B&L
For further reading see Bailey and Love, Chapter 15.Why is correct patient positioning so important?
It is important to enable adequate access to the operation site, and to prevent the patient sliding off the operating table. Side supports may be needed if the patient is being placed into a semi-decubitus lateral position. It is also important to avoid injuries to the patient.
Nerve injuries
Most nerve injuries are due to careless positioning of the patient and inadequate padding resulting in direct compression. They can also result from direct surgical injury, compression by tourniquets, traction, and ischaemia secondary to hypotension. They are most likely to occur in extreme positions and prolonged surgery.
Most are due to a neuropraxia. Ninety per cent undergo complete recovery; 10 per cent are left with residual weakness or sensory loss.
Pressure sores
The operating table will be padded, but additional soft padding under the occiput (horseshoe head support), back, buttocks, elbows and heels (heel protectors) may be required dependent on the patient’s position for surgery.
Predisposing factors include elderly, malnourished, excessively thin or obese patients, patients on steroids, and those with peripheral vascular disease.
Joint injuries (fractures and dislocations)
Inappropriate handling and positioning may aggravate spinal or joint disorders. Special care is needed in patients with prosthetic hip joints.
Joints are most at risk in the lithotomy position and where there is a
‘break’ in the operating table. Be alert to the possibility of atlanto-axial dislocation in rheumatoid arthritis patients.
Patient positioning
Diathermy burns
No part of the skin surface should be in any contact with any metal if diathermy is being used.
Muscle injury
Compartment syndrome may occur after prolonged surgery, e.g. in the lithotomy position.
Eye injuries
Eyes should be closed and taped to prevent injury.
Deep vein thrombosis
Poor patient positioning during prolonged surgery increases the risk of DVTs.
Name some common nerve injuries due to incorrect patient positioning.
■ Ulnar nerve:
• caused by arms held beside the patient in pronation
• ulnar nerve compressed at the elbow between the table and medial epicondyle
• prevented by positioning the arms in supination, with additional padding to protect the ulnar nerve at the elbow
■ Brachial plexus:
• caused by excessive arm abduction or external rotation
• prevented by avoiding more than 60° abduction and preventing the arm from falling off the side of the table
■ Common peroneal nerve:
• caused by direct pressure on the nerve with the legs in the lithotomy position
• nerve compressed against the neck of the fibula
• prevented by adequate padding of lithotomy poles
■ Radial nerve:
• caused by compression from the operating table or arm board
• caused also by tourniquets or misplaced injections in the deltoid muscle
• prevented by adequate padding of tourniquets
■ Eyes and optic nerve:
• direct pressure from surgical instruments and elbows resting over face.
Consent
B&L
For further reading see Bailey and Love, Chapter 9.What is consent?
Informed consent is the process by which a patient is provided with sufficient information to make an informed, reasoned decision regarding the proposed treatment.
Section 5: Patient safety and surgical skills
In order for consent to be valid, three requirements must be met. It must be:
■ informed
■ voluntary (uncoerced)
■ competently given by the patient.
Competence to take the decision requires the ability:
■ to understand the information given
■ to retain and believe it, and
■ to weigh up the information given to reach a reasoned decision.
List the types of consent.
■ Implied consent (e.g. when a patient holds out their arm to have a blood test)
■ Verbal consent
■ Written consent.
What types of consent form might you find in the hospital setting?
■ Consent Form 1 – Patient agreement to investigation or treatment.
This is the standard consent form used for adults undergoing an operation under general anaesthetic.
■ Consent Form 2 – Parental agreement to investigation or treatment for a child or young person.
■ Consent Form 3 – Patient/parental agreement to investigation or treatment (procedures where consciousness is not impaired). In other words, procedures under local anaesthesia, or sedation
(e.g. endoscopy).
■ Consent Form 4 – For adults who are unable to consent to investigation or treatment (usually patients on the ICU).
What information is required for informed consent to take place?
This is easily remembered using the mnemonic CONSENTS:
■ C = condition and natural history
■ O = options/alternatives (conservative/medical/surgical)
■ N = name of procedure
■ S = side-effects and complications
■ E = extra procedures involved (stomas, drains, tracheostomy etc.)
■ N = name of the person operating
■ T = trial and training (research and medical students)
■ S = second opinion.
Finally, answer any questions the patient may have about the procedure and check they are happy to proceed before asking them to sign the consent form.
Consent
Who provides consent in the following clinical situations?
A 15-year-old boy requires an orchidopexy
The parent or guardian gives consent on his behalf. The procedure and its potential risks are explained to the child and the parent or guardian.
In some situations, consent for a child under 16 years of age may be obtained from the child, without their parents or legal guardian consenting on their behalf, if the child is deemed competent to understand the information and make an informed decision (termed
‘Gillick competence’). However, in practice this is a situation that should be avoided if at all possible.
A 75-year-old who is unconscious and requires an emergency operation In the case of an unconscious patient, the law recognises that it is in the patient’s best interest for such an emergency treatment to go ahead.
However, it is always good practice to involve the next of kin in any decision.
If no next of kin is available, it is wise to obtain a colleague’s agreement with the surgical procedure proposed and carefully document this in the notes.