All surgical team members have equal responsibility for maintaining patient safety during transfer. The anaesthetist, who has responsibility for the patient’s airway, generally coordinates the lift (Heizenroth, 2007). The duty of the registered nurse (RN) is to assess the surgical environment and patient, and ensure that the most appropriate transfer equipment, positional aids and staff are available. During the transfer a team leader, usually (but not always) the anaesthetist, directs the team, including the patient if he or she is conscious. When the patient is anaesthetised and/or unconscious, this role will normally revert to the anaesthetist, as maintenance of a patent airway and ventilation are the main priorities (Fell & Kirkbride, 2007).

When conscious patients participate in the move, interventions needed to secure a safe transfer include:

• ensuring there is a minimal gap between the trolley and the operating table

• using the brakes on both the trolley and the operating table

• making sure the patient’s gown is not caught in the trolley/bed side rails

• always placing a team member on the opposite side of the table to guide the patient.

Prior to and at each stage of the transfer of a fully conscious patient who is participating in the move, clear directions and explanations are necessary. The staff member instructing patients should direct patients to feel for the sides of the operating table as they move across, so they can be confident they are centrally located. The trolley or bed should not be moved away until the patient is securely positioned and confirms this. If the patient has reduced mobility and cannot move independently, then equipment such as patient slide boards, patient slide sheets or mechanical devices (e.g. hover mat) is needed. These devices enable patient transfer while reducing the risk of injury to staff members. A minimum of four staff members are generally required for the safe transfer of these patients, using the safety precautions described above.

When transferring unconscious or anaesthetised patients, the anaesthetist manages the patient’s airway and supports the head. As the patient has no muscle control, limbs need safeguarding so they do not overhang the operating table, predisposing them to injury.

Arms are secured across patients’ chest or by their side and legs are supported and moved in alignment with the body. These patients will have IV access and monitoring devices established and care must be taken not to obstruct or dislodge these.

Patient positioning

Correct patient positioning is essential to performing a safe and unconstrained surgical procedure. The required position can place patients at risk of injury, particularly if the procedure is lengthy and/or requires general anaesthesia. Patients are positioned so that:

• there is optimum surgical access

• cardiovascular and respiratory functions are not compromised

• body alignment is maintained

• injury and falls are prevented (Hamlin, 2005a).

Patients are immobile during surgery and, because they are no longer able to change and control their body position, they are at an increased risk of developing decubitus ulcers, venous thromboembolism and pulmonary dysfunction (Fulbrook & Grealy, 2007). Additionally, unconscious, immobile patients cannot change an uncomfortable position or complain of discomfort or pain related to their position.

Anatomical and physiological considerations for patient positioning

A patient’s tolerance of the stresses imposed by the surgical intervention depends significantly on the normal functioning of the vital systems, and each body system must be considered when planning the patient’s position for surgery. The goals of positioning include the prevention of injury from pressure, crushing, stretching, pinching or obstruction (Phillips, 2007). The development of such injuries is influenced by the:

• position required for the procedure—all positions pose a risk, some more so than others

• patient’s health status and physical condition—the very young and elderly patients present greater positional challenges (Phillips, 2007), as do obese patients (McChlery 2007), irrespective of any other underlying pathophysiology

• estimated length of time for the procedure and the associated immobility—the longer the surgery takes, the greater the risk (Phillips, 2007)

• type of operating table used and positioning aids required/available

• type of anaesthetic given

• planned surgical procedure (Fell & Kirkbride, 2007; Hamlin, 2005a; Heizenroth, 2007).

Nerve involved	Cause of damage
Brachial plexus	• Extending the arm beyond 90° angle, when an arm board is used • Pressure from shoulder braces (used in the Trendelenburg position) • Patient’s body weight on the lower (dependent) arm when in lateral position • Arm unsecured and allowed to fall off the table • Splitting of the sternum during cardiac surgery • Over-rotation and lateral flexion of the patient’s head (see Fig 4-2)
Median, radial and ulnar nerves	• Pressure on the medial aspect of the patient’s arm when devices used to secure the arm are unpadded, or restraints are too tight • Patient’s body weight on the lower (dependent) arm when in lateral position
Femoral nerve	• Inappropriate positioning of abdominal or vaginal retractors • Inappropriate positioning of the patient in the lithotomy position, resulting in over-stretching of the nerve (see Fig 4-3)
Sciatic nerve	• Hyperflexion of the hip joint, particularly when patient’s legs are lifted incorrectly during surgery (see Fig 4-4)
Common peroneal nerve	• Pressure of the stirrups or leg-holding devices on the patient’s calf when in lithotomy position (all variants) • Failure to place a pillow between the patient’s legs when lateral position used • Incorrectly sized or inappropriate application of sequential compressive devices • Pressure from devices placed under the patient’s knees (see Fig 4-5)

Heizenroth (2007)

Figure 4-2 Brachial plexus on the right side (Drake et al., 2008, p 369).

Figure 4-3 Nerves of the inner thigh (Rothrock, 2007, p 140).

Figure 4-4 Right sciatic nerve (Drake et al., 2008, p 295).

Figure 4-5 Right leg, lateral view (Drake et al., 2005, p 554).

Cardiovascular system

Anaesthetic agents can affect the cardiovascular system by causing peripheral vasodilation and subsequent pooling of blood in the extremities, resulting in hypotension (Heizenroth, 2007). Patient positioning can further affect this phenomenon; for example, a head-up, supine (reverse Trendelenburg) position will cause blood to pool in the lower extremities. Consequently, the movement of patients into and out of these positions must be measured and unhurried. Pregnant patients and those with large abdominal masses are particularly at risk of supine hypotensive syndrome (Fell & Kirkbride, 2007).

Adequate arterial circulation is necessary to perfuse tissue, and occlusion or pressure on peripheral vessels, such as might be caused by positioning devices or safety belts/ straps, must be avoided (Phillips, 2007). For example, patients who are placed in the lithotomy position are at risk of compartment syndrome in their lower limb(s), which occurs when perfusion pressure falls below tissue pressure in a closed anatomical space or compartment (Wilde, 2004). This can occur when patients are in this position for extended periods of time. Compartment syndrome develops via a combination of prolonged tissue ischaemia and subsequent reperfusion of muscle within a tight osseofascial compartment and, untreated, leads to necrosis and functional impairment (Dua et al., 2002).

Additionally, there is increased potential for thromboembolic episodes. Different positions, such as lithotomy, the time spent in these positions and the devices used to maintain them (e.g. safety belts, stirrups or other leg-holding devices) contribute to venostasis and the formation of thrombi.

Respiratory system

Respiratory function can also be compromised, particularly when a patient is positioned head-down, supine (Trendelenburg), which causes the abdominal viscera and organs to shift up towards the diaphragm, subsequently affecting inspiratory and expiratory tidal volumes. This is especially so for patients who are obese, pregnant or have pre-existing respiratory disease (Heizenroth, 2007). The prone position also impedes respiratory function. Ideally, patients should spend as little time as possible in these positions. Excessive pressure caused by positional aids or the placement of the patients’ arms on the chest area should also be avoided (Heizenroth, 2007).

Surgical positions

There are several standard surgical positions, with a range of variations, and standard operating tables are designed to accommodate this range. Positions commonly used include:

• Trendelenburg and reverse Trendelenburg

• fracture table position

• Fowler’s and semi-Fowler’s position.

Supine position

In the supine position, patients lie on their back with their arms either secured at their sides or placed out on an arm board. This commonly used position provides access to the abdominal, peritoneal and cardiothoracic cavities, the extremities and the head and neck. Table 4-2 shows nursing interventions and rationales for this position.

Table 4-2 Supine position—nursing interventions and rationales

Nursing intervention	Rationale
1. Padded operating table mattress—gel mattress or air support surface overlay.	1. Padding or special mattress overlays protect occiput, scapulae, olecranon, vertebrae, sacrum, coccyx and calcaneus from undue pressure.
2. Padding or gel pads placed on extensions or other positional aids as required (arm boards, J boards).	2. Protects ulnar nerve from pressure-induced damage.
3. Heels may require padding/sheepskin bootees, especially if the patient is elderly or malnourished.	3. Padding/bootees protect the heels from undue pressure.
4. Keep arm board(s) level with the operating table and at an angle of 90° (or less). Arm(s) must be loosely secured to the board.	4. Protects peripheral vasculature and nerves from damage, including the brachial plexus and ulnar nerve.
5. Legs remain uncrossed at the ankle.	5. Relieves undue pressure, decreasing risk of venous thrombosis.

Heizenroth (2007); Phillips (2007); Rank (2008)

Prone position

In the prone position, patients lie face down. This position is used when surgical access to the spine, rectum or dorsal areas of the extremities is required. It can be achieved on a standard operating table or it may require a specially designed table or table fittings (e.g. a laminectomy frame); the choice is determined by the particular surgical intervention.

The patient is anaesthetised in the supine position prior to transfer, and the airway is secured using a reinforced, flexible endotracheal tube (ETT), which will not kink. The ETT is secured with tape by the anaesthetist. The patient is then lifted and placed with the abdomen down on the operating table, and the face turned to one side. This transfer requires a minimum of four people to be executed safely, with one member of the team, usually the anaesthetist, supporting the patient’s head and neck and safeguarding the airway at all times. The position requires additional padding (often in the form of multiple pillows or rolls on the operating table) to protect vulnerable areas, such as patient’s ear and cheek on the dependent side, the breasts (females), genitalia (males), patellae and toes (see Fig 4-6). Table 4-3 shows nursing interventions and rationales for the prone position.

Figure 4-6 Prone position (Rothrock, 2007, p 154).

Table 4-3 Prone position—nursing interventions and rationales

Nursing intervention	Rationale
1. Padded operating table mattress—gel mattress or pillows/rolls (or gel pad over laminectomy frame, if used).	1. Extra padding needed to protect vulnerable areas, such as the dependent cheek, ear, breasts (female), genitalia (males), patellae and toes.
2. Padding placed on extensions as required (arm boards, J boards). Arms should be secured loosely, palm down on padded arm boards and kept in natural alignment. They should not be allowed to hang over the edge of the operating table.	2. Arms are moved down and forward and placed on the arm board slowly and carefully to minimise the risk of damage to the brachial plexus. Arms hanging over the table edge can sustain damage to the radial nerve.
3. Eye ointment placed in both eyes, eyelids are then securely taped closed.	3. The eyes are vulnerable to corneal abrasion.

Heizenroth (2007); Phillips (2007); Rank (2008)

Lateral position

In the lateral position, which is used for procedures involving the chest, kidney or hip joint, the patient lies on the non-operative (dependent) side, with the operative side uppermost. It requires a selection of positional aids to secure the patient because there is a risk of the patient rolling forward or backwards intraoperatively or even falling off the table. The patient is anaesthetised in the supine position and then transferred or turned onto the dependent (non-operative) side. Positional aids include specially designed, padded arm rests (e.g. Carter Brain arm rest) to support the upper arm and keep it away from the operative area; table/safety straps and pliable bean bags are used to hold the patient securely to the operating table and maintain the position throughout surgery (Fig 4-7). Alternatively, padded table attachments (lateral supports or kidney braces), one at the patient’s back and a larger one supporting the abdomen, can be used. Table 4-4 shows nursing interventions and rationales for the lateral position.

Figure 4-7 Lateral position (Rothrock, 2007, p 156).

Table 4-4 Lateral position—nursing interventions and rationales

Nursing intervention	Rationale
1. Padded operating table mattress and padding placed on extensions as required (arm boards and arm supports) and pillow for head.	1. Protection of pressure points on the dependent side—the ear, shoulder, hip, ankle.
2. Pillow is placed between the patient’s knees.	2. Knees will rub against each other, damaging the skin; additionally, undue pressure can damage the peroneal nerve.
3. Spine is kept in alignment by placing a pillow under the patient’s head.	3. The spine is vulnerable to misalignment and twisting; this misalignment can place pressure on the dependent brachial plexus.
4. Patient needs securing by the use of either lateral supports (kidney braces) (padded) at the abdomen and back, or the use of devices such as bean bags or a Vac-Pac and a safety belt/ table strap over the patient’s upper thigh.	4. Prevents the patient from falling off the operating table. The use of these devices also ensures the patient does not move intraoperatively.
5. Ensure the patient’s shoulder on the non-operative (dependent) side is not over-extended and the lower arm is protected, usually by securing it to an arm board. The upper arm is placed on a lateral arm support.	5. Prevents damage to the brachial plexus and ulnar nerve.
6. Kidney surgery requires access to the retroperitoneal area of the flank. In this case, the patient is positioned so that the lower iliac crestis below the lumbar break where the kidney bridge is located on operating table. The latter is subsequently elevated (slowly) and the operating table flexed to lower the patient’s upper torsoand legs.	6. Prevents the dependent flank area from compression and subsequent pooling of blood in the lower extremities.