Perioperative Care of the Morbidly Obese Patient

Transcription

Perioperative Care of the
Morbidly Obese Patient in the
Lithotomy Position
3.0
GERALDINE BENNICOFF, RN, CNOR
www.aorn.org/CE
ABSTRACT
The lithotomy position is used daily in the OR to position patients for vaginal,
rectal, and urologic procedures. Use of this position requires a careful nursing
assessment to ensure that the patient can tolerate having his or her legs placed in
the stirrups and to ensure that no pressure points exist for the duration of the
surgery. Caring for a patient who is morbidly obese and who requires surgery in
the lithotomy position can be especially challenging, and the possibility of
injury to the patient or staff members should be considered. A case study
involving the care of a patient who weighed almost 600 lb undergoing surgery in
the lithotomy position demonstrates ways to provide safe care for this type of
challenging patient. AORN J 92 (September 2010) 297-309. © AORN, Inc, 2010.
doi: 10.1016/j.aorn.2010.04.016
Key words: lithotomy position, morbidly obese patients, alternate stirrup use.
P
ositioning a patient plays a major part in
the successful outcome of any surgery.1
Nurses routinely place patients’ legs into
different types of stirrups when the lithotomy position is required. This position presents challenges with any patient; complications can range
from staff member injuries (eg, muscle strain,
backache) to serious patient complications (eg,
nerve palsy, compartment syndrome).1,2 The paindicates that continuing education contact
hours are available for this activity. Earn the contact hours by reading this article, reviewing the
purpose/goal and objectives, and completing the
online Examination and Learner Evaluation at
http://www.aorn.org/CE. The contact hours for
this article expire September 30, 2013.
tient who is underweight, debilitated, disabled,
elderly, or obese, however, can present additional
challenges.1
The average weight of patients is increasing,
and according to the National Health and Nutrition
Examination Survey, 34% of US adults could be
classified as obese in 2006.3 Morbid obesity is defined as a body mass index greater than 40 kg/m2.4
Often, standard equipment is not adequate to provide safe care for larger patients. Medical equipment manufacturers have developed new and
larger table attachments and equipment (eg, lifts,
moving devices) to assist in the care of patients
who are morbidly obese; however, in some instances, innovation is required on the part of a
multidisciplinary perioperative team to provide
safe care.
doi: 10.1016/j.aorn.2010.04.016
© AORN, Inc, 2010
September 2010
Vol 92
No 3 ● AORN Journal
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THE LITHOTOMY POSITION
BENNICOFF
changes in position can damage skin tissue, especially in patients who are older, debilitated, or
obese. Proper patient-moving techniques should
be used to prevent shearing forces.
The lithotomy position is used to allow maximum
surgical exposure in vaginal, rectal, and urologic
procedures. There are four levels of the lithotomy
position ranging from low lithotomy, which
Potential Respiratory and
places a patient’s legs at approximately a
Hemodynamic Complications
35-degree angle to his or her recumbent torso, to
Respiratory complications can occur because the
the exaggerated lithotomy position with the papatient’s abdominal organs shift when the patient’s legs at more than a 90-degree angle.5
tient’s legs are raised and placed in stirrups. This
Patient leg abduction
increases pressure on
should be limited to
the diaphragm and
the degree needed
Patients who are morbidly obese can experience can result in respirafor adequate surgical
tory compromise.5
the common positioning problems that place
exposure to avoid
any patient at risk, and morbid obesity increases Raising or lowering
the patient’s legs too
a patient’s risk of additional complications that
stress on the pathe
nurse
must
consider
in
the
plan
of
care.
rapidly can result in
tient’s hip joints and
fluid volume shifts
prevent compromise
that affect blood
of lower extremity
6
pressure. When team
circulation. Physiologic responses, including musculoskeletal, cutamembers lower the patient’s legs after the proceneous and neurologic, and respiratory and hemodure, fluid volume deficits can quickly become
dynamic responses occur when the patient’s legs
more obvious, making the patient’s hemodynamic
are elevated into lithotomy stirrups; perioperative
status unstable and complicating the anesthesia
team members must take these issues into considcare provider’s management of the patient.5
eration when caring for patients undergoing surgery that requires the lithotomy position.1,5,7
GENERAL NURSING CARE FOR PATIENTS
WHO ARE MORBIDLY OBESE
Potential Musculoskeletal Complications
Patients who are morbidly obese present special
Injuries to the patient’s hips and knees can result
challenges to all members of the perioperative
from lithotomy positioning. Abductor muscles and
team. These patients can experience any of the
hip capsule joint problems can develop if the pacommon positioning problems that place any patient’s legs are stretched or the patient remains in
tient at risk; however, morbid obesity increases a
the lithotomy position for an extended period.
patient’s risk of additional complications that
The patient’s fingers, if tucked at his or her sides,
must be considered in the plan of care (Table 1).8
are in danger of injury when the bottom of the
Nursing interventions to prevent problems include
OR bed is raised or lowered.5
ensuring that sequential compression stockings fit
to prevent constriction and monitoring the paPotential Cutaneous and
tient’s clothing and bed linen to prevent constricNeurologic Complications
Soft tissue problems can result from incorrect
tion and prevent the patient from lying on
handling or positioning by health care providers
bunched or wrinkled material that could cause
and can include injuries to the patient’s femoral,
tissue damage. Drapes must be large enough to
cutaneous, sciatic, and obturator nerves. Pressure
cover the patient and provide a sterile field. Inpoints from inadequate padding and positioning
struments must be large enough to provide ademay cause tissue damage. Shearing force from
quate exposure and allow the surgeon to perform
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CARE OF THE OBESE PATIENT IN LITHOTOMY
the planned procedure, which may require special
bariatric instrument sets.
Potential Musculoskeletal Complications
As a result of the patient’s size and potential mobility difficulties, routine care may be more complicated and require the help of additional support
personnel to avoid injury to the patient or staff
members.1,5,7 There is an increased risk of injuring the patient’s joints, muscles, nerves, and soft
tissues when lifting and moving the patient because of his or her size, and the inability of
health care providers to clearly see the patient’s
anatomic markers (eg, joints) can make safe knee
and hip flexion difficult to determine.1,5,7 Overabduction can occur because of the size and weight
of the patient’s thighs and the need to create adequate space in which the surgeon and staff
members can work.1,5,7 For example, the nurse
should have additional personnel support the
patient’s legs and prevent overabduction when
placing the patient in the frog leg position during
insertion of an indwelling urinary catheter.
Potential Anesthetic Complications
Patients who are morbidly obese present significant challenges for the anesthesia care provider.
Often, these patients experience medication problems as a result of altered absorption and increased storage of medications in their excess fat.
Cardiovascular and respiratory concerns may include increased cardiac afterload, decreased oxygen supply, and a respiratory system taxed by
increased fat metabolism.9 Additional chest
weight, abdominal pressure, and the presence of
coexisting conditions unrelated to the procedure
(eg, hiatal hernia, sleep apnea) increase the patient’s respiratory workload. The patient’s chest
weight and abdominal pressure also increase the
patient’s risk of aspiration and its serious consequences.9 Intubating a patient who is morbidly
obese can be difficult because of limited cervical
neck movement, reduced oxygen reserves, and
increased oxygen consumption.9 Anesthesia care
providers may have difficulty seeing the vocal
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cords because of limited neck movement and fat
deposits that can obstruct the airway. As a result
of these complications, intubating the patient
while he or she is awake may be necessary.9 The
anesthesia care provider may require special head
positioning and support aids such as an airway
management head cradle and an elevation wedge
specifically designed to assist with induction and
head support during procedures on patients who
are obese. Emergency response carts also should
be in the room in the event of a difficult intubation or other emergency. The patient also may
require appropriately sized blood pressure cuffs.
Potential Cardiovascular Complications
Cardiac conditions that often present in patients
who are morbidly obese may include hypertension, diabetes, bradycardia or tachycardia, and
slow cardiac conduction and ischemia. As a complicating factor, the electrocardiogram conduction
signal may be distorted as a result of excess chest
fat. Furthermore, patients who are obese have an
increased incidence of deep vein thrombosis, and
superficial veins may be difficult to access for IV
placement.9
PLACING THE PATIENT WHO IS
MORBIDLY OBESE IN THE
LITHOTOMY POSITION
“Obese patients are more prone to difficulty with
positioning and positioning injuries during surgery
because of the strain excessive weight places on
their musculoskeletal and nervous systems.”9(p45)
Patients who are obese also may present with existing areas of skin damage that need to be assessed
and taken into consideration during positioning.
It is imperative that the perioperative nurse has
a preoperative discussion with the surgeon and
the anesthesia care provider about plans and
needs for the surgery. The circulating nurse
should perform a careful preoperative assessment
of the patient to identify cardiac, vascular, or neurologic conditions that could affect the patient’s
safety or care during surgery. Additionally, the
nurse should identify any issues that might
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TABLE 1. Nursing Care Plan for Patients Who Are Morbidly Obese
Diagnosis
Body image
disturbance
Nursing interventions

Imbalanced nutrition:
more than body
requirements or
ineffective health
maintenance

Ineffective family
therapeutic
regimen
management or
compromised
family coping

Outcome indicator
Identifies psychosocial status
Assesses coping mechanisms
Identifies barriers to
communication
Identifies the patient’s and
designated support person’s
educational needs
Identifies expectations of home
care
Implements measures to provide
psychological support
Includes the patient and
designated support person in
perioperative teaching
Explains the expected sequence of
events
Provides status reports to the
designated support person
Evaluates psychosocial response
to the plan of care
Evaluates response to instructions

Identifies baseline gastrointestinal
status
Assesses nutritional habits and
patterns
Assesses psychosocial issues
specific to the patient’s nutritional
status
Includes the patient and
designated support person in
perioperative teaching
Provides instruction regarding
dietary needs
Evaluates response to instructions
Evaluates response to nutritional
instruction

Develops an individualized plan of
care
Consults with appropriate health
care providers to initiate new
treatments or change existing
treatments
Minimizes the length of the
operative or invasive procedure by
planning care
Uses a clinical pathway
Ensures continuity of care

Outcome statement
The patient verbalizes the
sequence of events to expect
before and immediately after
surgery.
The patient states realistic
expectations regarding
recovery from the procedure.

The patient or
designated support
person demonstrates
knowledge of the
expected responses to
the operative or invasive
procedure.
The patient verbalizes
compliance with food and
fluid restrictions before
surgery.
The patient describes the
recommended postoperative
nutritional intake regimen for
the recovery period at the
time of discharge.

The patient or
designated support
person demonstrates
knowledge of nutritional
management related to
the operative or invasive
procedure.
The patient reports that
individual choices were
honored before and after
surgery.

The patient’s care is
consistent with the
individualized
perioperative plan of
care.
(table continued)
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TABLE 1. (continued) Nursing Care Plan for Patients Who Are Morbidly Obese
Diagnosis
Risk of perioperative
positioning injury
Nursing interventions

Risk of impaired skin
integrity, risk of
falls, impaired bed
mobility, or
impaired transfer
ability

Outcome indicator
Assesses baseline skin condition
Identifies baseline cardiac status
Identifies baseline tissue perfusion
Identifies baseline musculoskeletal
status
Identifies physical alterations that
require additional precautions for
procedure-specific positioning
Verifies presence of prosthetics or
corrective devices
Positions the patient
Implements protective measures
to prevent skin/tissue injury
caused by mechanical sources
Applies safety devices
Evaluates tissue perfusion
Evaluates musculoskeletal status
Evaluates for signs and symptoms
of physical injury to skin and tissue

Confirms patient identity
Assesses baseline skin condition
Identifies baseline musculoskeletal
status
Transports according to individual
needs
Evaluates for signs and symptoms
of physical injury to skin and tissue
Evaluates musculoskeletal status

Ineffective breathing
pattern, ineffective
airway clearance,
impaired gas
exchange, risk of
aspiration, or
anxiety

Identifies baseline respiratory
status
Identifies physiologic status
Reports deviation in diagnostic
study results
Reports deviation in arterial blood
gas studies
Monitors physiologic parameters
Monitors changes in respiratory
status
Uses monitoring equipment to
assess respiratory status
Evaluates respiratory status

Outcome statement
The patient’s pressure points
demonstrate hyperemia for
less than 30 minutes.
The patient has full return of
movement of extremities at
the time of discharge from
the OR or procedure room.

The patient is free from
signs and symptoms of
injury related to
positioning.
The patient reports being
comfortable when reclined on
the transport equipment/
device.
The patient is free from signs
and symptoms of injury
related to transfer/transport
on discharge from the OR or
procedure room.
The patient’s skin is warm,
dry, and free from edema.
Capillary refill and SaO2 show
adequate tissue perfusion.

The patient is free from
signs and symptoms of
injury related to transfer/
transport.
The patient’s tissue
perfusion is consistent
with or improved from
baseline levels.
The patient is breathing
spontaneously with
supplemental oxygen without
assistance on transfer at the
time of discharge from the
OR or procedure room to the
postoperative unit.
The patient’s SaO2 and
respiratory rate are in the
expected range at discharge
from the postoperative care
unit.

The patient’s respiratory
status is maintained or
improved from baseline
levels.
SaO2 ⫽ arterial oxygen saturation.
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adversely affect the patient when he or she is
placed in the lithotomy position, such as
inability to tolerate the lithotomy position,
restrictions to mobility or joint range of motion, and
conditions of the skin or circulation.

The nurse should note any concerns in the patient’s medical record and convey these concerns
to the surgical team.
Assembling additional staff members to help
during moving and positioning also prevents injuries to staff members. A verbal walk-through of
the planned move and positioning needs can help
reduce injuries. Depending on the patient’s status
and the surgical exposure needs, team members
may need to experiment with positioning with a
volunteer staff member standing in for the patient.
The RN in charge of the patient should act as
the person in charge of the move to reduce
confusion and prevent injury to the patient or
staff members. Before taking the patient into the
OR, the nurse should ensure that all positioning
equipment (eg, heavy-duty stirrups, gel pads, pillows) is available, is in position, and has been
checked for function and safety. Transporting patients who are obese may necessitate the use of
special assistance devices or carts.
Equipment (eg, OR bed, stirrups, arm boards)
must support the patient’s weight and fit the extremities to avoid causing injury. When caring for
patients who are morbidly obese, the surgical
team must modify many aspects of routine care to
deal with the patient’s larger size and weight. A
bariatric OR bed is needed that can support the
patient’s weight and provide additional width.
Typical bariatric beds are capable of supporting
up to 1,000 lb and are extra wide, and the mattresses are well constructed to help prevent full
compression of the mattress. Other equipment
considerations include providing appropriately
sized arm boards and safety belts for the bed. Devices to support the extremities (eg, slings) may
be needed.
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Bariatric stirrups should hold up to an 800-lb
patient, but stirrups manufactured for bariatric
beds must be assessed for each patient. For instance, although the stirrup could support the
weight of the patient’s leg, the sides of the boot
may be too narrow to accommodate the size and
circumference of the leg without creating pressure. Perioperative team members may have to
improvise stirrups to accommodate the patient
without causing problems. Methods to improvise
should not be undertaken that would contradict
the manufacturer’s instructions for use or negate
the product warranty, however.
Different types of stirrups are available for the
lithotomy position, but candy-cane shaped, kneecrutch, and boot-type stirrups are used most often.
Instructions for use from the manufacturer and
AORN positioning recommendations should always be followed during use of positioning aids,
including stirrups.1 Candy-cane shaped stirrups
provide good exposure of the surgical site, are
easy to use, and allow room for the team to work.
Knee-crutch stirrups are commonly used during
cystoscopy procedures, which tend to be shorter
in duration. Boot-type stirrups are often used during procedures in which the patient is awake (eg,
local anesthesia, monitored anesthesia care) because they allow the patient’s legs to be in a
lower, more comfortable position and can be
raised if necessary. Use of each type of stirrup
has the potential to cause problems (eg, nerve or
pressure injuries, overrotation).
Candy-Cane Shaped Stirrups
These stirrups look similar to a cane and are attached to the side of the OR bed (Figure 1). After
attaching the stirrups to the bed, perioperative
personnel can rotate them to change the angle at
which the stirrups hold the legs. The patient’s
foot is secured in a double sling made of cotton
webbing and suspended from the end of the cane
by a fastener. Injury can occur if the patient’s
legs are allowed to relax and extend outward to
rest on the cane bar.2 Pressure from the cane bar
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Figure 1. Candy-cane shaped stirrups.
Figure 3. Boot-type stirrups.
on the lateral aspect of the calf or knee can result
in footdrop or nerve injury to the leg. Although
padding can be placed between the cane bar and
the patient’s leg, pressure injury can still occur.
The patient’s hips can be externally overrotated
when in these stirrups to a point of hyperabduction,2 which can cause sciatic and obturator nerve
injury and injury to the patient’s hip and knee
joints and leg muscles. Gel boots and wide straps
can pad and reduce pressure to the ankle and
foot. The patient’s leg weight and the duration of
the procedure can increase the potential for further injury to the distal sural and plantar nerves.
on the popliteal space. Knee-crutch stirrups also
have the potential to cause injury to the posterior
and the common peroneal nerves and the popliteal
artery because they place pressure on the popliteal
fossae and may not evenly distribute pressure.2
Knee-Crutch Stirrups
These stirrups resemble the top of a walking
crutch (Figure 2). The nurse places the patient’s
leg over the crutch and positions the leg so it is
resting over the supporting arch. All weight is
resting on the knee, which can put undue pressure
Figure 2. Knee-crutch stirrups.
Boot-Type Stirrups
These stirrups resemble boots attached to the
sides of the OR bed and give more support to the
entire leg (Figure 3). They are commonly used
for procedures in which the patient is receiving
local anesthesia or monitored anesthesia care as
well as during pelviscopy procedures. The support
that boot-type stirrups provide reduces the potential for nerve and pressure injury because pressure
is evenly distributed to the leg and foot; however,
the same types of injuries that occur with other
stirrups can occur when these stirrups are used.
Boot-type stirrups are attached to the bed at the
level of the patient’s hip socket and reduce stress
on the hip joint. It is important to remember that
these stirrups may appear easier to use, but incorrect placement of the bed attachment bracket can
cause stress injury to the patient’s hip.
General Concerns With Any
Type of Stirrup
In general, stirrups are secured on the OR bed
rails at the level of the patient’s hip socket, with
the patient’s buttocks at the end of the break in
the bed. The nurse can adjust the height of the
boot or foot location to match the patient’s leg
size. To prevent shearing injuries, care should be
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taken to use transfer devices to lift, not slide or
at regular intervals during the procedure,
each time the patient’s position is changed,
pull, the patient if repositioning the patient to the
and
break in the bed is necessary. When placing a
when the patient has been in the lithotomy
normal-weight patient into the lithotomy position,
position for a prolonged period (ie, more than
two team members lift, slightly externally rotate,
four hours).
and flex the patient’s legs and raise them together
while holding the
Procedural time
feet and supporting
should be kept to a
the calves close to
minimum. AORN’s
After the team has completed positioning, the
the knee joints.
“Recommended praccirculating nurse should assess the patient
When the leg is at an thoroughly for alignment, possible pressure
tices for positioning
points and potential sites of injury, and make
appropriate level, the
the patient in the
any necessary adjustments.
team members place
perioperative practice
the patient’s feet in
setting” suggests that
the stirrups. If using
the perioperative
team should consider repositioning the patient if
candy-cane shaped stirrups, staff members should
the procedure lasts longer than four hours.1 The
place the gel boots or straps on the patient before
circulating nurse should then document all posiraising the legs. This decreases the difficulty of
tioning and the names of the staff members ingetting the foot into the strap while holding the
volved as well as all equipment and padding used.
leg, which then provides safer lifting of the leg to
Before moving any lower extremity into or out
the stirrup attachment. Several staff members may
of stirrups, team members should alert the anesbe needed to lift each leg if the patient is morthesia care provider. When the anesthesia care
bidly obese, or pneumatic slings may be required
provider is ready, team members should remove
to position the patient’s legs; no one person
the patient’s legs from the stirrups simultaneously
should attempt to lift the extremity alone. Abducand slowly to minimize lumbosacral strain on the
tion of the patient’s legs should be limited to the
patient. If possible, staff members should bring
degree needed for good surgical exposure, and the
the patient’s legs together simultaneously and
position should not allow either leg to hyperrotate
then lower the patient’s legs to the bed surface
or hyperextend. The nurse should gently secure
one at a time to prevent rapid or unexpected cirthe patient’s arms on padded arm boards at less
culatory changes.1(p339) Before the patient is
than a 90-degree angle and ensure that the patransferred to the postanesthesia care unit, the
tient’s hands, if placed at the sides of the OR bed,
circulating nurse should carefully assess the paare clear of the breaks in the bed to prevent intient for skin, nerve, or pressure injury.
jury when the bottom of the bed is lowered.2
The circulating nurse should assess the patient
CASE STUDY
thoroughly after the team has completed positionTwo weeks before a scheduled surgery, perioperaing. He or she should check the patient for aligntive team members were notified of a lithotomy
ment, possible pressure points and potential sites
procedure to be performed on a patient weighing
of injury (eg, sacrum, arms, hands), and other
approximately 600 lb. Previously, a physician had
potential problems (eg, respiratory or circulatory
attempted to perform an examination with this
compromise as a result of leg positioning) and
patient under anesthesia, and staff members had
make any necessary adjustments. The nurse also
been unable to position the patient or support her
should check the patient’s position
legs in a way that would work for the surgeon
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and be safe for the patient and staff members.
Stability, positioning, and padding needs could
not be met, so the examination had been cancelled. After talking with this physician, the surgical team members determined that stirrups available at the facility, even the ones used for
bariatric surgery patients, would not fit this patient. The gynecology coordinator, circulating
nurse, scrub person, and facility safety officer met
in advance of the procedure to
develop a safe lithotomy positioning device
for a patient who is morbidly obese;
collect, set up, and test equipment;
review potential positioning risks for the patient and staff members; and
determine how to
prevent pressure injury,
provide adequate exposure for the surgeon,
prevent the patient’s position from compromising anesthesia care, and
provide safe, effective care for the patient.

The gynecology coordinator contacted the facility’s stirrup vendor to see whether any currently manufactured stirrups would work for a
patient of this size. The vendor was not able to
find any stirrup that would support this patient
despite checking with several other manufacturers. The vendor suggested that some ORs used
padded Mayo stands or bedside tables to support
Figure 4. Inflated patient transfer pad used to
transfer patients from the OR bed to the transfer
cart and then to the patient’s postoperative bed.
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Figure 5. Mock OR setup with pneumatic lifts in
place at the sides of the bed.
the patient’s legs, but the team decided that these
pieces of OR furniture were not intended for that
use and therefore the team could not ensure the
patient’s safety. The gynecology coordinator discussed options with the facility safety officer and
had the idea of using two patient lifts, one for
each leg. These lifts are capable of supporting
450 lb each, so team members decided that if the
lifts met the team’s positioning needs, they would
provide a safe way to support this patient’s legs.
Practice Session
The team members set up a mock OR that included a special bed used for bariatric procedures
to develop and perfect a modified lithotomy position. A team member placed a full-length inflatable patient transfer device on the OR bed. This
inflatable pad is placed under the patient and
buckled in place (Figure 4). When the device is
inflated, team members can more easily move the
patient to the OR bed with little effort and safely
place the patient in position on the bed. They
then deflate the pad and leave it in place for use
in moving the patient to the transfer cart and later
to the patient bed. Both reusable and disposable
pads are available.
Team members positioned lifts at either side of
the bed in the mock OR setup (Figure 5). After
the safety officer answered team members’ questions about how the lifts functioned and the team
members had a chance to work with the lifts to
become familiar with them, the team members
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Figure 6. Perioperative nurse volunteer in position in
the pneumatic lift stirrups.
locked the lifts in place and one team member
volunteered to be positioned using the lifts (Figure 6). Team members assessed their colleague
for positioning problems or pressure points while
she was on the bariatric bed and in the slings and
experimented with different padding options. The
team chose to use thick gel pads to cover any
surface that would come into contact with the
patient on the bed. Team members placed pillows
in the slings to reduce their concave shape and to
support the patient’s knees and covered the pillows with gel pads extending beyond the sling
edges to reduce calf pressure. Team members
used wide, thick, egg-crate foam pads to further
protect the patient’s ankles. Special care was
planned to pad and protect the folds and rolls of
tissue present on the patient’s legs where
necessary.
During induction before positioning, the patient
would be placed in a supine position. The team
planned to secure two long, wide safety belts together to cover the patient’s thigh area and use a
second set over the patient’s calves. They planned
to use two padded, extra-wide arm boards with
gel pads and wide arm straps to secure the
patient’s arms.
Additionally, the anesthesia care provider
planned to use the airway management head cradle and elevation wedge to prevent an increase in
abdominal and thoracic pressure when the patient
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was in the supine position (Figure 7). Both the
wedge and the head cradle would be left in place
throughout the procedure to assist in anesthesia
care. Team members anticipated that this patient
might experience a difficult induction and intubation and made sure that the emergency cart for
difficult airways was in the room and that a circulating nurse would be present to assist the anesthesia care provider during induction.
Finally, the team planned to provide thermoregulation assistance. Warm blankets would be
placed over the patient and a temperatureregulating blanket would be placed over the patient’s chest.
Preoperative Phase
On the day of surgery, the preoperative nurse reviewed the patient’s chart in the holding area and
admitted the patient. The nurse reviewed the patient’s history and interviewed the patient about
her allergies, previous surgeries, NPO status, and
problems that would affect perioperative care and
then answered the patient’s questions. The nurse
verified the intended surgery with the patient and
the surgical consent. The nurse noted that the surgeon had explained to the patient, and documented on the informed consent, that a somewhat
“experimental” positioning device that was not
specifically designed for the lithotomy position
would be used to facilitate positioning of the
Figure 7. Airway management head cradle and
elevation wedge.
patient for the procedure and that there might be
additional risks associated with the equipment
used in this manner. The patient acknowledged
her understanding and accepted the risks.
The nurse ensured that an inflatable patient
transfer pad was placed on the bariatric stretcher
before the patient got onto the stretcher, after
which the nurse placed extra-large sequential
compression device (SCD) leggings on the patient. The anesthesia care provider started an IV
line, and the nurse administered the prescribed
antibiotics. All concerns about the patient were
communicated to the anesthesia care provider and
the surgeon. The nurse explained to the patient
how she would be moved to the OR bed, and when
the patient was cleared to go to the OR, perioperative team members transferred her to the OR.
Intraoperative Phase
In the OR, a team member inflated the patient
transfer pad and the five-member team and the
anesthesia care provider moved the patient to the
OR bed, ensuring that she was properly positioned
on the chest wedge support. After connecting the
SCD leggings to the unit and securing the safety
belts, the circulating nurse asked the patient if she
was comfortable and made adjustments accordingly. The circulating nurse placed an upper-body
Figure 8. Patient positioned on the bariatric OR bed.
The safety straps have been temporarily removed
so the patient’s legs can be positioned in the
pneumatic lifts. Elements in this photo do not
necessarily comply with AORN standards and
recommended practices.
www.aornjournal.org
Figure 9. Patient in the lithotomy position in
pneumatic lifts. The nurse ensures that no part of
the lift frame or other part of the bed is in contact
with the patient’s legs. Elements in this photo do
not necessarily comply with AORN standards and
recommended practices.
temperature-regulating blanket on the patient and
then assisted the anesthesia care provider with
induction. The emergency cart was not needed
because the induction went smoothly. After induction, the anesthesia care provider inserted additional IV lines and an arterial line.
Team members used the inflatable patient
transfer pad to move the patient into a lower position on the bed and then deflated it and tucked
the ends through the table break to prevent soiling
of the mat during the surgery. Team members
moved the leg lifts with pillows and gel pads into
position on either side of the OR bed and locked
them in place (Figure 8). As a result of the patient’s large size, team members lifted both legs
and then placed each of the patient’s legs into the
slings separately while the slings were at table
height, ensuring that hip rotation was appropriate
to avoid patient injury. Three people were needed
to lift each of the patient’s legs, bend the legs at
the knee, and place them in the slings. After both
legs were in the slings (Figure 9) and the
patient’s hands were checked for safe positioning
to prevent her fingers from being trapped by the
bed as it was repositioned, a team member
dropped the end of the bed to prepare for the procedure. Team members placed enough padding
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around the patient’s ankles and lower legs on top
of the SCDs to redistribute pressure and then
carefully adjusted the height of the lifts to an appropriate height for the procedure.
The circulating nurse assessed the patient’s
position for potential pressure areas and made
adjustments as needed; however, the patient’s size
made finding bony landmarks difficult and ruled
out the use of graduated compression stockings.
The nurse monitored the patient’s legs throughout
the procedure.
The scrub person, surgeon, and surgical assistants placed the drapes for the surgical field. Extra drapes were needed to adequately cover the
lifts. After draping the surgical field, the surgeon
began the surgical procedure. One limitation that
team members noted was that space at the end of
the bed to perform the surgery was unavoidably
limited by the sling size and placement. The circulating nurse provided team members with extra
steps so team members could participate as
needed (eg, retracting surgical tissue) without
leaning on the patient or inadvertently moving the
patient’s legs.
The procedure lasted 90 minutes and was uneventful. After the procedure was completed, the
team members carefully lowered the slings and
moved the patient’s legs from the slings back
onto the bed surface. The circulating nurse assessed the patient for positioning injuries and did
not observe any. The patient’s skin appeared to
be in the same condition as it had been on arrival
in the OR. Team members reinflated the patient
transfer pad to move the patient back onto the
bariatric cart and transferred her to the postanesthesia care unit without incident. The patient recovered well and was discharged to home the
next day.
Postoperative Phase
A postanesthesia care unit nurse called the patient
48 hours after surgery. The patient reported that
she had not noted any positioning injuries, which
indicates that the preoperative anticipation and
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BENNICOFF
No 3
planning contributed to the patient’s positive outcome. The surgeon informed the team members
that the patient’s recovery had been uneventful
and that the patient was pleased with the results
of the surgery.
Evaluation
After the surgery, the team members discussed
their success and identified opportunities for
improving this modified positioning protocol. In
caring for this patient, team members discovered that

preplanning for positioning and padding was
required to prevent patient and staff member
injury,
additional transport and transfer help was
required,
use of transfer devices (eg, an inflatable patient transfer pad) was essential,
extra staff members were needed and care had
to be taken to avoid injury to staff members
when moving a patient of this size,
power lifts for the slings were necessary and
functioned successfully,
draping had to be adjusted to adequately cover
the lifts and provide a sterile field,
space at the end of the bed to perform the surgery was unavoidably limited by the sling size
and placement, and
extra steps were needed to ensure visibility of
the surgical site and prevent inadvertent patient injury.
In reviewing the modified equipment used in positioning the patient for this procedure and the
patient’s surgical outcomes, the team members
determined that use of patient slings was a safe
alternative to stirrups when caring for this patient
who was morbidly obese and required surgery in
the lithotomy position.
CONTINUED SUCCESS
Team members have since participated in additional procedures requiring this method of leg
support and experienced the same success. Team
members have discussed patient needs with the
facility stirrup vendor and have evaluated the use
of newer slings that also would provide safe support to patients who cannot be cared for with
standard equipment. This learning experience required team members to combine creativity and
perioperative knowledge to provide the type of
care that all patients deserve.
Editor’s note: Patient lifts were used as stirrups
in this article; this represents an off-label use of
these medical devices.
References
1.
Recommended practices for positioning the patient in the
perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN,
Inc; 2010:327-350.
2. Graling PR, Colvin DB. The lithotomy position in colon
surgery: postoperative complications. AORN J. 1992;
55(4):1029-1039.
3. FastStats: obesity and overweight. Centers for Disease
Control and Prevention. http://www.cdc.gov/nchs/fastats/
overwt.htm. Accessed May 14, 2010.
4. Statistics related to overweight and obesity. US Department of Health and Human Services. Weight-Control
www.aornjournal.org
5.
6.
7.
8.
9.
Information Network. http://win.niddk.nih.gov/statistics.
Accessed May 14, 2010.
AORN bariatric surgery guideline. In: Perioperative
Standards and Recommended Practices. Denver, CO:
AORN, Inc; 2010:481-499.
Heizenroth PA. Positioning the patient for surgery. In:
Rothrock JC, ed. Alexander’s Care of the Patient in
Surgery. 13th ed. Philadelphia, PA: Mosby; 2008:130157.
AORN guidance statement: Safe patient handling and
movement in the perioperative setting. In: Perioperative
Standards and Recommended Practices. Denver, CO:
AORN, Inc; 2010:673-695.
Petersen C, ed. Positioning injury. In: Perioperative
Nursing Data Set: The Perioperative Nursing Vocabulary. 3rd ed. Denver, CO: AORN, Inc; 2010:178-184.
Ide P, Farber ES, Lautz D. Perioperative nursing care
of the bariatric surgical patient. AORN J. 2008;
88(1)30-58.
Geraldine Bennicoff, RN, CNOR, is the gynecology coordinator at Meriter Hospital, Madison, WI. Ms Bennicoff has no declared affiliation that could be perceived as posing a
potential conflict of interest in the publication
of this article.
AORN Journal
309
EXAMINATION
CONTINUING EDUCATION PROGRAM
3.0
www.aorn.org/CE
Perioperative Care of the Morbidly
Obese Patient in the Lithotomy Position
PURPOSE/GOAL
To educate perioperative nurses about perioperative care of patients who are
morbidly obese and undergoing surgery in the lithotomy position.
OBJECTIVES
1.
2.
3.
4.
Identify complications of using the lithotomy position.
Describe stirrups commonly used for placing a patient in the lithotomy position.
Explain perioperative care of the patient who is morbidly obese.
Discuss potential complications that a patient who is morbidly obese may
experience.
The Examination and Learner Evaluation are printed here for your convenience. To receive continuing education credit, you must complete the Examination and Learner Evaluation online at http://www.aorn.org/CE.
QUESTIONS
1. Respiratory complications can occur when a patient is placed in the lithotomy position because
1. the patient’s abdominal organs shift, which
increases pressure on the diaphragm.
2. the patient becomes anxious when he or she
realizes that the surgery is about to start.
3. fluid volume shifts may affect blood pressure
if the patient’s legs are raised or lowered too
rapidly.
4. surgical personnel put pressure on the patient’s chest, which can cause the patient to
hypoventilate.
a. 1 and 3
b. 2 and 4
c. 1, 2, and 4
d. 1, 2, 3, and 4
2. When a patient who is morbidly obese is placed
in the lithotomy position, overabduction of the
patient’s legs can occur because of the
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September 2010
Vol 92
No 3
1. size and weight of the patient’s thighs.
2. need to create adequate space for the surgeon
and staff members to work.
3. laxity of tendons and muscles common in patients who are morbidly obese.
4. inability to clearly see the patient’s anatomic
markers (eg, joints).
a. 1 and 3
b. 2, 3, and 4
c. 1, 2, and 4
d. 1, 2, 3, and 4
3. Electrocardiogram conduction signal distortion
can result from excess chest fat in patients who
are morbidly obese.
a. true
b. false
4. During the preoperative assessment, the circulating nurse should identify issues that might adversely affect the patient when he or she is
placed in the lithotomy position, including
© AORN, Inc, 2010
CE EXAMINATION
1.
2.
3.
4.
cardiac, vascular, or neurologic conditions.
conditions of the skin or circulation.
inability to tolerate the lithotomy position.
restrictions to mobility or joint range of
motion.
a. 1 and 3
b. 2 and 4
c. 1, 2, and 4
d. 1, 2, 3, and 4
5. Potential complications of using candy-cane
shaped stirrups include
1. footdrop or nerve injury to the leg.
2. sciatic and obturator nerve injury.
3. injury to the hip and knee joints and leg
muscles.
4. injury to the distal sural and plantar nerves.
5. undue pressure on the popliteal space.
a. 1 and 4
b. 2, 3, and 5
c. 1, 2, 3, and 4
d. 1, 2, 3, 4, and 5
6. Potential complications of using knee-crutch stirrups include
1. pressure on the popliteal fossae.
2. injury to the posterior and the common peroneal nerves and the popliteal artery.
3. injury to the distal sural and plantar nerves.
4. undue pressure on the popliteal space.
a. 1 and 3
b. 1, 2, and 4
c. 2, 3, and 4
d. 1, 2, 3, and 4
7. The circulating nurse should check the patient’s
position
1. after the team has completed positioning.
2. at regular intervals during the procedure.
3. each time the patient’s position is changed.
4. when the patient has been in the lithotomy
position for a prolonged period.
www.aornjournal.org
a. 1 and 3
c. 1, 2, and 4
b. 2 and 4
d. 1, 2, 3, and 4
8. Staff members should bring the patient’s legs together simultaneously and then lower the patient’s legs to the bed surface simultaneously to
prevent rapid or unexpected circulatory changes.
a. true
b. false
9. In the case study, when preparing the OR for the
procedure, team members
1. used thick gel pads to cover any surface that
would come into contact with the patient on
the bed.
2. placed pillows in the slings to reduce their
concave shape and to support the patient’s
knees.
3. covered the pillows with gel pads that extended beyond the sling edges to reduce calf
pressure.
4. used wide, thick, egg-crate foam pads to further protect the patient’s ankles.
a. 1 and 3
b. 2 and 4
c. 1, 2, and 4
d. 1, 2, 3, and 4
10. In the case study, one limitation that team members noted was that
a. the patient developed a decubitus ulcer under
her right heel.
b. the space at the end of the bed to perform the
surgery was unavoidably limited by the sling
size and placement.
c. the patient’s legs repeatedly slipped off the lift
slings.
d. the lifts could not be raised as high as the surgeon needed for access to the surgical site.
The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor,
with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewell
have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.
AORN Journal
311
LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM
3.0
www.aorn.org/CE
Perioperative Care of the Morbidly
Obese Patient in the Lithotomy Position
T
his evaluation is used to determine the extent to
which this continuing education program met
your learning needs. Rate the items as described
below.
OBJECTIVES
To what extent were the following objectives of this
continuing education program achieved?
1. Identify complications of using the lithotomy
position. Low 1. 2. 3. 4. 5. High
2. Describe stirrups commonly used for placing a
patient in the lithotomy position.
Low 1. 2. 3. 4. 5. High
3. Explain perioperative care of the patient who is
morbidly obese. Low 1. 2. 3. 4. 5. High
4. Identify potential complications that a patient
who is morbidly obese may experience.
Low 1. 2. 3. 4. 5. High
CONTENT
5. To what extent did this article increase your
knowledge of the subject matter?
Low 1. 2. 3. 4. 5. High
6. To what extent were your individual objectives
met? Low 1. 2. 3. 4. 5. High
7. Will you be able to use the information from
this article in your work setting? 1. Yes 2. No
8. Will you change your practice as a result of
reading this article? (If yes, answer question
#8A. If no, answer question #8B.)
8A. How will you change your practice? (Select all
that apply)
1. I will provide education to my team regarding why change is needed.
2. I will work with management to change/
implement a policy and procedure.
3. I will plan an informational meeting with
physicians to seek their input and acceptance
of the need for change.
4. I will implement change and evaluate the
effect of the change at regular intervals until
the change is incorporated as best practice.
5. Other:
8B. If you will not change your practice as a result
of reading this article, why? (Select all that
apply)
1. The content of the article is not relevant to
my practice.
2. I do not have enough time to teach others
about the purpose of the needed change.
3. I do not have management support to make a
change.
4. Other:
9. Our accrediting body requires that we verify the
time you needed to complete the 3.0 continuing education contact hour (180-minute)
program:
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center
approves or endorses products mentioned in the activity.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this
activity for relicensure.
Event: #10058; Session: #4022 Fee: Members $15, Nonmembers $30
The deadline for this program is September 30, 2013.
A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each
applicant who successfully completes this program can immediately print a certificate of completion.
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No 3
© AORN, Inc, 2010