Positioning the Patient

Get clinical answers to frequently asked questions about positioning the patient.

  • Are there positioning techniques that can be used to prevent postoperative alopecia?

    Alopecia, resulting from ischemic changes in the scalp may occur after exposure to prolonged pressure during operative procedures. Repositioning the patient's head, massaging the patient’s scalp, or implementing other actions to reduce scalp pressure (eg, removing the head strap) during the procedure may help to prevent the development of pressure alopecia or an occipital neuropathy. Resting the patient’s head on pressure-reducing surfaces rather than hard surfaces, such as horseshoe-shaped head positioners may also help to prevent alopecia.

    Efforts to reposition the patient’s head or massage the scalp should be implemented in collaboration with the anesthesia professional because changing the patient's head position during the procedure may be difficult or may dislodge or change the position of the airway maintenance device.

    Resources

    Guideline for positioning the patient. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated April 11, 2017

  • Does AORN recommend using prophylactic dressings to prevent pressure injury?

    According to the AORN Guideline for Positioning the Patient, “Prophylactic dressings may be applied to bony prominences (eg, heels, sacrum) or other areas subjected to pressure, friction, and shear.”(V.g.) The use of prophylactic dressings may reduce the effects of pressure, shear, and friction on healthy skin at increased risk of pressure injury. There is evidence to support the use of prophylactic dressings for prevention of pressure injury; however, further research is warranted regarding the use of prophylactic dressings in perioperative patients.

    Relative to the use of prophylactic dressings, AORN further recommends:

    • A multidisciplinary team should determine the type of prophylactic dressings that will be used in the perioperative setting as part of the health care organization's pressure injury prevention program.
    • Prophylactic dressings used for prevention of pressure injury should be sized according to the manufacturer's instructions for use.
    • Multiple layers of prophylactic dressings should not be used.
    • Prophylactic dressings should be replaced if damaged, displaced, loosened, or moist.

    Resources

    Guideline for positioning the patient. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated April 11, 2017

  • How long should a patient remain in the lithotomy position before being repositioned?

    According to the AORN Guideline for Positioning the Patient, “Patients in the lithotomy position should be repositioned at established intervals during the procedure, if possible. Repositioning interventions and repositioning intervals should be based on the individual patient and the specific situation and established by the perioperative team before the beginning of the procedure, if possible.”(XII.b.1., XII.b.2.)

    The length of time a patient may remain in the lithotomy position without risk of injury is unknown. The risk of injury is multifactorial and may be related to patient condition as well as patient position. The longer the patient's legs are maintained in the lithotomy position, the greater the potential for developing a neuropathy, neurovascular complication, or compartment syndrome.

    Evidence indicates that repositioning the patient at established intervals during the procedure may reduce the risk of compartment syndrome or other injury associated with prolonged lithotomy position. However, evidence regarding the most effective repositioning strategies or repositioning intervals for the lithotomy position is inconclusive.

    Resources

    Guideline for positioning the patient. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated April 11, 2017

  • How should the patient’s legs be removed from the leg holders used in lithotomy position?

    According to the AORN Guideline for Positioning the Patient, “The patient’s legs should be removed from the leg holders in a two-step process:

    1. A minimum of two people (ie, a minimum of one person per leg) should remove the legs slowly and simultaneously from the leg holders and bring them together before the legs are lowered to the OR bed.
    2. The patient’s legs should be simultaneously lowered to the OR bed.”(XII.k.)

    Having a minimum of two people move the patient’s legs simultaneously out of the leg holders helps avoid torsional stresses at the hip joint and pelvis and prevent patient and personnel injury. In some cases, additional personnel (eg, two people per leg) may be needed to safely remove the patient’s legs from the leg holders. Simultaneously lowering the patient’s legs to the OR bed may help to prevent rapid or unexpected circulatory changes.

    Notably, the practice of slowly and simultaneously removing the legs from the leg holders, bringing the legs together before the legs are lowered to the OR bed, and then lowering one leg at a time to the OR bed is not incorrect and may further help to prevent rapid circulatory changes; however, there is no evidence to show this is necessary.

    Resources

    Guideline for positioning the patient. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated April 11, 2017

  • Is it acceptable to use a rolled towel or an IV bag as an axillary roll?

    According to the AORN Guideline for Positioning the Patient, “Positioning equipment and devices should be designed and intended for use in positioning surgical patients”(V.b.1.) and, “Towels, sheets, and blankets should not be used as positioning devices.”(VII.d.1.)

    Neither rolled towels nor IV bags are designed and intended for use in positioning surgical patients. Using items not intended for use in positioning surgical patients, such as IV bags, increases the risk for injury. Using a rolled towel increases pressure, contributes to friction injury, and decreases the pressure-redistributing properties of the support surface.

    Resources

    Guideline for positioning the patient. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated April 11, 2017

  • Does AORN recommend using vacuum-packed positioning devices for positioning patients?

    According to the AORN Guideline for Positioning the Patient, “A vacuum-packed positioning device may be used.”(VII.d.3.) Using a vacuum-packed positioning device provides stability and helps maintain the patient in the desired position. Vacuum-packed positioning devices are designed to reduce pressure injury by providing a surface on which the patient’s weight is evenly distributed and supported. However, after decompression, these devices can increase pressure on nerves and over bony prominences. When vacuum-packed positioning devices are used to support patients in the lateral position, the circulatory system may be compromised not only by the tight restraint provided by the device, but also by the overall effects of gravity on the patient’s body and the horizontal body posture.

    Resources

    Guideline for positioning the patient. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated April 11, 2017

  • What is a high-specification reactive foam surface and why does AORN recommend using this type of surface for perioperative patients?

    According to the AORN Guideline for Positioning the Patient, “Perioperative patients identified as being at high risk for pressure injury should be positioned on high-specification reactive foam surfaces, if possible”(VII.e.) High-specification surfaces are pressure-redistributing pads or mattresses composed of high-density or viscoelastic foam that conforms to the body contours. These surfaces may include multiple layers of foams of various grades and types. Properties of a high-specification foam mattress include:

    • A density of 35 kg/m3,
    • An indentation force deflection of 35 to 130,
    • Hardness (ie, the ability to push back and carry weight) of 130 Newtons,
    • A support factor of 1.75 to 2.4,
    • A depth of 5.9 inches (150 mm), and
    • A mattress cover with a moisture vapor transmission rate of 33 g/m2/24 hours.

    A reactive support surface is designed to reduce the risk for pressure injury by changing its load distribution in response to an applied load (ie, the patient’s weight). Reactive support surfaces provide deep immersion and a high degree of envelopment to reduce high pressure concentrations over bony prominences. Using high-specification reactive foam surfaces may be an effective strategy to reduce the incidence of pressure injury in perioperative patients.

    Resources

    Guideline for positioning the patient. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated April 11, 2017

  • How does AORN recommend positioning pregnant women?

    According to the AORN Guideline for Positioning the Patient, “Pregnant women undergoing obstetric surgery should be positioned in a left lateral tilt by:

    • Placing a 4.7-inch (12-cm) wedge-shaped positioning device under the right lumbar region above the iliac crest and below the lower costal region to achieve a 12-degree to 15-degree lateral tilt,
    • Placing a wedge-shaped positioning device under the right pelvis to achieve a 12-degree to 15-degree lateral tilt, or
    • Tilting the OR bed 15 degrees to 45 degrees to the left.”(XVI.a.)

    Implementing patient positions that displace the uterus to the left may help prevent supine hypotensive syndrome caused by the gravid uterus compressing the aorta and inferior vena cava.

    Resources

    Guideline for positioning the patient. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated April 11, 2017

  • Why does AORN recommend flexing the patient’s knees in the supine position?

    According to the AORN Guideline for Positioning the Patient, when in the supine position, “the patient’s knees should be flexed approximately 5 degrees to 10 degrees.”(IX.d.) Positioning the knees in slight flexion prevents popliteal vein compression and reduces the patient’s risk for deep vein thrombosis (DVT). Extending the patient’s legs and elevating the heels may increase pressure at the sacrum and allow the knee to hyperextend, compressing the popliteal vein and increasing the risk for DVT.

    Resources

    Guideline for positioning the patient. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated April 11, 2017

  • Does AORN recommend offloading the supine patient’s heels? If so, how should this be accomplished?

    According to the AORN Guideline for Positioning the Patient, when in the supine position, “the patient’s heel should be elevated off the underlying surface.”(IX.d.) Offloading the supine patient’s heel (ie, suspending the heels above the OR bed surface) increases perfusion and helps prevent pressure injury.

    Pressure on the heels should be redistributed by:

    • Using a heel-suspension device designed to elevate the heel and distribute the weight of the patient’s leg along the calf (Figure 1), or
    • Elevating and supporting the patient’s calves with a pressure-redistributing surface that is wide enough to accommodate the externally rotated malleolus (Figure 2).

    Redistributing the weight of the patient’s leg along the calf reduces the risk for pressure injury to the skin over the sacrum and the Achilles tendon. Using a wide support surface helps prevent localized pressure on the lateral malleolus if the leg rotates externally.


    Offloading supine patient's heels


    Resources

    Guideline for positioning the patient. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated April 11, 2017