Once induction is complete, lines are placed, and the surgeons begin positioning, this is the time to take stock of your essential items’ checklist:
IV lines: Ensure all IVs are secure, free of kinks, and screwed in tightly.
Stopcocks and Y-connectors: Confirm correct orientation. Nothing should be open to air or inadvertently clamped.
Airway: The endotracheal tube should be well secured, and the circuit tubing must be firmly attached with enough slack to prevent traction.
Foley catheter: Ensure there is no undue tension or kinking.
Miscellaneous positioning touch-ups: Review the patient’s final position and check for any incidental hazards. An IV tourniquet left in place, leftover IV supplies stuck under the patient during movement, and no pressure points.
Remember that you and the surgeon share responsibility, both practical and legal, for safe positioning. A solid grasp of positioning physiology and pressure injury prevention is essential to good anesthetic care.
Arms should be in a neutral position, gently supinated, and padded to avoid pressure over the ulnar groove. Periodically examine the arms to make sure they haven’t fallen off the boards, and that IVs remain in place and intact.
Lateral
Primary risk: brachial plexus injury.
Your job: Maintain a neutral head/neck position and support the arms in a slightly flexed, adducted posture.
The axillary roll should be placed under the chest, not in the axilla, to relieve pressure on the dependent shoulder. In obese patients, its benefit may be limited as there is cushioning from adipose tissue.
Lithotomy
Primary risk: femoral, sciatic, and peroneal nerves.
Be aware: The peroneal nerve is vulnerable to compression against the fibular head by stirrups. This setup is usually surgical domain, but you should still monitor for signs of compression.
Prone
This position introduces more complex considerations:
When flipping the patient, maintain neutral neck alignment to protect the spine and airway.
The head must remain neutral with eyes completely free of pressure. Checking and re-checking the eyes to ensure they are free from pressure cannot be overemphasized. If using a head cradle or pillow, gently palpate the orbits every hour.
Watch the lips and tongue to ensure they aren’t caught or pinched; swelling can become critical in long cases.
Risks of postoperative vision loss are heightened in prone surgeries, since the ocular nerve is particularly prone to ischemia. Risk factors include ocular pressure, significant anemia, excessive hypotension, excessive crystalloid use, and prolonged duration.
The surgical team will position the lower half of the patient. Ensure there is no genital pressure, and that the legs are neutral and gently flexed. Torso bolsters are used to avoid abdominal compression. Arms should rest naturally, gently supinated. Chest and bony prominences should be cushioned with soft supports.
Complications of Positioning: Your Responsibility
Regardless of who performed the positioning, you are responsible for recognizing and responding to complications:
Rhabdomyolysis: Can result from prolonged pressure on the thighs or buttocks; leads to acidosis and elevated CPK.
Compartment syndrome: Especially, a risk in lithotomy and lateral positions during prolonged procedures, due to sustained tissue ischemia.
Even a short positional break can restore perfusion and reduce risk. Moving the legs around and temporarily relieving the patient from lithotomy during long cases is recommended.
The risk for compartment syndrome is higher in obese patients or those with preexisting vascular disease.
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