Supine position

8.3.1 Head

In the supine position, the head must be padded with various positioning aids so that the cervical spine is in the middle/neutral position (awake) and there is no local pressure on the back of the head (O Figs. 8.7-8.9).

8.3.2 Shoulders and arms

Normally in general surgery, both of the patient's arms are spread out to the side. For pronation positioning, the spread arms should be put into abduction to approx. 6o° bent at the elbows, and positioned and fixed with the lower arm on the arm positioning device. Support, for example with a short armrest, should always be provided for

Fig. 8.10. Correct arm positioning with short armrest

Fig. 8.11. Incorrect arm positioning, dropped wrist

D Fig. 8.13. Abducted arm with padding, fixed on a long arm positioning device

Fig. 8.11. Incorrect arm positioning, dropped wrist

D Fig. 8.13. Abducted arm with padding, fixed on a long arm positioning device

D Fig. 8.12. Positioning the arm on short arm positioning device in abduction

Fig. 8.14. Head and arm positioning with double wedge cushion

D Fig. 8.12. Positioning the arm on short arm positioning device in abduction

Fig. 8.14. Head and arm positioning with double wedge cushion the lower arm and hand. This positioning of the arm prevents the so-called wristdrop (D Figs. 8.10, 8.11).

For abduction of the arm between 60° and 90°, the patient should always be adjusted from pronation to supination position (Texas position). A pad can be placed under the wrist in this position (D Figs. 8.12, 8.13).

The nerves in the elbow must lie free of pressure. Padding under the shoulder consisting of a special double wedge pad, gel pad or a 250/500 ml infusion bag raises the shoulder from the level of the table and enlarges the gap between clavicle and first rib, with a clear reduction in the risk of harming the nerves. The arm must be lifted over the level of the shoulder (D Fig. 8.14).

The rule of thumb for positioning the arm in supine patients is as follows: place pads under the shoulder to lift it from the level of the table, with the distal joint higher than the proximal joint.

So the elbow is higher than the shoulder and the wrist higher than the elbow. The arm can be positioned at the body (e.g. heart surgery) using an arm holder (D Figs. 8.15, 8.16).

D Fig. 8.15. Arm positioning with arm protection

8.3.3 Back and pelvis

Hips and knees should be preferably slightly bent; pads should be placed under the frequently exposed lumbar spine. The pads can consist of a small pile of cellulose, a small rolled/folded towel or an additional small gel pad. The thickness and position of the padding depends on

Fig. 8.16. Hand and elbow are protected

D Fig. 8.19. Positioning with vacuum mat and operating table in Trendelenburg position and tilted to the left

Fig. 8.16. Hand and elbow are protected

D Fig. 8.19. Positioning with vacuum mat and operating table in Trendelenburg position and tilted to the left

D Fig. 8.17. Positioning without positioning aids and straight operating table

Fig. 8.20. Increased pressure on the heels

D Fig. 8.17. Positioning without positioning aids and straight operating table

Fig. 8.20. Increased pressure on the heels

8.3.4 Legs

D Fig. 8.18. Positioning without positioning aids with adapted adjustment of the operating table

the patient. The padding is placed under the top surface of the operating table (e.g. gel mat) so as not to interrupt the homogeneous top surface and impair its effect. If no positioning aids are available, the operating table should be adjusted to support parts of the body which are not flat on the table (D Figs. 8.17-8.19).

If necessary, a half roll is placed under the knees at the distal thigh. Another possibility is to adjust the leg plates at the knee joint. Pressure on the heels should always be reduced to a minimum. D Figure 8.20 shows increased pressure on the heels with the use of a gel mat. One possibility is to use small gel mats placed under the lower leg (D Fig. 8.21). But the leg should always have the greatest possible contact with the patient board with every kind of padding. These requirements can also be fulfilled by using a vacuum mat, as in D Figs. 8.19 and 8.22.

Fig. 8.21. Reduced pressure with clearance of the heels
D Fig. 8.22. Reduced pressure with clearance of the heels using a vacuum mat
Fig. 8.24. Positioning with gel head ring and shoulder supports

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