[Damage due to patient positioning in anesthesia and surgical medicine (1)]

Positioning a patient for surgery requires great care and caution. Correct positioning provides the surgeon with good access to the site, minimizes blood loss and reduces the risk of damage to nerves, soft tissue, compartments and the cardio-pulmonary system. Each position has its specific risks. These have to be evalued against the benefits. Extreme positions of the joints should be avoided whenever possible. The ulnar nerve or the plexus brachialis are at highest risk in the positioning of extremities. Good anatomical comprehension makes it possible to take effective counter-measures. In the case of damage to the ulnar nerve in spite of optimal positioning, some authors found pre-existent non-symptomatic dysfunction in up to 30% of the cases. Patients suffering from peripheral vascular disease are usually at higher risk to suffer acute ischaemia, or, in the extreme, rhabdomyolysis with compartment syndrome, when positioned with elevated extremities (as in lithotomy position) or when a tourniquet is applied. Next to other factors, the duration of surgery seems to be of some importance. Operation sites above the heart carry a higher risk of venous air embolism unrelated to the positioning. In these cases adequate monitoring should be generously applied. Loss of visus is a rare but very severe complication most often seen in connection with the prone position. Still, postoperative blindness has occurred in all positions. It is absolutely imperative to avoid all pressure to the bulbus. The same law applies to surgery and positioning: indicated and correctly executed positioning, to which the patient has effectively consented, is legal, even if damage should occur. If the plaintiff demands compensation for damage, the distribution of onus of proof depends essentially on the accuracy of documentation. If documentation is faulty, the plaintiff may be granted relief or even shift of the onus of proof. This does not apply to a criminal lawsuit; in that case, culpable medical fallibility must be proven, since otherwise, the principle of "in dubio pro reo" applies. The interdisciplinary responsibilities concerning the positioning must be clearly defined and it is essential that the documentation of positioning as well as the documentation of positioning control is carried out as accurately as possible. Correct positioning can effectively aid surgery. Slovenly positioning should not be accepted, as there is a high probability of ill effects, possibly of permanent damage.