Prone position - NYSORA

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Contributors

Prone position

Prone position

Learning objectives

  • 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

RespiratoryIncreased functional residual capacity
Increased arterial oxygen pressure
Chest wall and lung compliance remain unchanged
CardiovascularReduced stroke volume
Compensatory sympathetic tachycardia and increase in peripheral vascular resistance
Increased pulse pressure and stroke volume variation
Cerebral blood flowReduced cerebral blood flow
Increased intracranial pressure
Vessel distension
Renal functionSlight increase in urine output

Complications

  • Pressure injuries
Direct pressure injuriesSkin necrosis
Contact dermatitis
Tracheal compression
Salivary gland swelling
Breast injury
Injury to the genitalia
Compression of the pinna
Compression of the femoral neurovascular bundle
Indirect pressure injuriesMacroglossia and orpharyngeal swelling
Mediastinal compression
Visceral ischemia (liver, pancreas)
Avascular necrosis of femoral head
Peripheral vessel occlusion
Limb compartment syndrome and rhabdomyolysis
  • Ophthalmic complications ranging from corneal abrasions to postoperative visual loss
    • 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

prone position, log-rolling, jackson table, moniroting, infusions, breathing system, reinforced cuffed tracheal tube, supine, bronchospasm, endobronchial intubation, airway pressure, leak test, laryngeal mask airway, fiberoptic reintubation, cardiac arrest, defibrillation

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.

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