Thanks to the increasingly rapid pace of medical advancement, endoscopists are encroaching on what has often been thought of as surgical territory. Procedures such as peroral endoscopic myotomy (POEM) and endoscopic submucosal dissection (ESD) are exploring the limits of the endoscope and obviating the need for once traditional surgical interventions.
Surgeons already know that angling a patient’s body during a procedure can greatly facilitate success. Laparoscopic procedures in particular often involve tilting the surgical bed, which can help avoid negative outcomes. Polise, et al., wrote, “It is useful to take into account the effect of gravity on lesion exposure, tumour traction during dissection, crushing by body weight, risk of sample drop, risk of damage to adjacent organs, and anatomical exposure for procedures with radiological support.”
The problem is that often such surgical positioning isn’t all that safe or comfortable for the patient, who sometimes has to lie on something hard or sharp or in a physically taxing position. According to the Association of periOperative Registered Nurses, or AORN, patient positioning goals include exposing the surgical site, maintaining the patient’s comfort and privacy, ensuring equipment and IVs are safe and accessible, maintaining optimal patient ventilation, maintaining circulation, protecting the patient’s organs, skin, muscles, joints, eyes, fingers and toes and genitalia, and stabilizing the patient to prevent shifting or motion.
Maggie Armstrong and Ross Moore observed in StatPearls that practitioners should consider several factors when positioning patients. Obviously the patient’s age, weight and size are major considerations, but the team should also look at the patient’s general health and medical history, including any issues with respiration or circulation.
Meeusen wrote, “There are well-established rules for [patient positioning] during surgical operations, and nurses and surgeons are well-versed in how to follow them. Unfortunately, endoscopic treatments do not have these criteria.”
In the journal Frontiers in Oncology, Li-Jun Zhou and associates agreed. “Each position carries some degree of risk which is maximized in the anaesthetized patient who cannot make others aware of compromised conditions,” they wrote. “Patients may also be transferred and positioned on operating tables whilst they are unconscious. The maneuvering and the final positioning have an impact on potential injuries sustained under anesthesia as endotracheal tubes, intravascular lines, and urinary catheters should be free to move and adequately secured before any movement. This all adds to challenges encountered by both the endoscopist and anesthetist attempting changing patient position during the procedure.”
“There are well-established rules for [patient positioning] during surgical operations, and nurses and surgeons are well-versed in how to follow them. Unfortunately, endoscopic treatments do not have these criteria.”
To help clarify patient positioning in endoscopy, Meeusen and colleagues created guidelines in the journal Gastroenterology Nursing using an observational feasibility study. “Endoscopy units face new challenges arising from the increasing numbers of complex and prolonged advanced procedures on patients who have comorbidities and are obese,” they wrote. “It would be beneficial for the latter if surgical positioning practice guidelines could be adopted during gastrointestinal endoscopic interventions.”
Under Pressure
Pressure injury in gastroenterology is no joke. In International Wound Journal, Jin et al., wrote, “[Intraoperative acquired pressure injuries, or IAPI,] intensify both the physiological and psychological burden on patients. As PI progresses, the incidence of postoperative complications goes up and the length of hospital stay is extended, thus adding difficulty to nursing and elevating the consumption of medical resources. Moreover, there is also an increase in the readmission and mortality rates of IAPI patients within 30 days after surgery.”
In an article for Research Outreach, Dr. Vera Meeusen wrote that patients “can also experience overstretching or compressing nerves and squeezing skin tissue, which can result in temporary or permanent injuries/damage.”
In addition, IAPI is one of the criteria examined by tertiary general hospitals when evaluating clinical care quality and quality improvement efforts.
While studies have examined anesthesia duration, skin temperature and total time of low diastolic blood pressure to help identify IAPI, the primary cause of injury is direct force of continuous pressure on the patient’s skin.
Jin and associates found that “micromovement” for patients undergoing surgery in the supine position reduced the incidence of IAPI by five times over the control group. This movement—accomplished by tilting the surgical table.
15 degrees to the left and then 15 degrees to the right, maintaining the tilt angle for five minutes and alternating every hour—also yielded reduced relative skin temperature differences in the region under pressure, as well as leading to increased job satisfaction in nurses.
Jared Bilski, the editor-in-chief of Outpatient Surgery Magazine, wrote, “A major part of proper positioning involves pressure ulcer prevention, which often comes down to paying close attention to problem areas inherent in the various positions and getting foam or gel rollers underneath the patient’s legs, hips or any other vulnerable areas.”
Assume the Position
Patients generally are placed in one of three positions prior to a procedure: prone (face down, generally with the head turned to the side), lateral (lying on one side or the other), or supine (lying on the back). Each position has its challenges and advantages.
The lateral position is often used for endoscopic procedures. In addition, patients who can’t tolerate being placed in a prone position—such as those who are obese or pregnant— are placed in the lateral position. To prevent peripheral nerve damage, a nurse or technician will place a pillow between a patient’s knees. In right-handed physicians, Somchai Amornyotin wrote in the Journal of Clinical Anesthesia and Intensive Care, “the left lateral position is usually used for esophagogastroduodenoscopy and colonoscopy procedures.”
Zhou wrote that patient positioning was an important element during full-thickness resection of large gastric tumors when the patient is under general anesthesia. “Typically,” they wrote, “the patient is placed in left lateral position for the endoscopic therapy, and during the procedure, [the] patient’s position is changed to maintain the tumor above the gastric fluids to prevent gastric juices and tumor or tumor fragments from falling into the peritoneal cavity in the event of perforation.”
Preplanning, they wrote, is critical. Endoscopy combined with CT scans can help accurately pinpoint the location of the tumor so the clinician can then decide which position will create the most beneficial outcome. “The supine position (include anterior lateral) and left lateral position is convenient for most patients requiring endoscopic full-thickness resections. For patients where the tumor is located on the posterior wall and greater curvature of gastric body and fundus, the prone position or right lateral is best.” They added that water can be injected into the gastric cavity to ensure the placement will be best for the patient and procedure.
It is also possible to perform ERCP in the left lateral position; however, this is not recommended because it can cause pancreatic duct cannulation. On the other hand, the posi- tion can reduce the risk of aspiration. Clinicians weigh the pros and cons of each position and determine what is best for the patient.
The prone position can be a minefield of physiological changes. Increased intra-abdominal pressure. Labored respiration. Increased systemic vascular resistance and decreased venous return. The potential of hypoxia during sedation.
That said, the prone position is ideal for fluoroscopy and radiologic imaging. Using it, as is standard, for endoscopic retrograde cholangiopancreatography (ERCP) can mean a higher technical success rate, but also an increased rate of adverse events. In addition, it’s a difficult position to change on the fly, which can be a real problem if resuscitation becomes necessary. “For this reason,” Amornyotin wrote, “general anesthesia with tracheal intubation is used for ERCP in the morbidly obese patients.”
The supine position’s challenges include impaired respiration via upper airway obstruction, reduced tidal volumes and regurgitation. But supine is the position of choice for percutaneous endoscopic gastrostomy, and it’s also potentially beneficial for airway management during ERCP. “Previous studies demonstrated that technical success of therapeutic ERCP in the supine patient positioning was high and no increased need to use needle-knife papillotomy,” Amornyotin wrote. “However, ERCP performed with the patient in the supine position was often more difficult technically.” They also observed that the supine position created a “higher risk of adverse events” in nonintubated patients than when patients were in the prone position.
Amornyotin wrote, “Particular care is needed for positioning anesthetized patients to avoid passive movements that would not normally be tolerated. Poor positioning can create pressure necrosis and peripheral nerve damage.”
There are more positions, of course, which depend on surgical specialty and necessary requirements.
But Will it Play in Peoria?
Just as every doctor has a slightly different way of doing things, each endoscopy department might, as well. A team in Peoria, Arizona might handle patient positioning completely differently than the way a team in Peoria, Illinois would. And this can create real problems for nurses and technicians, and—by extension—patients. AORN offers tips and keys to help departments standardize this process. This is no small challenge, especially as teams change and new hires come aboard. Bilski wrote, “Even the most seemingly insignificant variations in your positioning processes can cause major safety issues for your patients.”
And it’s definitely a team effort. Per AORN, the RN, anesthesiologist, surgeon and other nurses and techs should act as patient advocates. “Perioperative team members are responsible for maintaining the patient’s autonomy, dignity, and privacy and for representing the patient’s interests throughout the procedure. Some elements of patient positioning are core to anesthesia practice; therefore, the ability of the perioperative team to support the activities of the anesthesia professional is essential.”
Zhou, et al., agreed, emphasizing the importance of allowing the anesthetist to take charge of moving the patient once the patient is under general sedation. “If the patient position needs to be adjusted during endoscopy therapy, extra care must be taken to secure and tape the endotracheal tube to prevent dislodgement while the patient is left lateral or prone or during position changes. Placing an anesthetized patient in the prone position requires the coordination of the entire staff (endoscopist, anesthetist, nurses),” they wrote.
A complication of improper position can include peripheral nerve injuries, which can be difficult to prevent.
During the process, the anesthesiologist will maintain stabilization of the cervical spine and monitor the trach tube, which should be disconnected from the circuit before shifting the patient from a supine to prone position. “Which, and how many, lines and monitors are disconnected during the
shifting is up to the clinical judgment of the anesthesiologist. Ventilation and monitoring should be resumed as rapidly as possible,” Zhou wrote.
Educating staff on the aspects of proper positioning is critical to success. AORN stated that every team member should be responsible for understanding the nuances and potential pit-falls of shifting a patient. They wrote, “All perioperative team members involved in positioning activities are responsible for:
- understanding physiologic changes that occur during operative and other invasive procedures;
- evaluating the patient’s risk for injury based on an assess- ment of identified needs and the planned operative or invasive procedure;
- anticipating the surgeon’s requirements for surgical access;
- gathering positioning equipment and devices;
- using positioning equipment and devices correctly;
- verifying device and equipment integrity;
- monitoring the patient during the procedure;
- applying principles of body mechanics and ergonomics during patient positioning;
- respecting the patient’s individual positioning limitations; and
- implementing interventions to provide for the patient’s comfort and safety and to protect the patient’s circulatory, respiratory, musculoskeletal, neurological, and integumentary ”
Both patients and personnel risk injury if patient positioning is performed incorrectly. Patients are especially vulnerable when under sedation or anesthesia, as their reflexes are blunted and they can’t tell you what their bodies are feeling.
A complication of improper position can include peripheral nerve injuries, which can be difficult to prevent. Such injures are caused by a combination of factors, including stretching, compression, ischemia, and transection, and individual systemic factors like inflammation or hypotension. A stretching injury can cause damage to the neck or spine. A compression injury, on the other hand, can cause edema, ischemia or necrosis.
Standardization, Bilski wrote, starts at the top. Protocols should be tattooed on everyone’s eyeballs, and new hires especially should have the freedom to ask questions or request help. The company culture should welcome questions to ensure everyone’s on the same page.
Before surgery, interview the patient. Talk about issues with lower back, neck, hips or knees. Ask about prior drug re- actions or interactions. Have they had any past surgeries? Review their med- ical history. Be thorough. Go over the prep process—fasting, meds and other necessary changes in their routine.
And be kind. Many patients may be afraid of an upcoming procedure but won’t want to admit it. Give them as much information as you can without overwhelm. Ask what concerns they may have—whether before, during or after the procedure—and what you can do to help allay their worries. Be an advocate.
Organize positioning materials before you need them. And, Bilski wrote, “Focus on the fundamentals. A major part of proper positioning involves pressure ulcer prevention, which often comes down to paying close attention to problem areas inherent in the various positions and getting foam or gel rollers underneath the patient’s legs, hips or any other vulnerable areas.” Pay particular attention to heels, knees, elbows, fingers and toes. Also examine whether you have enough team members to help with positioning. Lisa Croke wrote in AORN Journal, “Good planning allows the perioperative team to ensure the equipment works correctly and helps to avoid last-minute problems.” In other words, focusing on being proactive means your team will have to be less reactive.
Then bring the team together just before the procedure to cover details and coordinate care. This includes anesthesiologists, surgeons, nurses and techs. The briefing should include potential problems or issues such as cardiology challenges, respiratory conditions or obesity. Anything that came up in the patient interview should be shared with the team, including fears and concerns.
Patient positioning is a challenging aspect of patient care. However, the educational materials and resources available can help practitioners, nurses and technicians to avoid potential pit-falls that can cause injury, and empower them to provide each patient with the best possible care.
For article references, visit www.EndoProMag.com.
