The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [613]
All movements of the limbs of the unconscious patient should take into account the anatomy and natural planes of movement of that limb to avoid stretching and pressure on the related nerve planes (AORN 2001). Hyperabduction of the arm when placed on a board, for example, could stretch the brachial plexus, causing some postoperative loss of sensation and reduced movement of the forearm, wrist and fingers. To prevent this, the board should be angled at 45° and not 90° with hands facing more towards the feet rather than the head. The ulnar and radial nerves may be affected by direct pressure as a result of insufficient padding on arm supports.
Compartment syndrome is a life-threatening complication of the Lloyd Davies position (Figure 14.2) and occurs when perfusion falls below tissue pressure in a closed anatomical space or compartment such as hand, forearm, buttocks, legs, upper arms and feet. It develops through a combination of prolonged ischaemia and reperfusion of muscle within a tight osseofascial compartment (Malik et al. 2009). Untreated, it can lead to necrosis, functional impairment, possible renal failure and death (Callum and Bradbury 2000, Paula 2002). If patients are placed in Lloyd Davies position and Trendelenburg tilt for longer than 4 hours, the legs should be removed from the support every 2 hours, or as close to 2 hours as possible, for a short period of time to prevent reperfusion injury (Raza et al. 2004). The use of compression stockings and intermittent compression devices in the Lloyd Davies position needs to be reviewed as this may contribute to compartment syndrome (Malik et al. 2009). There is insufficient evidence to suggest that use of one device over another will reduce the risk of compartment syndrome, nor is there enough evidence to recommend use of both devices at the same time because this will place pressure on the calf in the Lloyd Davies position. The use of devices will depend very much on the surgeon and anaesthetist and the patient’s co-morbidity.
Figure 14.2 Patient in Lloyd Davies position.
Methods of infection prevention
It is imperative that during surgical procedure infection prevention is maintained at all times. The area around the patient and the scrub assistant’s trolley area are all classified as a sterile field meaning that only those staff who have donned gloves and gowns after washing their hands can access this area. Presurgical handwashing is essential to the maintenance of asepsis in the operating theatre. New research has recommended a 1-minute hand wash with a non-antiseptic soap followed by hand rubbing with liquid aqueous alcoholic solution, prior to each surgeon’s first procedure of the day (Tanner et al. 2007). Before subsequent procedures the process should be repeated. However, this is applicable to minor cases only. This has been shown to be as effective as traditional hand scrubbing with antiseptic soap in preventing surgical site infections (Parienti et al. 2002). However, the traditional 3-minute first scrub of the day is recommended for all intermediate, major and complex cases.
Surgical gloves have a dual role, acting as a barrier for personal protection from the patient’s blood and other exudate and preventing bacterial transfer from the surgeon’s hand to the operating site. It has been suggested that double gloving significantly reduces the number of perforations to the innermost glove in high-risk surgical patients, thus reducing infection rates during surgical procedures (Tanner and Parkinson 2002).
Legal and professional issues
Transferring and positioning
When a patient is transferred between the trolley or bed and operating table, adequate personnel should be present to ensure patient and staff safety (AORN 2001).