Individual circumstances can differ greatly. But experience indicates that the following situations occur with particular frequency:
The patient comes into the operating suite in a hospital bed under resuscitation conditions
Depending on the situation, the patient is positioned for surgery in the hospital bed (acute bleeding) or is transferred to the operating table (if absolutely necessary).
Arguments in favour of positioning the patient in the hospital bed instead of on the operating table include the time factor until surgery can begin, reduced manpower requirements, better space conditions for heart massage and less manipulation of the patient. These advantages have to be weighed up against the major drawbacks such as poorer intraoperative handling, poorer hygiene and pressure sores in the dorsal parts of the body (resuscitation board). Consideration should certainly be given to the fact that particularly for obese patients, adequate heart massage is not possible under transport conditions on the operating table.
If the decision is taken to use an operating table, preferably all materials should be ready at the table before the patient arrives in the operating suite to prevent any unnecessary delays.
The patient is transferred from the hospital bed to the operating table under the following conditions: Do not interrupt the resuscitation measures. Any time lost by measures such as 4 exact positioning on the operating table, 4 padding the extremities, 4 shaving,
4 keeping the dorsal parts of the body dry during skin disinfection can have a marked negative effect on the resuscitation measures.
Procedures in these circumstances should rather concentrate on elementary measures such as positioning and fixing the extremities to be used for measuring blood pressure, securing infusion and signal leads, and positioning and fixing the head and extremities for puncture procedures.
Rapid patient transfer can be assisted by using a simple transfer aid in the form of a roll board, prefixed arm extension and infusion and perfusor supports fitted to the operating table. A trolley should be ready with medication and respirator.
The patient needs resuscitation during the transfer process
The causes for resuscitation in surgical patients are manifold and rarely calculable. An indispensable prerequisite for providing adequate patient care under these conditions is to ensure that qualified, trained staff are present during the transfer process. The staff should be capable of detecting when the patient is in a critical condition and taking the necessary immediate measures. Depending on the individual situation, here again the decision has to be taken whether to resuscitate the patient, including surgical components, in the hospital bed or on the operating table. Furthermore, immediate availability of several qualified assistants and aids (e.g. board for heart massage in the hospital bed, defibrillator, mobile cardiovascular monitor) must also be guaranteed in the patient transfer section of the operating suite.
Transferring the patient from the operating table to the hospital bed after the operation constitutes a typical danger particularly for patients with an instable cardiovascular system. This is why adequate resources must be provided in advance, and the corresponding operating table with all its padding and special anaesthesia/surgical features not dismantled until the patient has left the operating suite.
Generally the various requirements for positioning the patient come from the specific surgical procedures and are only extremely rarely influenced by the probable need for perioperative resuscitation.
But ideally in an emergency, priority should be given to positioning for resuscitation over optimum positioning for the operation.
As a rule, the anaesthetist co-ordinates the necessary measures. He is also responsible for deciding before the operation to reduce the ideal positioning for the surgical procedure to the maximum tolerable positioning. In certain cases, it would appear to be quite justified to reject a prone or lateral positioning under certain circumstances because of the anticipated need for resuscitation, because heart massage can in fact only be performed effectively in the supine position.
If the need for resuscitation occurs in the prone position, the patient should be turned into the supine position immediately. Under these conditions, all surgical counter-indications can only be relative. Under certain circumstances it can be a great help to have a second operating table at the ready. This allows for rapid patient transfer with only a few assistants by rolling the patient onto the parallel operating table.
Transfer from the lateral to the supine position is possible without problems in most cases without any considerable delay to starting heart massage.
But thorax surgery can often pose an absolute counter-indication to changing the patient's position, if resuscitation should become necessary with the patient in the lateral position, because as a rule direct manual compression of the heart is given preference in the case of an open thorax.
In principle there is an increased incidence of positioning injuries in patients who had to undergo resuscitation. While fractures to the ribs and sternum can be caused by heart massage and also occur regularly even with optimum positioning, typical positioning injuries such as nerve lesions, pressure sores, burns and eye injuries are far more rare. They frequently result from the relatively slight relevance of prophylactic measures under resuscitation conditions. Every resuscitation attempt proceeds along its own dynamic lines so that it is difficult to give general recommendations as to when the prophylactic measures should have been implemented. Even so, responsible assistants should keep adequate records of their careful working procedures, because even following successful resuscitation, legal disputes are not rare in the case of suspected positioning injuries.
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