Prone Positioning Under

Anesthesia

Aarti Vadhavkar, M.D.

CA-2
February 15, 2008
Overview
• Importance of Positioning

• Physiologic Effects

• Support Devices

• Establishing Prone Position

• Complications

2
Positioning Under Anesthesia
• Optimal position: offers maximum anatomical access; yet
is physiologically safe for the anesthetized patient.
• Peripheral nerve injury: 2nd most common anesthetic
complication represented in the ASA Closed Claims
Database1.
• First article in literature on effects of body position on
anesthesia published by Dutton2 in1933.
• General anesthesia abolishes normal protective reflexes →
significant physiologic and functional hazards for the
prone patient.

1
Cheney FW et al. Nerve Injury Associated with Anesthesia: A Closed Claims Analysis. Anesthesiology 90: 1062-
1069, 1999
2
Dutton A. The Effects of Posture During Anesthesia. Anesthesia Analgesia 1933; 12:66-74 3
Physiologic Effects
• Circulatory
• ↑ intraabdominal & intrathoracic pressure→ ↓cardiac
output, ↓BP
• IVC obstruction → vertebral venous plexus
engorgement → ↑ bleeding, ↑ risk of thrombosis
• Head low position: venous congestion of face and neck
→ facial, conjunctival and airway edema
• Head high position: risk of venous air embolism

4
Physiologic Effects
• Several studies3,4,5 to assess hemodynamic
response to prone position
• ↓Stroke volume, ↓ Cardiac index
• ↑SVR, ↑PVR
• HR, PAOP, Right atrial pressure: no change
• Recommend invasive hemodynamic monitors in
patients with precarious cardiovascular status

3
Backofen JE, Schauble JF. Hemodynamic changes with prone positioning during general anesthesia. Anesthesia
Analgesia 1995; 64: 194
4
Wadsworth R. et al. The effect of four different surgical prone positions on cardiovascular parameters in healthy
volunteers. Anaesthesia. 1996 Sep;51(9):819-22
5
Sudheer PS et al.. Haemodynamic effects of the prone position: a comparison of propofol total intravenous and
inhalation anesthesia. Anaesthesia, 2006 Feb;61(2): 138–141 5
Physiologic Effects
• Respiratory
• Cephalad shift of diaphragm, compression abdominal
viscera → ↓ FRC, ↑work of breathing, ↑airway pressures
• Ventral supports: improved lung volumes, oxygenation,
and compliance, esp in obese patients6
• Ventilation and perfusion are more uniform in prone
position → ↓ V/Q mismatch → Improved oxygenation7

6
Pelosi P. et al: Prone positioning improves pulmonary function in obese patients during general anesthesia.
Anesthesia Analgesia 83:578-583, 1996
7
Nyren S. et al. Pulmonary perfusion is more uniform in the prone than in the supine position: scintigraphy in
healthy humans. Journal of Applied Physiology. 1999;86:1135-41.
6
Support Devices – Head & Neck
• Surgical pillow/ foam
donut, C-shaped face
piece, horseshoe
head rest, Prone
Positioner, Prone Prone Positioner C-Shaped Face Piece

View Helmet.

• Mayfield tongs: most

stable; recommended
in cervical disc
disease
Horseshoe Head Rest Mayfield Tongs
7
Support Devices - Ventral
• Rolls of tightly packed sheets,
bean bags, convex frames (e.g.
Wilson frame), pedestal
frames (e.g. Relton), special
OR tables (e.g. Jackson)
• Study8 of 51 spine surgery
patients to compare different
prone positioners.

• Jackson spine table: minimal

effects on cardiac function
8
Dharmavaram S. et al. Effect of prone positioning systems on
hemodynamic and cardiac function during lumbar spine surgery:
an echocardiographic study. Spine. 2006 May 20;31(12):1388-
93
8
Support Devices
• Limited comparative studies: skewed,
inconclusive

• Choice based on patient’s physique, available

equipment, requirements of surgical procedure

9
Establishing Prone Position
• Adequate anesthetic depth and muscle relaxation
• Monitoring leads, IV lines, catheters: secure and
sufficiently long to sustain position change
• Anesthesiologist manages head and airway
• ETT disconnected briefly; reconnected after turn
• Acceptable ventilation assured, all monitors
rechecked and secured

10
Establishing Prone Position
• Head
• Check for migrated monitoring wires, IV lines
underneath
• Eyes
• Padded, taped shut
• Lubricants: controversial
• Ears
• Check for compression, folding of pinna

11
Establishing Prone Position
• Neck
• Assess ROM of C-spine
& shoulders in pre-op
visit
• Rule out cervical spine
arthritis, thoracic
outlet syndrome,
cerebrovascular
disease .

12
Establishing Prone Position
• Arms
• Padded armboards • Protective padding:
• Arms abducted, flexed at Ulnar nerve at cubital
elbows tunnel, radial nerve in
spiral groove of
• <90⁰ arm abduction
humerus
• relieves tension on shoulder
muscles
• ↓compression of axillary
• Check for full pulses at
neurovascular bundle by wrists
humeral head

13
Establishing Prone Position
• Torso
• Ventral longitudinal supports to relieve chest and
abdominal wall compression
• Breasts
• Positioned medially and checked for compression
• Genitalia
• Pillow placed over caudal end of longitudinal supports
• Knees, Toes
• Flexed and padded, esp in prone kneeling position
• Pillow to support ankles off table surface

14
Establishing Prone Position

9
Martin JT and Warner MA (eds). Positioning in Anesthesia and Surgery (3 rd edition) . WB Saunders, PA 1997.
15
Complications
Risk Factors
• Peripheral neuropathies • Advanced age
• Nerve entrapment • Alcohol abuse
syndromes e.g. carpal • Malnutrition
tunnel
• Vitamin deficiencies
• Diabetes mellitus
• Corticosteroid use
• Osteoarthritis,
• Contractures
Rheumatoid arthritis
• Pre-existing decubiti • Morbid obesity
• Venous stasis • Hypothyroidism
• Previous traumatic injury, • Renal disease
fractures
16
Complications
• Airway
• Accidental extubation
• Obstruction of ETT
bloody secretions/
sputum plugs
• Facial, Airway edema
• Prolonged head low
position, ↑ crystalloid
infusion
• Problems with
extubation

17
Complications
• Accentuation of pre-existing trauma
• Multiple skeletal injuries may be further exacerbated
during positioning

• Neck injury
• Excessive lateral torsion or hyperflexion → Post-op
pain, cervical nerve root or vascular compression

18
Case Report
• 40/M w/h/o C-spine whiplash injury s/p C4-5-6 discectomy
underwent excision of soft tissue mass in prone position ↓GA 10
• C-spine stabilization, awake fiber optic intubation, horseshoe
head rest
• PACU: c/o dizziness, headache, painful numbness of right face,
slurred speech and myoclonic spasms of left side extremities
• MRA: Rt vertebral artery stenosis → lateral medullary syndrome
• Causes: excessive rotation or extension of head during
positioning, hypoperfusion under GA → exacerbated vertebral
arterial insufficiency.

Chu YC et al. Lateral Medullary Syndrome after Prone Position for General Surgery. Anesthesia Analgesia. 2002
10

Nov;95(5):1451-3 19
Injuries: Skin & Soft Tissue
• Key factors: amount and duration of pressure

• High risk areas: face, breasts, genitalia & bony

prominences e.g. malar regions, chin, iliac crests, knees,
toes
• Uncontrollable factors e.g. duration of surgery may
override protective measures → pressure injury

20
Case Report
• 44/M ASA–I underwent revision of right lower extremity
scar in prone position ↓GA11 . H/o multiple LE surgeries in
prone position. No known allergies.
• PronePositioner used, uneventful operative course
• POD#1: Red rash over face , took Benadryl.
• POD#2: To ER with c/o facial, lip and orbital swelling and
itching. Treated with prednisone and Benadryl
• Allergy/Immunology Consult: Allergic contact dermatitis
from sensitization to urethane foam in PronePositioner
during his previous surgeries.

11
Jericho BG and Skaria GP. Contact Dermatitis After the Use of the PronePositioner Anesthesia Analgesia
2003,97(6):1706-8 21
Injuries: Eye
• Corneal abrasions
• Orbital edema
• Postoperative visual loss ( POVL)
• Rare; unclear etiology
• ASA Closed Claims Project 12 : management of
anesthesiologists frequently implicated
• ASA Professional Liability Committee created the
POVL Registry 13 in 1999

12
ASA Closed Claims Project [Link]
13
American Society of Anesthesiologists Task Force on Perioperative Blindness: Practice advisory for perioperative
visual loss associated with spine surgery: a report by the American Society
22
POVL Registry
• Goal: Identify risk factors associated with POVL
• Retrospective analysis of patients who reported visual loss
< 7 days postop

CRA
O1
CA

Un 9%
RD

1%
kn
IA
C

ow
9%

n
VASCULA
R 5%
SPINE 72% AION 20% PION 60%
O. 4%
ORTH %
. 10
SC
MI

Distribution of cases from the Distribution of 93 ophthalmic lesions

ASA POVL Registry associated with POVL after spine surgery 23
POVL
Ischemic Optic Central Retinal Artery
Neuropathy (ION) Occlusion (CRAO)
Etiology Intraop ↓ BP Direct external pressure
Prolonged surgery Emboli
↑ Blood loss
↑ Crystalloid infusion
Mechanism Ischemia ↓Ocular perfusion pressure
Orbital edema → stretch
and compression of ON
Clinical Painless Painless
Features Bilateral Unilateral
↓Light perception Periorbital swelling or
↓ Visual fields ecchymosis

24
Injuries: Nerves
• Mechanisms
• ↑ stretch, compression → ischemia
• Occur despite adequate protection1,12 → other factors?
• Prone patient
• Supraorbital, facial, mandibular nerves
• Brachial plexus and its peripheral components

1
Cheney FW et al. Nerve Injury Associated with Anesthesia: A Closed Claims Analysis. Anesthesiology 1999. 90:
1062-1069.
12
ASA Closed Claims Project [Link]
25
Injuries: Brachial Plexus

9
Martin JT and Warner MA (eds). Positioning in Anesthesia and Surgery (3 rd edition) . WB Saunders, PA 1997.
26
Complications
• Other
• Compartment syndrome, Rhabdomyolysis

• Venous air embolism

• Visceral ischemia: pancreatitis

• Undiagnosed space occupying lesions

27
Case Report
How does one manage cardiac arrest in a prone patient?

• 60/F underwent decompression laminectomy T11-L1 for

invasive tumor ↓GA in prone position14
• Prolonged surgery, ↑ blood loss
• 9 hrs: ↓BP → pulseless V tachycardia: VAE ?
• Field flooded with NS, ventilated with 100% O2
• Open surgical wound, bleeding, protruding surgical
metalwork
• Defibrillator paddles placed in right axilla and left apex →
200J DC shock → Sinus rhythm

14
Brown J. et al. Cardiac arrest during surgery and ventilation in the prone position: a case report and systematic
review. Resuscitation 2001. 50(2) : 233-238 28
Core Competencies
• Patient Care: provided medical care to patient discussed
• Medical Knowledge: reviewed current literature regarding
physiologic effects, support devices, complications and
management of prone positioning under anesthesia
• Practice-based learning and improvement: assimilated
scientific evidence pertinent to this case; provided
reflective practice for future improvement in patient care
• Interpersonal and Communication skills: discussed the
complication with the patient and neurosurgical team
• Professionalism: showed respect and accountability to the
patient and provided follow-up care to the patient
• Systems-based practice: coordinated care between
Neurosurgical, Anesthesia and Dermatology services.

29
Reflective Practice
• In addition to risks inherent with general
anesthesia, it might have been prudent to discuss
complications associated with positioning in
informed consent
• Earlier detection could have resulted in faster
healing of lesions.

30
References
1. Cheney FW, Domino KB, Caplan RA, Posner KL Nerve Injury Associated with Anesthesia: A Closed Claims
Analysis. Anesthesiology 1999. 90: 1062-1069.
2. Dutton Adena The Effects of Posture During Anesthesia. Anesthesia Analgesia 1933. 12:66-74
3. Backofen JE, Schauble JF. Hemodynamic changes with prone positioning during general anesthesia. Anesthesia
Analgesia 1995. 64: 194
4. Wadsworth R. et al. The effect of four different surgical prone positions on cardiovascular parameters in healthy
volunteers. Anesthesia 1996. Sep;51(9):819-22
5. Sudheer PS et al.. Haemodynamic effects of the prone position: a comparison of propofol total intravenous and
inhalation anesthesia. Anesthesia 2006. Feb;61(2): 138–141
6. Pelosi P. et al: The prone position during general anesthesia minimally affects respiratory mechanics while
improving FRC and increasing oxygen tension. Anesthesia Analgesia 1995. 80:955,
7. Nyren S. et al. Pulmonary perfusion is more uniform in the prone than in the supine position: scintigraphy in
healthy humans. Journal of Applied Physiology. 1999;86:1135-41.
8. Dharmavaram S. et al. Effect of prone positioning systems on hemodynamic and cardiac function during lumbar
spine surgery: an echocardiographic study. Spine 2006. May 20;31(12):1388-93
9. Martin JT and Warner MA (eds). Positioning in Anesthesia and Surgery (3rd edition) . WB Saunders, PA 1997.
10. Chu YC et al. Lateral Medullary Syndrome after Prone Position for General Surgery. Anesthesia Analgesia
2002 .Nov;95(5):1451-3
11. Jericho BG and Skaria GP. Contact Dermatitis After the Use of the PronePositioner. Anesthesia Analgesia
2003,97(6):1706-8.

31
References
12. ASA Closed Claims Project [Link]
13. American Society of Anesthesiologists Task Force on Perioperative Blindness: Practice advisory for perioperative
visual loss associated with spine surgery: a report by the American Society of Anesthesiologists Task Force on
Perioperative Blindness Anesthesiology 2006. 104:1319–1328.
14. Brown J. et al. Cardiac arrest during surgery and ventilation in the prone position: a case report and systematic
review. Resuscitation 2001. 50(2) : 233-238 Atwater BI et al. Pressure on the face while in the prone position:
Prone View™ versus Prone Positioner™. Journal of Clinical Anesthesia 2004. Mar;16(2):111-6.
15. Baig MN et al. Vision loss after spine surgery: review of the literature and recommendations. Neurosurgery Focus
2007. 23(5):E1.
16. Chen SH et al. Paraplegia by acute cervical disc protrusion after lumbar spine surgery. Chang Gung Medical
Journal 2005..Apr;28(4):254-7.
17. Palmon SC, et al. The effect of the prone position on pulmonary mechanics is frame-dependent. Anesthesia
Analgesia 1998. Nov;87(5):1175-80.
18. Rehder K. et al. Regional intrapulmonary gas distribution in awake and anesthetized-paralyzed prone man.
Journal of Applied Physiology 1978. 45:528.
19. Kaneko K. et al. Regional distribution of ventilation and perfusion as a function of body position. Journal of
Applied Physiology 1966. 21:767–777.
20. Manna EM et al. The effect of prone position on respiratory mechanics during spinal surgery. Middle East Journal
of Anesthesiology 2005. Oct;18(3):623-30

32