Evidence Informing Policies Regarding Positioning Patient to Prevent Compartment Syndrome - Essay Example

?Evidence Informing Policies Regarding Positioning (Lithotomy) Patient to Prevent Compartment Syndrome Introductions: Compartment Syndrome has been broadly reported in legs located in lithotomy, for urologic, as well as prolonged general surgical and gynecologic procedures. The literature review of the orthopaedic part also encloses reports of this complication in legs located as a fracture or break in the hemilithotomy position. Compartment Syndrome is a situation in which augmented pressure in a closed compartment compromise or negotiate the function and circulation of the various tissues in that space. It happens most generally in an osseofascial compartment of the forearm or leg, but it may happen in the upper foot, arm, abdomen, thigh, buttock, and hand. Positioning the particular patient for a surgical practice is the shared duty of the entire group of medicos. “There are many concerns to address when placing a patient in the lithotomy position. The patient can be injured while being placed in and out of the position, as well as while in the position. When placing the patient in the lithotomy position, both legs should be moved in unison to avoid overstretching the nerves of the lumbosacral plexus” (Rank 2012). Patient positioning in operation theatre relates to how a particular patient is transferred and positioned for a specific procedure. The incident I came across in this case in related with a patient in recovery, subsequent to prostactectomy, handed over by the anaesthetist. That particular patient was in the position of lithotomy - rendelenburg for 8 hours, with bilateral extremities supported on the parts with stirrups. While the patient woke up from anesthesia, he appeared to be restless with complaining ache on his right leg. Though in a higher amount of analgesia, the patient complained of severe pain with passive movements. He also complained of decreased feeling on the toes and feet in the right leg. His feet were temperate and warm, and he had a palpable pulse. I noticed his calf was tender, and tense on the right side of the leg. The study is carried out to understand the Evidence informing policies regarding positioning (lithotomy) patient to prevent Compartment Syndrome. “In the lithotomy position, calf compression is almost inevitable and this predisposes to venous thromboembolism and compartment syndrome. The aetiology of compartment syndrome is probably a decrease in perfusion pressure caused by a combination of the weight of extremities against the supportive devices, reduction in compartment capacity and elevation of the lower limb above the heart” (Knight & Mahajan 2012). Aim of the Study: 1) To identify the various policies regarding positioning (lithotomy) patient to prevent Compartment Syndrome. 2) To identify the various symptoms of Compartment Syndrome. 3) To identify the various types of risk factors for growth of acute Compartment Syndrome, resultant from this kind of leg positioning. Safety of the patient is the central focus of patient care in the framework of NHS (Carruthers & Philip 2006), and all healthcare practitioners should guarantee that patients are defended from harm as far as possible. Appropriate positioning decreases the risk of pressure-connected damage to joints, nerves, skin, and muscle. The sedated or anaesthetised patient, are not capable to converse if they have been positioned in a compromising or hazardous position. Therefore a proactive approach must be taken to stop the delerious consequences of the patient mal-positioning. Right positioning of a patient permits the most selected exposure of the operative field (Millsaps 2006). Positioning should also consider the scale of movement that may be essential for the duration of the procedure, for example, for shoulder and knee arthroscopy, it needs considerable movement of the upper and lower limbs respectively for the duration of the process, and that the surgical field should be setup accordingly. Discussion: Compartment Syndrome is one of the problems that may occur because of the poor positioning of the patient. “There is probably no way to prevent this condition; however, early diagnosis and treatment will help prevent many of the complications. Persons with casts need to be made aware of the risk of swelling. They should see their health care provider or go to the emergency room if pain under the cast increases despite pain medicines and raising the area” (Compartment Syndrome 2012). Lengthened compression of the vessels of a limb may obstruct blood circulation to the limb, and that creates a compartment syndrome, resulting in loss of function and muscle necrosis. Roher et al. (2008), in his study, noted that any of the long-lasting operations of the patient in the position of lithotomy is accompanied by the danger and risk of an acute compartment syndrome of lesser extremities'. Like safe positioning of the patient, it should also permit sufficient blood flow to every four limbs. “Prevention of compartment syndrome involves avoiding the conditions and activities that might lead to increased pressure in the compartment. Using the techniques below will help prevent compartment syndrome” (Compartment Syndrome and Compartment Syndrome Treatment 2012). Warming the muscle correctly will organize it for the upcoming activity and permit a slow rise in the size of the muscle. This will also reduce the possibilities of wounding the muscles. Heat retaining and warm pack coverings may be employed to warm the region, prior to keeping it warm and active in the duration of exercise. Activities that create pain must be limited or avoided as much as possible. When additional activities are included to the plan, it is significant to note any ache, and if they cannot be adjusted to ease the pain, they must be discontinued. Slow rising duration and intensity of activities are significant in the context. Rapid rising without a sufficient conditioning in the training period can lead to pain in the bones and muscles, and it may cause injury and bleeding in the compartment. By gradually increasing the workload of the muscles, and nearby fascia, it will have time to adapt. Elongating the muscles will assist in relieving pressure in the compartment? Elongating the muscle endless it to lengthen, decrease its thickness, and reduce pressure. Elastic muscles are also less vulnerable to injury. “Risk factors for Leg Compartment Syndrome include: Lithotomy position Procedure duration (longer than 4 hours) Trendelenburg position Ankle dorsiflexion (increases the pressure in the anterior compartment) Being overweight Having muscular lower limbs Pneumatic calf compressors (a common perioperative treatment) Intraoperative hypotension (It turns out that our patient did have surgery performed with intraoperative hypotension, to reduce bleeding.) Vasoconstrictive drugs” (Huston 2007). Compartment Syndrome may be initiated by a lot of circumstances, including fractures, crushing injury, burns, hypothermia, vascular injury, overexertion, prolonged limb compression or contusions. In orthopedics, it is common in connection with both open and closed tibia fractures. It also happens with other fractures, after extrinsic compression and soft tissue trauma, for instance, from medical antishock trousers. Compartment Syndrome has been illustrated in most every location, as well as in the deltoid, arm, hand, forearm, glutel compartments, thigh, foot and leg. In North America, failure to correctly diagnose Compartment syndrome is one of the most general reasons of litigation against medical profession. “The classic symptoms for the diagnosis of Compartment syndrome are known as the five Ps: pain, pallor, pulselessnss, parenthesis and paralysis. However, these criteria are subjective, are not uniformly present, are often difficult to assess, and when present are indicative of an advanced stage of injury and pain out of proportion to the injury that may be irreversible. The most reliable symptom of acute Compartment syndrome is pain with passive stretching of the involved muscles” (Stannard et al. 2008, p. 46). One should evade the use of regional painkiller blockade in patients with Section syndrome, and yet the use of standard patient controlled anesthesia can totally mask the increase in pain that occur with Compartment syndrome. Compartment syndrome can follow crush injuries, penetrating injury of closed compartments of limit, and cracks with vascular trauma as mentioned in the previous part. Burns, animal bite injuries, high stress pain, gun injuries, and infiltrated combinations in closed tissue compartments also contribute to Compartment Syndrome. Pressure in the compartment is more than 30 mm Hg, and is assessable by plethysmography. “Treatment consists of fasciotomy immediately and so, alerts the trauma surgeon, elevates the limb above the heart level; remove any pressure dressings that may have been applied to the limb” (Nayak 2008, p. 144). General positions where compartment syndromes happen are anatomic closed spaces exist in the hand, abdomen, forearm, gluteal regions, upper arm, and in lesser extremities and have an important probable for compartment syndromes. Compartment Syndrome happens as an outcome of arterial compression that leads to poor tissue perfusion, fluid leaking into a closed compartment, and possible cell death. The compartments of the extremities are bound by intramuscular septa, bones and superficially by deep fascia and usually they don’t have any connection with the other parts. As a result, the infection that persists will be confined to only one compartment. “Lower extremity compartment syndrome is not a common complication but has been reported to occur more frequently in the lithotomy position than in other positions, especially during prolonged procedures. The acute angles at the hips and knees may cause the major vessels to be compromised and may cause compression of the calf muscles and the popliteal fossa, especially when knee crutch stirrups are used” (Denholm 2011). The patient is also at risk of respiratory and circulatory complications that may result from being in the lithotomy position. The improved risk of blood pooling in the patient's calf muscles throughout the process enhances the chance of contracting vein thrombus. On removing the patient’s leg from it support after the procedural activities, blood is seen to be returning to the patient’s tangential circulation, and it can cause an overall hypovolemic condition. Procedures executed in the lithotomy position frequently need the head to be tilted down, which enhances the risk for respiratory compromise and pulmonary congestion, and it also decreases limb perfusion. (Denholm, 2008). In longer operations, Compartment Syndrome can be caused by the positioning of the legs. The most applicable publications refer to the semi lateral lithotomy position or the lithotomy position. This complication also happens extremely rarely in processes of lateral position or in the knee elbow position. “Most cases involve the Compartments of the lower leg. The mean operating time in the published cases was about 7h. All age groups can be affected. The crucial increase in pressure in the Compartments for the development of Compartment syndrome and the corresponding drop in the arteriovenous pressure gradients is caused on the one hand by persistent body weight” (Aschemann 2006). Additionally, in the lithotomy position the increased position of the legs and probably further position induced compression of arteries and veins can result in further impairments to movement. A common drop in blood pressure through the operation can be just as difficult as imminent arteriosclerosis. In contrast to position persuaded isolated nerve injuries, the initial probable detection of the growth of Compartment syndrome is crutial regarding the essential therapy, so as to stop permanent injuries. (Positioning Techniques in Surgical Applications: Thorax, and Heart Surgery ... by Christian Krettek, Dirk Aschemann, pg -128, 2006) “Compartment Syndrome” (Compartment Syndrome 2012) is a significant situation that entails improved stress in a muscle compartment. It can cause nerve and muscle damage, and troubles with blood flow. Causes Incidence and Risk Factors: Thick layers of tissue, called fascia, divide collections of muscles in the legs and arms from each other. Inside every layer of fascia there is a limited space, called compartment. The compartment contains the nerves, muscle tissue, and blood vessels. Fascia surrounds these structures, like the method in which insulation protects wires. “Any swelling in a compartment will lead to increased pressure in that area, which will press on the muscles, blood vessels, and nerves. If this pressure is high enough, blood flow to the compartment will be blocked. This can lead to permanent injury to the muscle and nerves. If the pressure lasts long enough, the muscles may die and the limb may need to be amputated” (Compartment Syndrome 2011). Swelling, related to compartment syndrome occurs from trauma, for example, a crush injury or surgery or car accident. Swelling can also be caused by complex fracture or soft tissue injuries because of trauma. Long-term compartment syndrome can be caused by repetitive actions like running. The stress in a compartment rises throughout that activity. Compartment syndrome is quite common in the lesser leg and forearm, even though it can also happen in the foot, hand, thigh, and higher arm. Treatment: Surgery is needed. Long surgical cuts are made through the face to reduce the pressure. The injuries can be left closed and open throughout a second surgical procedure, characteristically about 48 to 72 hours later. Skin grafts may be required to close the injury. If a cast or bandage is causing the difficulty, the dressing must be cut down to reduce the pressure. Preventions: There is probably no way to prevent this condition; however, early diagnosis and treatment will help prevent many of the complications. “Compartment syndrome occurs when elevated pressure in an osteofascial compartment compromises local perfusion and often results in neurovascular damage and permanent disability. Surgeons must recognize this association and provide appropriate preventative measures, have a high index of suspicion in all patients, and be prepared to make an early diagnosis when it is encountered.” (Scott et al. 1997). People with casts require to be made conscious of the risk of swelling. They must see their health care supplier or go to the emergency room if soreness under the cast enhances despite administering pain killers. Recommendations: Proper positioning of the patient must be done to overcome various problems related to positioning. For particular patients in the position of lithotomy, perioperative RNs must receive the following precautions in the safety of the patient. * “Place the stirrups at an even height. * Position the patient's buttocks so that the sacrum is securely supported on the bed surface, and even with the lower break of the OR procedure bed. * Lift the patient's legs slowly and simultaneously into the leg holders to prevent lumbosacral strain” (Denholm 2008). * Place the heels of the patientin the lowest possible position. * Give support over the leading possible surface part of the leg. * Defend the patient's legs to guarantee that they do not rest in opposition to the stirrup posts. On time diagnosis is of supreme importance, in order to keep away from irreversible tissue alterations leading to neurological deficit, muscle necrosis, myoglobinuria, potential mortality and renal failure. Patients must be cautiously monitored subsequent to urological cases. In case of suspected Compartment Syndrome, it is suggested that early fasciotomy, has to be considered with the with the intention of keeping away from irreversible damage to the limbs. Reference List Aschemann, K 2006. Positioning Techniques in Surgical Application. Springer. [Available at [Accessed on 19 April 2012] Compartment Syndrome 2012. The New York Times. [Online] Available at [Accessed on 19 April 2012] Compartment Syndrome 2012. Patient.co.uk. [Online] Available at [Accessed on 19 April 2012] Compartment Syndrome and Compartment Syndrome Treatment 2012. The Streching Institute. [Online] Available at [Accessed on 19 April 2012] Compartment Syndrome 2011. My Optum Health. [Online] Available at [Accessed on 19 April 2012] Denholm, B 2008. Lithotomy Position. Life & Health Library. [Online] Available at [Accessed on 19 April 2012] Huston, K 2007. Round 11: A High Pressure Operation. The Johns Hopkins Arthritis Center. [Online] Available at [Accessed on 19 April 2012] Knight, DJW & Mahajan, RP 2012. Patient Positioning in Anaesthesia. Oxford University Press. [Online] Available at [Accessed on 19 April 2012] Nayak, NH 2008. Guidelines to Practice of Emergency Medicine. 2nd Edn. Elsevier. Available at [Accessed on 19 April 2012] Rank, DS 2012. Patient Positioning an OR Team Effort. Lippincott’s Nursing Center.com. [Online] Available at [Accessed on 19 April 2012] Scott et al. 1997. Prevention of Compartment Syndrome Associated with Dorsal Lithotomy Position. PubMed.gov. [Online] Available at [Accessed on 19 April 2012] Stannard et al. 2008. Surgical Treatment of Orthopaedic Trauma. Thieme. Available at < http://books.google.co.in/books?id=zSy-FzCbWBkC&pg=PA45&lpg=PA45&dq=The+classic+symptoms+for+the+diagnosis+of+Compartment+syndrome+are+known+as+the+five+Ps:+pain,+pallor,+pulselessness,+paresthesia+and+paralysis.+However,+these+criteria+are+subjective,+are+not+uniformly+present,+are+often+difficult+to+assess,+and+when+present+are+indicative+of+an+advanced+stage+of+injury+and+pain+out+of+proportion+to+the+injury+that+may+be+irreversible.+The+most+reliable+symptom+of+acute+Compartment+syndrome+is+pain+with+passive+stretching+of+the+involved+muscles&source=bl&ots=8ZEZyrxBBW&sig=PwyGLYbazAV5P439csDRjScVbk8&hl=en&sa=X&ei=j5qOT8aDLoXJrQeCpKihCQ&ved=0CCEQ6AEwAA#v=onepage&q&f=false> [Accessed on 19 April 2012] Read More