Sine surgery patients who aren’t properly positioned, padded or monitored are vulnerable to any number of complications, including pressure sores, nerve injuries and even vision loss. Overlook one detail and you may end up with devastating, potentially life-changing events.

The most common complication following lumbar spine surgery performed on patients in prone and knee-chest positions? Vision loss, researchers found (osmag.net/sDt7GN). It’s a potentially catastrophic turn of events for providers, too. A disc surgery patient who lost his vision after spending nearly 9 hours in the prone position and under general anesthesia won a $22 million malpractice suit (osmag.net/aHkQR3). How to prevent vision loss?

Use the reverse Trendelenburg to get the head above the level of the heart. “This will minimize edema,” says a New York CRNA. That’s in line with expert recommendations that you position patients, especially those considered high-risk, such that their heads are either at or above the height of their hearts.

Experts also suggest periodically checking head position both before and during surgery, as improper shifting can obstruct blood flow to the optic nerve. You should also keep a close eye on intraoperative eye swelling and pressure.

“We use mirrored prone head positioners,” says Sue Hrnicek, MSN, CNOR, RN, director of surgical services at the Columbus (Neb.) Community Hospital. “Our anesthesia providers check the patient’s face, and document the status every 15 minutes.”

Other steps you can take to ensure your patients’ vision is always protected: lubricate their eyes and tape them closed, and place their heads in foam headrests. Foam eye goggles are also a good choice, says Ashlie Cramer, RN, MSN, CNOR, ST, administrator of the Delray Beach (Fla.) Surgical Suites. “Nursing should work with anesthesia to make sure everything is protected,” she adds.

Another risk factor for post-op vision loss: prolonged operative time, although “if the patient is positioned properly in the beginning, prolonged operative times shouldn’t have an effect,” says Ms. Cramer. “Consistency is key with positioning maneuvers and with staff who are positioning patients.”

Still, an extra dose of caution can only help, says Ms. Hrnicek: “We prepare ahead of the procedure for any possibilities of a prolonged procedure. It’s better to look ahead and overprotect than to endanger a patient.”

One way to do that: Before anesthesia induction, make sure all implants and team members are present, open all sterile goods and check pack integrity.

Hitting a nerve?

Proper placement of extremities can help prevent nerve damage, but intraoperative neuromonitoring might be the most effective way to be sure you’re not missing something. Although most often used to monitor the integrity of the spinal cord, somatosensory evoked potential (SSEP) monitoring while patients are under general anesthesia can also detect peripheral nerve conduction abnormalities that indicate peripheral nerve stress and the potential for injury.

“Peripheral nerve stress is definitely a concern,” says Ms. Cramer. “We use intraoperative neuromonitoring to identify potential disruption to the nerve and to know when the instrumentation could be compressing it. If we note changes, a tech notifies the surgeon. It’s all about preventing permanent nerve damage. The most important thing you can do is try to get patients in the most neutral of positions. Neutral neck, neutral hips, neutral knees.”

“We often reposition arms or legs based on neuromonitoring abnormalities,” says a CRNA.

Monitoring might also help if legal issues arise. “In a court of law, it’s important to provide the critical values [should an injury occur],” adds another facility manager.

The right OR equipment can help, too. Some newer spine tables are hinged mid-table, allowing for ranges of ideal flexion and extension with total spine access across cervical, thoracic and lumbar procedures.

Under pressure

To prevent pressure injuries, be sure to thoroughly assess skin before and after surgery, and pad, pad, pad during surgery.

“Pad everything,” says Ms. Cramer. “We pad every part of the body that’s weight-bearing. You want to put a barrier between it and the table, arm board or cradle.”

“Use memory foam mattresses and padding under all bony prominences,” says an RN from the Northeast. “When patients are in prone positions, you need to protect everything, including toes, foreheads, genitalia and breast tissue.”

How about one last double-check and sign-off before proceeding? “We have the physician check the position before draping for the procedure,” says Susan G. Midgett, BSN, RN, CNOR, an operating room analyst at CalvertHealth Medical Center in Prince Frederick, Md. “But our perioperative staff makes sure the patient is in the proper position. They’ve been trained and educated on the importance of asking questions when there’s any doubt.”

That makes sense, because “the surgeon is focused on the incision site and the position of the spine,” says Ms. Cramer, “so the OR team needs to be aware of the knees, the arms, the shoulders, the feet, the face, the genitals and the breasts. The perioperative staff is there to advocate for the patient, and to address all of the small details.”

Trust the process

The Einstein Medical Center Montgomery in East Norriton, Pa., has developed a process bundle for spine patients and has gone nearly 2 years without a perioperative generated pressure injury, says clinical educator Diane Kimsey, MSN, MHA, RN, CNOR. “Our perioperative staff are in-serviced upon hire and every year thereafter on prevention of pressure injuries through the use of a bundle, and by exercising care in positioning strategies.”

They’re instructed on all pressure points, she says, and are careful to apply preventive dressings to those areas. “We also flag high-risk patients based upon risk assessment and skin assessment, upon admission to the perioperative area,” she says. “A high-risk designation triggers high-risk nursing interventions pre-, intra- and post-operatively.”

That kind of teamwork is essential for dealing with high-risk and obese patients, agrees Ms. Cramer. “You need more manpower and resources available for lifting, shifting, and moving, and also more padding and more protective barriers are usually indicated.”

Another hint: If you’re dealing with heavier patients, don’t forget to verify your table’s weight limit, says Carol Giese, MSN, RN, CNOR, CSSM, director of surgical services, at the Christus St. Michael Health System in Texarkana, Texas. “And assess for impingement immediately after positioning,” she adds.

Finally, keep in mind that when a spine patient gets to recovery, the PACU staff won’t know the position that the patient had been put in during surgery. It wouldn’t hurt to relay the information. OSM