Describe the physiological effects and possible complications of prone positioning
Manage patients presenting for surgery in the prone position
Background
Prone positioning is commonly used for access to the posterior head, neck, and spine during spinal surgery, access to the retroperitoneum and upper urinary tracts, and access to posterior structures when required during plastic surgery
Prone surgery is associated with a variety of complications and requires specific considerations
Physiology
Respiratory
Increased functional residual capacity
Increased arterial oxygen pressure
Chest wall and lung compliance remain unchanged
Cardiovascular
Reduced stroke volume
Compensatory sympathetic tachycardia and increase in peripheral vascular resistance
Increased pulse pressure and stroke volume variation
Direct pressure on the eye: central retinal artery occlusion
No direct pressure on the eye: Ischemic optic neuropathy
Risk factors: Atherosclerosis, diabetes, hypertension, male gender, blood loss, long duration of the procedure
Prevention: Avoid direct ocular pressure
Peripheral nerve injuries
All superficial peripheral nerves should be considered at risk
Usually does not present in the recovery room, 90% present within 7 days
Can be sensory or mixed motor/sensory
Risk factors: Male gender, prolonged hospital stay, diabetes, advanced age, extremes in BMI
Prevention: Place arms at side, <90° at elbow or shoulder if arms are abducted, avoid direct pressure in the axilla, pad the elbows
Management
Suggested reading
Kwee MM, Ho YH, Rozen WM. The prone position during surgery and its complications: a systematic review and evidence-based guidelines. Int Surg. 2015;100(2):292-303.
Feix B, Sturgess J. Anaesthesia in the prone position. Continuing Education in Anaesthesia Critical Care & Pain. 2014;14(6):291-7.
Edgcombe H, Carter K, Yarrow S. Anaesthesia in the prone position. BJA: British Journal of Anaesthesia. 2008;100(2):165-83.