The patient's hysterectomy was nearly a decade ago, yet the pain and anguish from that surgery remain. In an unlikely place: her right arm, which hangs there, numb, weak and without function. From an unlikely source: a poorly positioned armboard that court records say contorted the woman's arm well beyond a right angle for the duration of the 3-hour, 50-minute procedure.

A liability claim still winds its way through the courts to determine whether patient positioning caused the permanent neurological damage. An orthopedist pulled no punches when giving his expert opinion in the lawsuit that the patient filed against the surgeon, anesthesiologist and surgical center: The positioning of the patient during surgery — either while she was anesthetized, in recovery or both — caused her brachial plexus injury.

Proper positioning and padding
Proper patient positioning is a basic standard of care to which all who perform this service are held; no specialty or profession is excused. Yet in today's high-tech ORs, where most positioning devices are decidedly low-tech — gel and foam pads, beanbag positioners, rolled towels and pillows — positioning might seem like a pedestrian pursuit.

Not to Maria Rosario C. Capino, MD, CNIM, who's "passionate about patient positioning," which she calls "an important and often overlooked aspect of perioperative care." Dr. Capino is a neuromonitoring technologist at a major hospital. That's a fancy way of saying that she intraoperatively records and interprets the electrical signals coming to and from the brain and spinal cord in real time. "This is done to protect and warn surgeons that at-risk neural structures such as the brain, spinal cord and peripheral nerves may be potentially injured during neuro, orthopedic and vascular surgeries," she says.

For Dr. Capino, positioning is part art, part science. Take face foam pads, for example. Some face foam pads have clearly measured interface pressures that mitigate the amount of friction and pressure between the face and the pad, she says. It's also easier to check the eyes in a prone position with a face foam pad that has a mirror mounted underneath it rather than a circular foam pad or regular foam pad. Good patient positioning, she says, maximizes exposure, minimizes repositioning errors and ultimately ensures patient safety.

While the attending surgeon should be present in the room during positioning, Dr. Capino stresses that the perioperative nurse, as patient advocate, mustn't be afraid to push for proper patient positioning, paying close attention to pressure sites in supine, prone and lateral positions.

Positioning aid pointers
Good positioning begins before the patient is wheeled into the OR. There's much you can do to prepare ahead of time, says Dr. Capino, from ensuring that an appropriate number of people are available to help transfer the patient from the stretcher to the operating table, to using the appropriate positioning aids. Much of this equipment consists of pads that come in a variety of sizes and shapes to protect pressure points: the head, elbows, knees, ankles, heels and sacral areas. Some of it attaches to the procedure table: headrests/holders, overhead arm supports, stirrups and footboards.

It's all designed to protect and relieve pressure points, to redistribute pressure from pressure points to a larger surface area (arm pads), to protect and cradle the patient's head (donut-shaped head pads), to lift certain areas of the body off the table (rolls), or to ease pressure on the patient's heel area (heel cups). Here are pointers on the proper use of aids:

• Foam pads for arms and legs that are about 3 to 4 inches thick provide a better cushion than the usual 1-inch-thick egg-crate foam mattress overlays.
• Shaped foam pads leave fewer indentation marks in patients who are thin or have histories of malnutrition or peripheral vascular disease. Egg-crate pads may leave reddish blanching marks on the dependent peripheral extremities.
• Never use cloth tape directly on the patient's skin when used as a positioning aid. Doing so may cause skin breakdown to occur.
• Gel foam pads used as axillary/shoulder rolls wrapped in gauze are more elastic and soft than rolls made out of rolled blankets or sheets held together by paper tape.
• Apply Bacitracin over dependent areas that may be compressed during positioning, especially in long cases with patients in the prone position.
• Obese patients need double safety belts.
• To keep pressure off heels, prop pillows under the lower part of patients' legs rather than using blankets to elevate legs. Blankets, says Mike Primiano, BSN, BA, RN, CNOR, nurse manager of the MetroHealth Medical Center in Cleveland, can get too hard and cause nerve damage.
• When patients are in the lithotomy position, be sure 2 staffers are available to raise the patient's legs and position them at the same time to avoid straining the hip joint, says Mr. Primiano.
• This might sound obvious, but be sure you provide a smooth, even surface on the OR bed. Check for wrinkles or uneven surfaces, says Mr. Primiano.
• Don't forget about pressure injuries. The 3 risk factors for skin breakdown are shearing, friction and moisture, says Mr. Primiano. Use a shoulder gel roll if you anticipate that a long case will place undue pressure on the patient's shoulder blade. For many reasons, including pressure-injury prevention, it's good practice to avoid the pooling of prep.

You can anticipate the patient's positioning needs by reading her medical history, says Dr. Capino. Patients who've undergone chemotherapy or radiotherapy, for example, have more fragile skin and are more prone to skin breakdown. Patients with histories of peripheral vascular disease should be free of tight ID bracelets or allergy bands on their wrists; skin breakdown because of constriction may occur when the arms are tucked in with a sheet or sled, she says.

Robotic surgery presents positioning challenges, says Dr. Capino. In transaxillary robotic-assisted thyroidectomies, for example, where the ipsilateral arm is positioned in extension to more than 90 degrees above the head (to allow the robotic arms enough room in the axillary space for maneuverability and access to the neck) the brachial plexus may be subject to stretch and mechanical stress. "This may result in post-operative numbness, tingling, pain and, possibly, weakness," she says. "Monitoring of the ipsilateral arm's muscles and sensory nerves during robotic-assisted thyroidectomies may protect the patient from developing a peripheral neuropathy."