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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 297 September 2010 Vol 92 No 3 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 298 AORN Journal 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 www.aornjournal.org 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 AORN Journal 299 September 2010 Vol 92 BENNICOFF No 3 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) 300 AORN Journal CARE OF THE OBESE PATIENT IN LITHOTOMY www.aornjournal.org 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. AORN Journal 301 September 2010 Vol 92 No 3 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. 302 AORN Journal BENNICOFF 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 CARE OF THE OBESE PATIENT IN LITHOTOMY www.aornjournal.org 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 AORN Journal 303 September 2010 Vol 92 No 3 BENNICOFF 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 304 AORN Journal CARE OF THE OBESE PATIENT IN LITHOTOMY 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. www.aornjournal.org 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 AORN Journal 305 September 2010 Vol 92 No 3 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 306 AORN Journal BENNICOFF 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. CARE OF THE OBESE PATIENT IN LITHOTOMY 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 AORN Journal 307 September 2010 Vol 92 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 308 AORN Journal 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 CARE OF THE OBESE PATIENT IN LITHOTOMY 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 310 AORN Journal ● 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. 312 AORN Journal ● September 2010 Vol 92 No 3 © AORN, Inc, 2010
