Perioperative Care of the Morbidly Obese Patient in the ... - AORN

Perioperative Care of theMorbidly Obese Patient in theLithotomy PositionGERALDINE BENNICOFF, RN, CNOR3.0ABSTRACTThe lithotomy position is used daily in the OR to position patients for vaginal,rectal, and urologic procedures. Use of this position requires a careful nursingassessment to ensure that the patient can tolerate having his or her legs placed inthe stirrups and to ensure that no pressure points exist for the duration of thesurgery. Caring for a patient who is morbidly obese and who requires surgery inthe lithotomy position can be especially challenging, and the possibility ofinjury to the patient or staff members should be considered. A case studyinvolving the care of a patient who weighed almost 600 lb undergoing surgery inthe lithotomy position demonstrates ways to provide safe care for this type ofchallenging patient. AORN J 92 (September 2010) 297-309. © AORN, Inc, 2010.doi: 10.1016/j.aorn.2010.04.016Key words: lithotomy position, morbidly obese patients, alternate stirrup use.www.aorn.org/CEindicates that continuing education contacthours are available for this activity. Earn the contacthours by reading this article, reviewing thepurpose/goal and objectives, and completing theonline Examination and Learner Evaluation athttp://www.aorn.org/CE. The contact hours forthis article expire September 30, 2013.Positioning a patient plays a major part inthe successful outcome of any surgery. 1Nurses routinely place patients’ legs intodifferent types of stirrups when the lithotomy positionis required. This position presents challengeswith any patient; complications can rangefrom staff member injuries (eg, muscle strain,backache) to serious patient complications (eg,nerve palsy, compartment syndrome). 1,2 The patientwho is underweight, debilitated, disabled,elderly, or obese, however, can present additionalchallenges. 1The average weight of patients is increasing,and according to the National Health and NutritionExamination Survey, 34% of US adults could beclassified as obese in 2006. 3 Morbid obesity is definedas a body mass index greater than 40 kg/m 2 . 4Often, standard equipment is not adequate to providesafe care for larger patients. Medical equipmentmanufacturers have developed new andlarger table attachments and equipment (eg, lifts,moving devices) to assist in the care of patientswho are morbidly obese; however, in some instances,innovation is required on the part of amultidisciplinary perioperative team to providesafe 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 BENNICOFFTHE LITHOTOMY POSITIONThe lithotomy position is used to allow maximumsurgical exposure in vaginal, rectal, and urologicprocedures. There are four levels of the lithotomyposition ranging from low lithotomy, whichplaces a patient’s legs at approximately a35-degree angle to his or her recumbent torso, tothe exaggerated lithotomy position with the patient’slegs at more than a 90-degree angle. 5Patient leg abductionshould be limited tothe degree neededfor adequate surgicalexposure to avoidstress on the patient’ship joints andprevent compromiseof lower extremitycirculation. 6 Physiologicresponses, including musculoskeletal, cutaneousand neurologic, and respiratory and hemodynamicresponses occur when the patient’s legsare elevated into lithotomy stirrups; perioperativeteam members must take these issues into considerationwhen caring for patients undergoing surgerythat requires the lithotomy position. 1,5,7Potential Musculoskeletal ComplicationsInjuries to the patient’s hips and knees can resultfrom lithotomy positioning. Abductor muscles andhip capsule joint problems can develop if the patient’slegs are stretched or the patient remains inthe lithotomy position for an extended period.The patient’s fingers, if tucked at his or her sides,are in danger of injury when the bottom of theOR bed is raised or lowered. 5Potential Cutaneous andNeurologic ComplicationsSoft tissue problems can result from incorrecthandling or positioning by health care providersand can include injuries to the patient’s femoral,cutaneous, sciatic, and obturator nerves. Pressurepoints from inadequate padding and positioningmay cause tissue damage. Shearing force fromchanges in position can damage skin tissue, especiallyin patients who are older, debilitated, orobese. Proper patient-moving techniques shouldbe used to prevent shearing forces.Potential Respiratory andHemodynamic ComplicationsRespiratory complications can occur because thepatient’s abdominal organs shift when the patient’slegs are raised and placed in stirrups. Thisincreases pressure onthe diaphragm andcan result in respiratorycompromise. 5Raising or loweringthe patient’s legs toorapidly can result influid volume shiftsthat affect bloodpressure. When teammembers lower the patient’s legs after the procedure,fluid volume deficits can quickly becomemore obvious, making the patient’s hemodynamicstatus unstable and complicating the anesthesiacare provider’s management of the patient. 5Patients who are morbidly obese can experiencethe common positioning problems that placeany patient at risk, and morbid obesity increasesa patient’s risk of additional complications thatthe nurse must consider in the plan of care.GENERAL NURSING CARE FOR PATIENTSWHO ARE MORBIDLY OBESEPatients who are morbidly obese present specialchallenges to all members of the perioperativeteam. These patients can experience any of thecommon positioning problems that place any patientat risk; however, morbid obesity increases apatient’s risk of additional complications thatmust be considered in the plan of care (Table 1). 8Nursing interventions to prevent problems includeensuring that sequential compression stockings fitto prevent constriction and monitoring the patient’sclothing and bed linen to prevent constrictionand prevent the patient from lying onbunched or wrinkled material that could causetissue damage. Drapes must be large enough tocover the patient and provide a sterile field. Instrumentsmust be large enough to provide adequateexposure and allow the surgeon to perform298 AORN Journal

CARE OF THE OBESE PATIENT IN LITHOTOMYwww.aornjournal.orgthe planned procedure, which may require specialbariatric instrument sets.Potential Musculoskeletal ComplicationsAs a result of the patient’s size and potential mobilitydifficulties, routine care may be more complicatedand require the help of additional supportpersonnel to avoid injury to the patient or staffmembers. 1,5,7 There is an increased risk of injuringthe patient’s joints, muscles, nerves, and softtissues when lifting and moving the patient becauseof his or her size, and the inability ofhealth care providers to clearly see the patient’sanatomic markers (eg, joints) can make safe kneeand hip flexion difficult to determine. 1,5,7 Overabductioncan occur because of the size and weightof the patient’s thighs and the need to create adequatespace in which the surgeon and staffmembers can work. 1,5,7 For example, the nurseshould have additional personnel support thepatient’s legs and prevent overabduction whenplacing the patient in the frog leg position duringinsertion of an indwelling urinary catheter.Potential Anesthetic ComplicationsPatients who are morbidly obese present significantchallenges for the anesthesia care provider.Often, these patients experience medication problemsas a result of altered absorption and increasedstorage of medications in their excess fat.Cardiovascular and respiratory concerns may includeincreased cardiac afterload, decreased oxygensupply, and a respiratory system taxed byincreased fat metabolism. 9 Additional chestweight, abdominal pressure, and the presence ofcoexisting conditions unrelated to the procedure(eg, hiatal hernia, sleep apnea) increase the patient’srespiratory workload. The patient’s chestweight and abdominal pressure also increase thepatient’s risk of aspiration and its serious consequences.9 Intubating a patient who is morbidlyobese can be difficult because of limited cervicalneck movement, reduced oxygen reserves, andincreased oxygen consumption. 9 Anesthesia careproviders may have difficulty seeing the vocalcords because of limited neck movement and fatdeposits that can obstruct the airway. As a resultof these complications, intubating the patientwhile he or she is awake may be necessary. 9 Theanesthesia care provider may require special headpositioning and support aids such as an airwaymanagement head cradle and an elevation wedgespecifically designed to assist with induction andhead support during procedures on patients whoare obese. Emergency response carts also shouldbe in the room in the event of a difficult intubationor other emergency. The patient also mayrequire appropriately sized blood pressure cuffs.Potential Cardiovascular ComplicationsCardiac conditions that often present in patientswho are morbidly obese may include hypertension,diabetes, bradycardia or tachycardia, andslow cardiac conduction and ischemia. As a complicatingfactor, the electrocardiogram conductionsignal may be distorted as a result of excess chestfat. Furthermore, patients who are obese have anincreased incidence of deep vein thrombosis, andsuperficial veins may be difficult to access for IVplacement. 9PLACING THE PATIENT WHO ISMORBIDLY OBESE IN THELITHOTOMY POSITION“Obese patients are more prone to difficulty withpositioning and positioning injuries during surgerybecause of the strain excessive weight places ontheir musculoskeletal and nervous systems.” 9(p45)Patients who are obese also may present with existingareas of skin damage that need to be assessedand taken into consideration during positioning.It is imperative that the perioperative nurse hasa preoperative discussion with the surgeon andthe anesthesia care provider about plans andneeds for the surgery. The circulating nurseshould perform a careful preoperative assessmentof the patient to identify cardiac, vascular, or neurologicconditions that could affect the patient’ssafety or care during surgery. Additionally, thenurse should identify any issues that mightAORN Journal 299

September 2010 Vol 92 No 3 BENNICOFFTABLE 1. Nursing Care Plan for Patients Who Are Morbidly ObeseDiagnosis Nursing interventions Outcome indicator Outcome statementBody imagedisturbance Identifies psychosocial status Assesses coping mechanisms Identifies barriers tocommunication Identifies the patient’s anddesignated support person’seducational needs Identifies expectations of homecare Implements measures to providepsychological support Includes the patient anddesignated support person inperioperative teaching Explains the expected sequence ofevents Provides status reports to thedesignated support person Evaluates psychosocial responseto the plan of care Evaluates response to instructions The patient verbalizes thesequence of events to expectbefore and immediately aftersurgery. The patient states realisticexpectations regardingrecovery from the procedure. The patient ordesignated supportperson demonstratesknowledge of theexpected responses tothe operative or invasiveprocedure.Imbalanced nutrition:more than bodyrequirements orineffective healthmaintenance Identifies baseline gastrointestinalstatus Assesses nutritional habits andpatterns Assesses psychosocial issuesspecific to the patient’s nutritionalstatus Includes the patient anddesignated support person inperioperative teaching Provides instruction regardingdietary needs Evaluates response to instructions Evaluates response to nutritionalinstruction The patient verbalizescompliance with food andfluid restrictions beforesurgery. The patient describes therecommended postoperativenutritional intake regimen forthe recovery period at thetime of discharge. The patient ordesignated supportperson demonstratesknowledge of nutritionalmanagement related tothe operative or invasiveprocedure.Ineffective familytherapeuticregimenmanagement orcompromisedfamily coping Develops an individualized plan ofcare Consults with appropriate healthcare providers to initiate newtreatments or change existingtreatments Minimizes the length of theoperative or invasive procedure byplanning care Uses a clinical pathway Ensures continuity of care The patient reports thatindividual choices werehonored before and aftersurgery. The patient’s care isconsistent with theindividualizedperioperative plan ofcare.(table continued)300 AORN Journal

CARE OF THE OBESE PATIENT IN LITHOTOMYwww.aornjournal.orgTABLE 1. (continued) Nursing Care Plan for Patients Who Are Morbidly ObeseDiagnosis Nursing interventions Outcome indicator Outcome statementRisk of perioperativepositioning injury Assesses baseline skin condition Identifies baseline cardiac status Identifies baseline tissue perfusion Identifies baseline musculoskeletalstatus Identifies physical alterations thatrequire additional precautions forprocedure-specific positioning Verifies presence of prosthetics orcorrective devices Positions the patient Implements protective measuresto prevent skin/tissue injurycaused by mechanical sources Applies safety devices Evaluates tissue perfusion Evaluates musculoskeletal status Evaluates for signs and symptomsof physical injury to skin and tissue The patient’s pressure pointsdemonstrate hyperemia forless than 30 minutes. The patient has full return ofmovement of extremities atthe time of discharge fromthe OR or procedure room. The patient is free fromsigns and symptoms ofinjury related topositioning.Risk of impaired skinintegrity, risk offalls, impaired bedmobility, orimpaired transferability Confirms patient identity Assesses baseline skin condition Identifies baseline musculoskeletalstatus Transports according to individualneeds Evaluates for signs and symptomsof physical injury to skin and tissue Evaluates musculoskeletal status The patient reports beingcomfortable when reclined onthe transport equipment/device. The patient is free from signsand symptoms of injuryrelated to transfer/transporton discharge from the OR orprocedure room. The patient’s skin is warm,dry, and free from edema.Capillary refill and SaO 2 showadequate tissue perfusion. The patient is free fromsigns and symptoms ofinjury related to transfer/transport. The patient’s tissueperfusion is consistentwith or improved frombaseline levels.Ineffective breathingpattern, ineffectiveairway clearance,impaired gasexchange, risk ofaspiration, oranxiety Identifies baseline respiratorystatus Identifies physiologic status Reports deviation in diagnosticstudy results Reports deviation in arterial bloodgas studies Monitors physiologic parameters Monitors changes in respiratorystatus Uses monitoring equipment toassess respiratory status Evaluates respiratory status The patient is breathingspontaneously withsupplemental oxygen withoutassistance on transfer at thetime of discharge from theOR or procedure room to thepostoperative unit. The patient’s SaO 2 andrespiratory rate are in theexpected range at dischargefrom the postoperative careunit. The patient’s respiratorystatus is maintained orimproved from baselinelevels.SaO 2 arterial oxygen saturation.AORN Journal 301

September 2010 Vol 92 No 3 BENNICOFFadversely affect the patient when he or she isplaced in the lithotomy position, such asinability to tolerate the lithotomy position,restrictions to mobility or joint range of motion,andconditions of the skin or circulation.The nurse should note any concerns in the patient’smedical record and convey these concernsto the surgical team.Assembling additional staff members to helpduring moving and positioning also prevents injuriesto staff members. A verbal walk-through ofthe planned move and positioning needs can helpreduce injuries. Depending on the patient’s statusand the surgical exposure needs, team membersmay need to experiment with positioning with avolunteer staff member standing in for the patient.The RN in charge of the patient should act asthe person in charge of the move to reduceconfusion and prevent injury to the patient orstaff members. Before taking the patient into theOR, the nurse should ensure that all positioningequipment (eg, heavy-duty stirrups, gel pads, pillows)is available, is in position, and has beenchecked for function and safety. Transporting patientswho are obese may necessitate the use ofspecial assistance devices or carts.Equipment (eg, OR bed, stirrups, arm boards)must support the patient’s weight and fit the extremitiesto avoid causing injury. When caring forpatients who are morbidly obese, the surgicalteam must modify many aspects of routine care todeal with the patient’s larger size and weight. Abariatric OR bed is needed that can support thepatient’s weight and provide additional width.Typical bariatric beds are capable of supportingup to 1,000 lb and are extra wide, and the mattressesare well constructed to help prevent fullcompression of the mattress. Other equipmentconsiderations include providing appropriatelysized arm boards and safety belts for the bed. Devicesto support the extremities (eg, slings) maybe needed.Bariatric stirrups should hold up to an 800-lbpatient, but stirrups manufactured for bariatricbeds must be assessed for each patient. For instance,although the stirrup could support theweight of the patient’s leg, the sides of the bootmay be too narrow to accommodate the size andcircumference of the leg without creating pressure.Perioperative team members may have toimprovise stirrups to accommodate the patientwithout causing problems. Methods to improviseshould not be undertaken that would contradictthe manufacturer’s instructions for use or negatethe product warranty, however.Different types of stirrups are available for thelithotomy position, but candy-cane shaped, kneecrutch,and boot-type stirrups are used most often.Instructions for use from the manufacturer andAORN positioning recommendations should alwaysbe followed during use of positioning aids,including stirrups. 1 Candy-cane shaped stirrupsprovide good exposure of the surgical site, areeasy to use, and allow room for the team to work.Knee-crutch stirrups are commonly used duringcystoscopy procedures, which tend to be shorterin duration. Boot-type stirrups are often used duringprocedures in which the patient is awake (eg,local anesthesia, monitored anesthesia care) becausethey allow the patient’s legs to be in alower, more comfortable position and can beraised if necessary. Use of each type of stirruphas the potential to cause problems (eg, nerve orpressure injuries, overrotation).Candy-Cane Shaped StirrupsThese stirrups look similar to a cane and are attachedto the side of the OR bed (Figure 1). Afterattaching the stirrups to the bed, perioperativepersonnel can rotate them to change the angle atwhich the stirrups hold the legs. The patient’sfoot is secured in a double sling made of cottonwebbing and suspended from the end of the caneby a fastener. Injury can occur if the patient’slegs are allowed to relax and extend outward torest on the cane bar. 2 Pressure from the cane bar302 AORN Journal

CARE OF THE OBESE PATIENT IN LITHOTOMYwww.aornjournal.orgFigure 1. Candy-cane shaped stirrups.on the lateral aspect of the calf or knee can resultin footdrop or nerve injury to the leg. Althoughpadding can be placed between the cane bar andthe patient’s leg, pressure injury can still occur.The patient’s hips can be externally overrotatedwhen in these stirrups to a point of hyperabduction,2 which can cause sciatic and obturator nerveinjury and injury to the patient’s hip and kneejoints and leg muscles. Gel boots and wide strapscan pad and reduce pressure to the ankle andfoot. The patient’s leg weight and the duration ofthe procedure can increase the potential for furtherinjury to the distal sural and plantar nerves.Knee-Crutch StirrupsThese stirrups resemble the top of a walkingcrutch (Figure 2). The nurse places the patient’sleg over the crutch and positions the leg so it isresting over the supporting arch. All weight isresting on the knee, which can put undue pressureFigure 2. Knee-crutch stirrups.Figure 3. Boot-type stirrups.on the popliteal space. Knee-crutch stirrups alsohave the potential to cause injury to the posteriorand the common peroneal nerves and the poplitealartery because they place pressure on the poplitealfossae and may not evenly distribute pressure. 2Boot-Type StirrupsThese stirrups resemble boots attached to thesides of the OR bed and give more support to theentire leg (Figure 3). They are commonly usedfor procedures in which the patient is receivinglocal anesthesia or monitored anesthesia care aswell as during pelviscopy procedures. The supportthat boot-type stirrups provide reduces the potentialfor nerve and pressure injury because pressureis evenly distributed to the leg and foot; however,the same types of injuries that occur with otherstirrups can occur when these stirrups are used.Boot-type stirrups are attached to the bed at thelevel of the patient’s hip socket and reduce stresson the hip joint. It is important to remember thatthese stirrups may appear easier to use, but incorrectplacement of the bed attachment bracket cancause stress injury to the patient’s hip.General Concerns With AnyType of StirrupIn general, stirrups are secured on the OR bedrails at the level of the patient’s hip socket, withthe patient’s buttocks at the end of the break inthe bed. The nurse can adjust the height of theboot or foot location to match the patient’s legsize. To prevent shearing injuries, care should beAORN Journal 303

September 2010 Vol 92 No 3 BENNICOFFtaken to use transfer devices to lift, not slide orpull, the patient if repositioning the patient to thebreak in the bed is necessary. When placing anormal-weight patient into the lithotomy position,two team members lift, slightly externally rotate,and flex the patient’s legs and raise them togetherwhile holding thefeet and supportingthe calves close tothe knee joints.When the leg is at anappropriate level, theteam members placethe patient’s feet inthe stirrups. If usingcandy-cane shaped stirrups, staff members shouldplace the gel boots or straps on the patient beforeraising the legs. This decreases the difficulty ofgetting the foot into the strap while holding theleg, which then provides safer lifting of the leg tothe stirrup attachment. Several staff members maybe needed to lift each leg if the patient is morbidlyobese, or pneumatic slings may be requiredto position the patient’s legs; no one personshould attempt to lift the extremity alone. Abductionof the patient’s legs should be limited to thedegree needed for good surgical exposure, and theposition should not allow either leg to hyperrotateor hyperextend. The nurse should gently securethe patient’s arms on padded arm boards at lessthan a 90-degree angle and ensure that the patient’shands, if placed at the sides of the OR bed,are clear of the breaks in the bed to prevent injurywhen the bottom of the bed is lowered. 2The circulating nurse should assess the patientthoroughly after the team has completed positioning.He or she should check the patient for alignment,possible pressure points and potential sitesof injury (eg, sacrum, arms, hands), and otherpotential problems (eg, respiratory or circulatorycompromise as a result of leg positioning) andmake any necessary adjustments. The nurse alsoshould check the patient’s positionAfter the team has completed positioning, thecirculating nurse should assess the patientthoroughly for alignment, possible pressurepoints and potential sites of injury, and makeany necessary adjustments. at regular intervals during the procedure, each time the patient’s position is changed,and when the patient has been in the lithotomyposition for a prolonged period (ie, more thanfour hours).Procedural timeshould be kept to aminimum. AORN’s“Recommended practicesfor positioningthe patient in theperioperative practicesetting” suggests thatthe perioperativeteam should consider repositioning the patient ifthe procedure lasts longer than four hours. 1 Thecirculating nurse should then document all positioningand the names of the staff members involvedas well as all equipment and padding used.Before moving any lower extremity into or outof stirrups, team members should alert the anesthesiacare provider. When the anesthesia careprovider is ready, team members should removethe patient’s legs from the stirrups simultaneouslyand slowly to minimize lumbosacral strain on thepatient. If possible, staff members should bringthe patient’s legs together simultaneously andthen lower the patient’s legs to the bed surfaceone at a time to prevent rapid or unexpected circulatorychanges. 1(p339) Before the patient istransferred to the postanesthesia care unit, thecirculating nurse should carefully assess the patientfor skin, nerve, or pressure injury.CASE STUDYTwo weeks before a scheduled surgery, perioperativeteam members were notified of a lithotomyprocedure to be performed on a patient weighingapproximately 600 lb. Previously, a physician hadattempted to perform an examination with thispatient under anesthesia, and staff members hadbeen unable to position the patient or support herlegs in a way that would work for the surgeon304 AORN Journal

CARE OF THE OBESE PATIENT IN LITHOTOMYwww.aornjournal.organd be safe for the patient and staff members.Stability, positioning, and padding needs couldnot be met, so the examination had been cancelled.After talking with this physician, the surgicalteam members determined that stirrups availableat the facility, even the ones used forbariatric surgery patients, would not fit this patient.The gynecology coordinator, circulatingnurse, scrub person, and facility safety officer metin advance of the procedure to develop a safe lithotomy positioning devicefor a patient who is morbidly obese; collect, set up, and test equipment; review potential positioning risks for the patientand staff members; and determine how to prevent pressure injury, provide adequate exposure for the surgeon, prevent the patient’s position from compromisinganesthesia care, and provide safe, effective care for the patient.The gynecology coordinator contacted the facility’sstirrup vendor to see whether any currentlymanufactured stirrups would work for apatient of this size. The vendor was not able tofind any stirrup that would support this patientdespite checking with several other manufacturers.The vendor suggested that some ORs usedpadded Mayo stands or bedside tables to supportFigure 4. Inflated patient transfer pad used totransfer patients from the OR bed to the transfercart and then to the patient’s postoperative bed.Figure 5. Mock OR setup with pneumatic lifts inplace at the sides of the bed.the patient’s legs, but the team decided that thesepieces of OR furniture were not intended for thatuse and therefore the team could not ensure thepatient’s safety. The gynecology coordinator discussedoptions with the facility safety officer andhad the idea of using two patient lifts, one foreach leg. These lifts are capable of supporting450 lb each, so team members decided that if thelifts met the team’s positioning needs, they wouldprovide a safe way to support this patient’s legs.Practice SessionThe team members set up a mock OR that includeda special bed used for bariatric proceduresto develop and perfect a modified lithotomy position.A team member placed a full-length inflatablepatient transfer device on the OR bed. Thisinflatable pad is placed under the patient andbuckled in place (Figure 4). When the device isinflated, team members can more easily move thepatient to the OR bed with little effort and safelyplace the patient in position on the bed. Theythen deflate the pad and leave it in place for usein moving the patient to the transfer cart and laterto the patient bed. Both reusable and disposablepads are available.Team members positioned lifts at either side ofthe bed in the mock OR setup (Figure 5). Afterthe safety officer answered team members’ questionsabout how the lifts functioned and the teammembers had a chance to work with the lifts tobecome familiar with them, the team membersAORN Journal 305

September 2010 Vol 92 No 3 BENNICOFFFigure 6. Perioperative nurse volunteer in position inthe pneumatic lift stirrups.locked the lifts in place and one team membervolunteered to be positioned using the lifts (Figure6). Team members assessed their colleaguefor positioning problems or pressure points whileshe was on the bariatric bed and in the slings andexperimented with different padding options. Theteam chose to use thick gel pads to cover anysurface that would come into contact with thepatient on the bed. Team members placed pillowsin the slings to reduce their concave shape and tosupport the patient’s knees and covered the pillowswith gel pads extending beyond the slingedges to reduce calf pressure. Team membersused wide, thick, egg-crate foam pads to furtherprotect the patient’s ankles. Special care wasplanned to pad and protect the folds and rolls oftissue present on the patient’s legs wherenecessary.During induction before positioning, the patientwould be placed in a supine position. The teamplanned to secure two long, wide safety belts togetherto cover the patient’s thigh area and use asecond set over the patient’s calves. They plannedto use two padded, extra-wide arm boards withgel pads and wide arm straps to secure thepatient’s arms.Additionally, the anesthesia care providerplanned to use the airway management head cradleand elevation wedge to prevent an increase inabdominal and thoracic pressure when the patientwas in the supine position (Figure 7). Both thewedge and the head cradle would be left in placethroughout the procedure to assist in anesthesiacare. Team members anticipated that this patientmight experience a difficult induction and intubationand made sure that the emergency cart fordifficult airways was in the room and that a circulatingnurse would be present to assist the anesthesiacare provider during induction.Finally, the team planned to provide thermoregulationassistance. Warm blankets would beplaced over the patient and a temperatureregulatingblanket would be placed over the patient’schest.Preoperative PhaseOn the day of surgery, the preoperative nurse reviewedthe patient’s chart in the holding area andadmitted the patient. The nurse reviewed the patient’shistory and interviewed the patient abouther allergies, previous surgeries, NPO status, andproblems that would affect perioperative care andthen answered the patient’s questions. The nurseverified the intended surgery with the patient andthe surgical consent. The nurse noted that the surgeonhad explained to the patient, and documentedon the informed consent, that a somewhat“experimental” positioning device that was notspecifically designed for the lithotomy positionwould be used to facilitate positioning of theFigure 7. Airway management head cradle andelevation wedge.306 AORN Journal

CARE OF THE OBESE PATIENT IN LITHOTOMYwww.aornjournal.orgpatient for the procedure and that there might beadditional risks associated with the equipmentused in this manner. The patient acknowledgedher understanding and accepted the risks.The nurse ensured that an inflatable patienttransfer pad was placed on the bariatric stretcherbefore the patient got onto the stretcher, afterwhich the nurse placed extra-large sequentialcompression device (SCD) leggings on the patient.The anesthesia care provider started an IVline, and the nurse administered the prescribedantibiotics. All concerns about the patient werecommunicated to the anesthesia care provider andthe surgeon. The nurse explained to the patienthow she would be moved to the OR bed, and whenthe patient was cleared to go to the OR, perioperativeteam members transferred her to the OR.Intraoperative PhaseIn the OR, a team member inflated the patienttransfer pad and the five-member team and theanesthesia care provider moved the patient to theOR bed, ensuring that she was properly positionedon the chest wedge support. After connecting theSCD leggings to the unit and securing the safetybelts, the circulating nurse asked the patient if shewas comfortable and made adjustments accordingly.The circulating nurse placed an upper-bodyFigure 8. Patient positioned on the bariatric OR bed.The safety straps have been temporarily removedso the patient’s legs can be positioned in thepneumatic lifts. Elements in this photo do notnecessarily comply with AORN standards andrecommended practices.Figure 9. Patient in the lithotomy position inpneumatic lifts. The nurse ensures that no part ofthe lift frame or other part of the bed is in contactwith the patient’s legs. Elements in this photo donot necessarily comply with AORN standards andrecommended practices.temperature-regulating blanket on the patient andthen assisted the anesthesia care provider withinduction. The emergency cart was not neededbecause the induction went smoothly. After induction,the anesthesia care provider inserted additionalIV lines and an arterial line.Team members used the inflatable patienttransfer pad to move the patient into a lower positionon the bed and then deflated it and tuckedthe ends through the table break to prevent soilingof the mat during the surgery. Team membersmoved the leg lifts with pillows and gel pads intoposition on either side of the OR bed and lockedthem in place (Figure 8). As a result of the patient’slarge size, team members lifted both legsand then placed each of the patient’s legs into theslings separately while the slings were at tableheight, ensuring that hip rotation was appropriateto avoid patient injury. Three people were neededto lift each of the patient’s legs, bend the legs atthe knee, and place them in the slings. After bothlegs were in the slings (Figure 9) and thepatient’s hands were checked for safe positioningto prevent her fingers from being trapped by thebed as it was repositioned, a team memberdropped the end of the bed to prepare for the procedure.Team members placed enough paddingAORN Journal 307

September 2010 Vol 92 No 3 BENNICOFFaround the patient’s ankles and lower legs on topof the SCDs to redistribute pressure and thencarefully adjusted the height of the lifts to an appropriateheight for the procedure.The circulating nurse assessed the patient’sposition for potential pressure areas and madeadjustments as needed; however, the patient’s sizemade finding bony landmarks difficult and ruledout the use of graduated compression stockings.The nurse monitored the patient’s legs throughoutthe procedure.The scrub person, surgeon, and surgical assistantsplaced the drapes for the surgical field. Extradrapes were needed to adequately cover thelifts. After draping the surgical field, the surgeonbegan the surgical procedure. One limitation thatteam members noted was that space at the end ofthe bed to perform the surgery was unavoidablylimited by the sling size and placement. The circulatingnurse provided team members with extrasteps so team members could participate asneeded (eg, retracting surgical tissue) withoutleaning on the patient or inadvertently moving thepatient’s legs.The procedure lasted 90 minutes and was uneventful.After the procedure was completed, theteam members carefully lowered the slings andmoved the patient’s legs from the slings backonto the bed surface. The circulating nurse assessedthe patient for positioning injuries and didnot observe any. The patient’s skin appeared tobe in the same condition as it had been on arrivalin the OR. Team members reinflated the patienttransfer pad to move the patient back onto thebariatric cart and transferred her to the postanesthesiacare unit without incident. The patient recoveredwell and was discharged to home thenext day.Postoperative PhaseA postanesthesia care unit nurse called the patient48 hours after surgery. The patient reported thatshe had not noted any positioning injuries, whichindicates that the preoperative anticipation andplanning contributed to the patient’s positive outcome.The surgeon informed the team membersthat the patient’s recovery had been uneventfuland that the patient was pleased with the resultsof the surgery.EvaluationAfter the surgery, the team members discussedtheir success and identified opportunities forimproving this modified positioning protocol. Incaring for this patient, team members discoveredthat preplanning for positioning and padding wasrequired to prevent patient and staff memberinjury, additional transport and transfer help wasrequired, use of transfer devices (eg, an inflatable patienttransfer pad) was essential, extra staff members were needed and care hadto be taken to avoid injury to staff memberswhen moving a patient of this size, power lifts for the slings were necessary andfunctioned successfully, draping had to be adjusted to adequately coverthe lifts and provide a sterile field, space at the end of the bed to perform the surgerywas unavoidably limited by the sling sizeand placement, and extra steps were needed to ensure visibility ofthe surgical site and prevent inadvertent patientinjury.In reviewing the modified equipment used in positioningthe patient for this procedure and thepatient’s surgical outcomes, the team membersdetermined that use of patient slings was a safealternative to stirrups when caring for this patientwho was morbidly obese and required surgery inthe lithotomy position.CONTINUED SUCCESSTeam members have since participated in additionalprocedures requiring this method of legsupport and experienced the same success. Team308 AORN Journal

CARE OF THE OBESE PATIENT IN LITHOTOMYwww.aornjournal.orgmembers have discussed patient needs with thefacility stirrup vendor and have evaluated the useof newer slings that also would provide safe supportto patients who cannot be cared for withstandard equipment. This learning experience requiredteam members to combine creativity andperioperative knowledge to provide the type ofcare that all patients deserve.Editor’s note: Patient lifts were used as stirrupsin this article; this represents an off-label use ofthese medical devices.References1. Recommended practices for positioning the patient in theperioperative practice setting. In: Perioperative Standardsand Recommended Practices. Denver, CO: AORN,Inc; 2010:327-350.2. Graling PR, Colvin DB. The lithotomy position in colonsurgery: postoperative complications. AORN J. 1992;55(4):1029-1039.3. FastStats: obesity and overweight. Centers for DiseaseControl and Prevention. http://www.cdc.gov/nchs/fastats/overwt.htm. Accessed May 14, 2010.4. Statistics related to overweight and obesity. US Departmentof Health and Human Services. Weight-ControlInformation Network. http://win.niddk.nih.gov/statistics.Accessed May 14, 2010.5. AORN bariatric surgery guideline. In: PerioperativeStandards and Recommended Practices. Denver, CO:AORN, Inc; 2010:481-499.6. Heizenroth PA. Positioning the patient for surgery. In:Rothrock JC, ed. Alexander’s Care of the Patient inSurgery. 13th ed. Philadelphia, PA: Mosby; 2008:130-157.7. AORN guidance statement: Safe patient handling andmovement in the perioperative setting. In: PerioperativeStandards and Recommended Practices. Denver, CO:AORN, Inc; 2010:673-695.8. Petersen C, ed. Positioning injury. In: PerioperativeNursing Data Set: The Perioperative Nursing Vocabulary.3rd ed. Denver, CO: AORN, Inc; 2010:178-184.9. Ide P, Farber ES, Lautz D. Perioperative nursing careof the bariatric surgical patient. AORN J. 2008;88(1)30-58.Geraldine Bennicoff, RN, CNOR, is the gynecologycoordinator at Meriter Hospital, Madison,WI. Ms Bennicoff has no declared affiliationthat could be perceived as posing apotential conflict of interest in the publicationof this article.AORN Journal 309

EXAMINATIONCONTINUING EDUCATION PROGRAMPerioperative Care of the MorbidlyObese Patient in the Lithotomy Position3.0www.aorn.org/CEPURPOSE/GOALTo educate perioperative nurses about perioperative care of patients who aremorbidly obese and undergoing surgery in the lithotomy position.OBJECTIVES1. Identify complications of using the lithotomy position.2. Describe stirrups commonly used for placing a patient in the lithotomy position.3. Explain perioperative care of the patient who is morbidly obese.4. Discuss potential complications that a patient who is morbidly obese mayexperience.The Examination and Learner Evaluation are printed here for your convenience.To receive continuing education credit, you must complete the Examinationand Learner Evaluation online at http://www.aorn.org/CE.QUESTIONS1. Respiratory complications can occur when a patientis placed in the lithotomy position because1. the patient’s abdominal organs shift, whichincreases pressure on the diaphragm.2. the patient becomes anxious when he or sherealizes that the surgery is about to start.3. fluid volume shifts may affect blood pressureif the patient’s legs are raised or lowered toorapidly.4. surgical personnel put pressure on the patient’schest, which can cause the patient tohypoventilate.a. 1 and 3 b. 2 and 4c. 1, 2, and 4 d. 1, 2, 3, and 42. When a patient who is morbidly obese is placedin the lithotomy position, overabduction of thepatient’s legs can occur because of the1. size and weight of the patient’s thighs.2. need to create adequate space for the surgeonand staff members to work.3. laxity of tendons and muscles common in patientswho are morbidly obese.4. inability to clearly see the patient’s anatomicmarkers (eg, joints).a. 1 and 3 b. 2, 3, and 4c. 1, 2, and 4 d. 1, 2, 3, and 43. Electrocardiogram conduction signal distortioncan result from excess chest fat in patients whoare morbidly obese.a. true b. false4. During the preoperative assessment, the circulatingnurse should identify issues that might adverselyaffect the patient when he or she isplaced in the lithotomy position, including310 AORN Journal ● September 2010 Vol 92 No 3 © AORN, Inc, 2010

CE EXAMINATIONwww.aornjournal.org1. cardiac, vascular, or neurologic conditions.2. conditions of the skin or circulation.3. inability to tolerate the lithotomy position.4. restrictions to mobility or joint range ofmotion.a. 1 and 3 b. 2 and 4c. 1, 2, and 4 d. 1, 2, 3, and 45. Potential complications of using candy-caneshaped stirrups include1. footdrop or nerve injury to the leg.2. sciatic and obturator nerve injury.3. injury to the hip and knee joints and legmuscles.4. injury to the distal sural and plantar nerves.5. undue pressure on the popliteal space.a. 1 and 4 b. 2, 3, and 5c. 1, 2, 3, and 4 d. 1, 2, 3, 4, and 56. Potential complications of using knee-crutch stirrupsinclude1. pressure on the popliteal fossae.2. injury to the posterior and the common peronealnerves 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 4c. 2, 3, and 4 d. 1, 2, 3, and 47. The circulating nurse should check the patient’sposition1. 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 lithotomyposition for a prolonged period.a. 1 and 3 b. 2 and 4c. 1, 2, and 4 d. 1, 2, 3, and 48. Staff members should bring the patient’s legs togethersimultaneously and then lower the patient’slegs to the bed surface simultaneously toprevent rapid or unexpected circulatory changes.a. true b. false9. In the case study, when preparing the OR for theprocedure, team members1. used thick gel pads to cover any surface thatwould come into contact with the patient onthe bed.2. placed pillows in the slings to reduce theirconcave shape and to support the patient’sknees.3. covered the pillows with gel pads that extendedbeyond the sling edges to reduce calfpressure.4. used wide, thick, egg-crate foam pads to furtherprotect the patient’s ankles.a. 1 and 3 b. 2 and 4c. 1, 2, and 4 d. 1, 2, 3, and 410. In the case study, one limitation that team membersnoted was thata. the patient developed a decubitus ulcer underher right heel.b. the space at the end of the bed to perform thesurgery was unavoidably limited by the slingsize and placement.c. the patient’s legs repeatedly slipped off the liftslings.d. the lifts could not be raised as high as the surgeonneeded 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 Bakewellhave no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.AORN Journal 311

LEARNER EVALUATIONCONTINUING EDUCATION PROGRAMPerioperative Care of the MorbidlyObese Patient in the Lithotomy Position3.0www.aorn.org/CEThis evaluation is used to determine the extent towhich this continuing education program metyour learning needs. Rate the items as describedbelow.OBJECTIVESTo what extent were the following objectives of thiscontinuing education program achieved?1. Identify complications of using the lithotomyposition. Low 1. 2. 3. 4. 5. High2. Describe stirrups commonly used for placing apatient in the lithotomy position.Low 1. 2. 3. 4. 5. High3. Explain perioperative care of the patient who ismorbidly obese. Low 1. 2. 3. 4. 5. High4. Identify potential complications that a patientwho is morbidly obese may experience.Low 1. 2. 3. 4. 5. HighCONTENT5. To what extent did this article increase yourknowledge of the subject matter?Low 1. 2. 3. 4. 5. High6. To what extent were your individual objectivesmet? Low 1. 2. 3. 4. 5. High7. Will you be able to use the information fromthis article in your work setting? 1. Yes 2. No8. Will you change your practice as a result ofreading this article? (If yes, answer question#8A. If no, answer question #8B.)8A. How will you change your practice? (Select allthat apply)1. I will provide education to my team regardingwhy change is needed.2. I will work with management to change/implement a policy and procedure.3. I will plan an informational meeting withphysicians to seek their input and acceptanceof the need for change.4. I will implement change and evaluate theeffect of the change at regular intervals untilthe change is incorporated as best practice.5. Other:8B. If you will not change your practice as a resultof reading this article, why? (Select all thatapply)1. The content of the article is not relevant tomy practice.2. I do not have enough time to teach othersabout the purpose of the needed change.3. I do not have management support to make achange.4. Other:9. Our accrediting body requires that we verify thetime you needed to complete the 3.0 continuingeducation 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 Centerapproves 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 thisactivity for relicensure.Event: #10058; Session: #4022 Fee: Members $15, Nonmembers $30The 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. Eachapplicant who successfully completes this program can immediately print a certificate of completion.312 AORN Journal ● September 2010 Vol 92 No 3 © AORN, Inc, 2010