requires constant diligence and focus, so that the patient receives a safe and effective anesthetic. Start practicing safe techniques early so that you will continue to form a strong foundation and grow professionally as a CRNA.
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