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

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

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