The Trauma of Poor Surgical Positioning

By Grant Law Office on May 2, 2018

When someone undergoes surgery, he is putting his life and his health in the hands of a surgical team. Though we should be able to trust these medical professionals to take the utmost care throughout the procedure, if they fail to do so and a patient suffers injury, they can be held accountable.

Most major surgical procedures require patients to be put under general anesthesia, a coma-like state that renders them completely unable to move their bodies, feel pain, or feel any other sensation. This condition can be dangerous for patients because they cannot react to any numbness or discomfort.

For instance, if you’re lying in a position that cuts off circulation to a body part or makes it difficult to breathe, you notice the discomfort and adjust your body appropriately. A patient under general anesthesia cannot do this. Prolonged obstruction of breathing, blood flow, or electrochemical impulses of nerve pathways can result in temporary or permanent injuries known as “surgical positioning injuries.”

Trained medical personnel are aware of the dangers of such injuries, and may employ different arrangements of a patient’s body and limbs to prevent them. However, not all do, and Americans are harmed every day by these avoidable surgical errors.

Types of Surgical Positioning Injuries

Surgical positioning injuries generally fall into the following four categories:

• Respiratory: When a patient’s position restricts movement or puts pressure on the rib cage, diaphragm, or chest, airflow to the lungs can be impeded. This is particularly a problem when operating on obese patients. Lack of oxygen to the brain for an extended period of time can result in brain damage.
• Circulatory: Extended periods where blood flow is restricted can result in tissue damage, damage to the cardiovascular system, and brain and nerve damage. This can be prevented by reducing the procedure time, changing the position of limbs during surgery, and massaging limbs at regular intervals during surgery.
• Skin: Prolonged compression of the skin between prominent bones and other surfaces can cause tissue damage. These injuries can range from mild irritation to severe pressure ulcers.
• Peripheral nerve injuries: There are various nerve injuries caused by poorly positioned patients. There are three main types to be aware of:
• Ulnar injury: The ulnar nerve, running along the ulna bone in the arm, gives sensation to the forearm and fourth and fifth fingers. Injuries to the ulnar nerve are the most common peripheral nerves to be injured during surgery. When compressed, feeling is completely cut from the area, and this often occurs when there is extreme flexion of the elbow that stretches the nerve.
• Brachial plexus injury: The brachial plexus is a network of nerves extending from the spinal cord through the neck and into the armpit, and when improperly positioned, patients can experience numbness and weakness in the upper extremity. Brachial plexus injuries are the second most common peripheral nerve injured due to improper positioning of patients during surgery.
• Spinal cord: The least likely but perhaps most severe peripheral nerve injury is to the spinal cord. Injury to the spinal cord can occur from improper placement of a patient’s neck during a surgical procedure.
• Tissue ischemia: A restriction of blood supply to tissues which causes a shortage of oxygen necessary to keep tissue alive, ischemia can occur when a patient is improperly adjusted while lying flat on their back.
• Compartment syndrome: Long surgeries in particular are susceptible to compartment syndrome, particularly when the surgery is done in lithotomy position (a patient lying on his or her back with legs apart) or lateral decubitus position (a patient lying on his or her side). Compartment syndrome is when pressure within muscles builds up to dangerous levels, decreasing blood flow and preventing oxygen from reaching nerve and muscle cells.
• Pulmonary compromise: When surgery is done in the lateral decubitus position, there is a chance of pulmonary problems, due to the movement of abdominal contents and the mediastinum, which improve airway movement and increase blood flow.
• Eye injuries: Prolonged surgical procedures associated with acute blood loss anemia, hypotension (low blood pressure), and/or hypoxia (low oxygen level) may lead to vision loss (posterior ischemic optic neuropathy). Also, direct pressure to the periorbital region of the eye, including, but not limited to, by Mayfield pins or a horseshoe headrest, can cause increased intraocular pressure and blindness as the result of central retinal artery occlusion. Patients undergoing spinal fusion surgery in the prone position are particularly vulnerable. Visual loss is usually the result of ischaemic optic neuropathy (ION), retinal vascular occlusion, or rarely, cortical blindness. Blindness can also occur if the eyes are improperly taped allowing antiseptic skin preparation solutions to flow into the eyes, especially when the patient is in the prone position (lying face down). The prone position contributes to the ability of the prep to get into the improperly taped eyes.

The surgical team is jointly responsible for avoiding these injuries. The team includes the surgical nurse/scrub nurse, anesthesiology, and the surgeon. The anesthesiologist, sometimes referred to as the “head of the bed,” has the authority to stop the procedure if the patient is in danger of a positioning injury, but everyone on the team should speak up if there is a concern for the patient due to positioning. With proper care, these injuries are preventable.

Determining Proper Surgical Positioning

When determining the safest surgical position for a patient, the preoperative team should take into account the patient’s overall health, medical history, age, body weight, height, type of surgery, expected duration of surgery, type of anesthesia to be used, nutritional status, and preexisting medical conditions, such as pressure ulcers, diabetes, circulation problems, etc.

Consideration should also be given to which position:

• Provides the entire surgical team a clear view of the surgery site.
• Provides the surgeon the best access to the surgery site.
• Provides the anesthesiologist with the optimal position for administering drugs.
• Reduces the amount of bleeding before, during, and after the procedure.
• Reduces the risk of nerve pressure, respiratory obstruction, and circulatory obstruction.

Common Surgical Positions

Based on the above considerations, the surgical team will decide on either one of or a variation of the following surgical positions:

• Supine: Patient lying on back
• Prone: Patient lying facedown
• Lateral: Patient lying on left or right side
• Lithotomy: Patient in supine position, but legs are lifted up in stirrups
• Trendelenburg: Patient in supine position, but with head lower than feet
• Reverse Trendelenburg: Patient in supine position, but with head higher than feet
• Kraske: Patient in prone position with hips elevated, and head and feet down
• Fowler’s: Patient in sitting position
• Knees to chest: Patient in prone position, with hips and knees flexed

With all positions, care should be taken that the patient is as comfortable as possible before applying anesthesia, and that appropriate padding is being used to alleviate pressure at contact points.

Did You Suffer a Damage Because of Surgical Positioning?

If a surgical positioning error caused you injury, you may face further costly medical treatments, lost wages, loss of career, even loss for your joy of living. These financial and lifestyle losses deserve fair compensation from the liable parties involved.

To find out how you can recover compensation for these surgical complications, contact the experienced medical malpractice attorneys at Grant Law Office for a free case evaluation. For over three decades, we have fought for the rights of Georgia injury victims, and we will do the same for you. Call us today at (404) 995-3955 to speak to an Atlanta medical malpractice attorney.