Surgical Positioning : Evidence for Nursing Care 1

The goal of surgical positioning is to promote access to the surgical site. It should be carried out correctly to ensure patient safety and prevent complications. This integrative literature review aimed to search for and evaluate available evidences in literature about nursing care related to surgical positioning of adult patients in the intraoperative period. Pubmed, Cinahl and Lilacs databases were used for the selection of the articles. The sample consisted of 20 articles. The synthesis of the available evidence showed that included studies focused on three main topics: risk factors for developing complications, complications due to surgical positioning and nursing care related to surgical positioning. Among the gaps in the research theme, the need to conduct studies on effective devices for each type of surgical position is highlighted.


Introduction
Intraoperative nurses are responsible for planning and putting in practice nursing interventions that minimize or make it possible to prevent complications deriving from the anesthetic-surgical procedure, with a view to the patient's safety, comfort and individuality (1) .The patient's surgical positioning is an important procedure in intraoperative nursing care.The main goal of this procedure is to promote optimal exposure of the surgical site and, at the same time, prevent complications deriving from surgical positioning.Therefore, teamwork and the use of specific positioning devices and equipment for each patient are essential.Nurses share the decision on how to best position the patient to facilitate activities during anesthesia and surgery with the team (surgeon, anesthetist and nursing staff).For this purpose, the patient's anatomic and physiological alterations need to be identified, associated with the type of anesthesia, procedure type and surgical time he/she will be submitted to, so that the positioning is adequate and does not cause postoperative complications (2) .This research is motivated by the lack of Brazilian research about nursing care in surgical positioning and Lopes CMM, Galvão CM.
the importance of research to support decision making by perioperative nurses, who have limited access to literature due to a lack of time and difficulties to seek and analyze available evidence and apply it in clinical practice.
The theoretical framework adopted to develop this research was Evidence-Based Practice (EBP).The EBP approach integrates the best evidence from research with professionals' clinical competency and patients and family members' preferences in decision making in highquality health care (3) .
The practice of EBP in nursing encourages nurses to do research directed at clinical practice needs and/or the use of research results available in literature (4) .

Purpose
This research aimed to search for and assess evidence available in literature about nursing care related to surgical positioning of adult patients in the intraoperative period.

Methodological procedure
The adopted research method was an integrative literature review.This method includes systemized analysis and synthesis of research results on the same theme, contributes to deepen the research theme, supports decision making and, consequently, the improvement of clinical practice, based on preexisting research results (5)(6) .
The following steps were followed to elaborate this integrative review: identification of theme or formulation of guiding question; sampling or literature search for studies; assessment of studies included in the review; discussion and interpretation of results and synthesis of knowledge evidenced in analyzed articles or presentation of integrative review results (5,7) .
review, the concepts proposed by nursing researchers were used (3,9) .
The articles were analyzed and summarized descriptively, allowing readers to assess the quality of evidence (evidence level) available in literature on the research theme, support decision making in daily intraoperative nursing and identifying knowledge gaps with a view to future research.

Results
Twenty articles were included in the review, nineteen of which were published in English and one in Portuguese; among the publications' countries of origin, the United States predominated with thirteen articles.
Papers were published in a range of journals, particularly the AORN Journal (four articles).
With regard to the evidence level, only one study showed a strong evidence level (level II) with an experimental design, i.e. controlled randomized clinical trials; one study was considered of moderate evidence level (level III) with a quasi-experimental design, i.e.
assessments (process analysis), and eight studies presented weak evidence (levels VI and VII), three with a non-experimental design, two descriptive, crosssectional studies and three experience reports.In the same sense, the other ten studies (narrative literature reviews) are not classified according to the adopted hierarchical system.Tables 2, 3, 4 and 5 show the synthesis of the analyzed articles.Feuchtinger et al. (10) Controlled randomized clinical trial (n=300) Assess the efficacy of using a 4cm thermoactive viscoelastic foam pad to reduce surgical positioning injuries.
No significant statistical difference was found between the trial (tested device) and control (usual care) groups.
Further research is needed to identify effective devices to prevent surgical positioning injuries.
Power (11) Assessment (process analysis)  Roeder et al. (12) Descriptive cross- Matos, Piccoli (13) Descriptive cross- Lopes CMM, Galvão CM. for deciding on patient positioning should be reviewed and updated every year and should be followed by all participants in this activity.
Richardson (16) Expert opinion Describe the use of a type of leg holder and its benefits during surgical patient positioning.
The author describes the use of a new type of leg holder to place the patient in the lithotomic position, which is called "Direct Placement Leg Holders" (DPLHs).This device is easy to move, fix and position, besides reducing heel and calf pressure.It facilitates routine and promotes patient safety.Nurses are responsible for providing the best equipment and guaranteeing its correct use so as to provide better patient care.
Carris, Franczek (17) Experience report Describe a surgical positioning device for patients submitted to endoscopic urological procedures.
The authors describe difficulties to place obese patients in the lithotomic position after induced anesthesia.They report on the use of a 91.44x60.96cmsmooth plastic device that is cheap and normally used for snow sliding, covered by a surgical drape and placed under the patient.Soon after anesthetic induction, this device helps to slide the patient to the lower part of the table, a simple procedure that facilitated patient positioning, avoiding injuries in the patient and team, and which can be used at any other surgical center.
Murphy (18) Experience report Report on three cases with legal decisions involving intraoperative injuries deriving from surgical positioning.
In the three cases of surgical positioning injuries, no negligence by the perioperative nursing team was evidenced.It serves as an alert to nurses though, so as to take care while transporting, transferring and positioning the patient on the surgery table, using due protection and padding, highlighting the importance of documentation so as to provide legal support for the delivered care.

Describe an intraoperative positioning technique for burned patients.
The technique is used to permit free access to structures that need to be debrided in burned patients.Correct positioning favors a shorter surgery time and, consequently, decreases the number of interventions and reduces the risk of complications.

Research Purpose Synthesis
Hoshowsky (20) Discuss the main points during surgical positioning of orthopedic surgery patients.
The goals of surgical positioning are: promote the best exposure of the surgical site, access to ventilation and monitoring, maintenance of physiological functions, patient comfort, safety and privacy.Nursing interventions for orthopedic surgery patients depend on the type of position and previous assessment is needed to know each patient's particularities.
Taylor, Campbell (21) Review the prevention of surgical procedure errors, surgical positioning and care with pressure areas.
The following is recommended for patient positioning: check if equipment and operation Keller (22) Describe the risk factors that can be intensified in obese surgical patients.
Transportation and surgical positioning of obese patients demand adequate planning to avoid injuries in operating room staff and patients.Surgical devices, equipment and instruments adequate to obese patients' size should be provided in advance.In obese patients, the author recommends the prohibition of the Trendelemburg, supine and prone positions.
Heizenroth (23) Describe the causes of nerve injuries in surgical patients, with a view to guiding practice and planning care.
Causes of injuries can be related to imposed forces due to surgical positioning for a long period; tissue hyperextension or compression, which can leave nerves without oxygen and cause damage, which can be temporary or permanent.Correct patient positioning, padding and monitoring in the intraoperative period help to prevent these complications Continue...

Research Purpose Synthesis
Troia (24) Analyze risk factors and care needed for obese surgical patients.
Planning and putting in practice effective actions can prevent complications.Adequate care for obese patients demands the availability of adequate positioning, transfer and mobilization equipment for the patient's body and some positions, such as the lithotomic position, should be avoided.
CS is a potentially fatal disease that occurs when perfusion pressure drops below tissue perfusion in one compartment, developing ischemia on the site.Correct and safe surgical positioning with the use of adequate devices and its maintenance during the intraoperative period is a fundamental conduct for all people involved in patient care.
Dybec (26) Appoint the main considerations about surgical positioning of obese patients.
Some surgical positions increase the potential risk of complications in obese patients, such as the supine and prone position; while others can be beneficial, such as the lateral position.Equipment needed to support positioning should be assessed and selected before the patient arrives at the surgery room.An adequate number of staff should be present for transfer to the surgery table.
Millsaps (27) Review the main points during surgical positioning.
The development of adequate positioning techniques, the use of support equipment and padding devices contribute to patient safety.Care planning, considering surgery time, surgery type and anesthesia, besides the identification of risk factors for each patient, will determine what device is adequate.
O'Connell (28) Describe the types of surgical positions and nursing care in patient positioning.
The main positions mentioned are supine, lithotomic, lateral and prone.Potential complications deriving from surgical positioning increase in anesthetized patients.Care should be taken with plexi and nerve sites, impeding the occurrence of nerve injuries; assess prominent bones in contact with the surgery table and guarantee that capillary pressure remains ≤32mmHg; respect body alignment and use specific devices to support positioning for each type of position and patient needs.
Murphy (29) Identify court cases related to operative injuries.
A literature review was carried out in the LexisNexis database between February 2002 and February 2004, using the keywords: "operating room and nurse", "negligence or malpractice".Seventy-eight cases were found in three legal instances, four of which were related to pressure ulcer deriving from surgical positioning.Positioning should be planned in advance and involve the entire team.

Discussion
The synthesis of research data from the review studies revealed that these focused on three main themes, which were: risk factors for the development of complications, complications deriving from surgical positioning and nursing care related to the patient's surgical positioning.
Preoperative assessment of each surgery patient's risk factors and their consideration in the elaboration of the care plan can contribute so as not to develop complications in the intraoperative period (20)(21)(22)(23)(24)(25)(26)(27)(28) .All identified risk factors should be documented, as well as orientations patients received (29) .
The main risk factors mentioned were: general anesthesia -situation in which the body loses physiological protection for compensation mechanisms and is susceptible to muscle and/or nerve injuries and pain.Using drugs like muscle relaxants and pain medication can mask and delay the diagnosis of intraoperative injuries (20)(21)(22)(23)(24)(25)(26)(27)(28) ; age -elderly or very young patients can have a more sensitive skin and greater probability to develop skin injuries (20-21, 25, 27-28) ; weight -assess the body mass index, as obesity and overweight can lead to a higher potential of complications due to positioning and low weight causes increased exposure of the patient's bone prominences, which are regions more susceptible to the appearance of skin injuries (20)(21)(22)(24)(25)(26)(27)(28) ; immobility or mobilization problems -make surgical positioning more difficult and can favor the formation of blood clots and pressure points (20, 23--25, 27-28) ; body temperature control problems -as a result of hypothermia, body structures depend on more oxygen and, without the necessary inflow, this can favor the formation of necrosis or tissue death (20)(21)26,28) ; Lopes CMM, Galvão CM.
The following stand out among nursing care recommendations in the analyzed articles: respect body alignment; take actions for pressure areas; reduce friction, shear and pressure; check bone prominences; select and make available positioning devices according to each patient's needs and relate them with the surgery type and time; move, transport and position the patient with an adequate number of staff and using adequate equipment to avoid occupational and patient injuries; document all positioning procedures (10,(20)(21)(22)24,(26)(27)(28) .
The main surgical position recommendations are: review was: what is the nursing care related to surgical positioning of adult patients in the intra-operative period?For the article search, the internet was used to access the following databases: PubMed (digital biomedical and health science files from the US National Institutes of Health), CINAHL (Cumulative Index to Nursing and Allied Health Literature) and LILACS (Latin American and Caribbean Health Science Literature).
Assess postoperative pain experience related to type of surgical positioning in patients submitted to gynecological surgeries.The frequency of patients' pain reports increased with age and duration of surgery.No difference was found in pain incidence or severity with regard to type of positioning.The author recommends that perioperative nurses should document the adopted interventions and relate them with clinical findings, so as to rethink practice and attempt to improve nursing care.
sectional research Assess capillary pressure supported in the heel and calf region in individuals in lithotomy position.Pressure increases with increased height of calf support in variation of lithotomy position and the larger the support surface, the lower the capillary pressure supported.The authors recommend the use of the lowest heel position; placement of support under the greatest contact area and maintaining the patient in the lithotomy position for the shortest possible time.
diagnosis was identified in 100% of the sample.The defining characteristics and identified factors were loss of habitual protective barrier after anesthesia and commitment of tissue perfusion after cold in surgery room with frequencies of more than 50%.Nurses should plan actions based on each patient's specific characteristics, the patient's surgical positioning is what determines a safe and efficient procedure.Stevens et al. (14) Retrospective correlation research Analyze the injuries of patients submitted to urological surgical procedures, correlated with predisposing factors.Surgical positioning and prolonged surgery time were significantly associated with the development of skin injuries.The risk of developing injuries is greater in patients placed in the lateral position, which is chosen in urological surgeries.The skin injuries developed by patients submitted to urological surgeries derived from surgical positioning and this procedures demands care and attention by the intraoperative team.
supine -use pillows or supports for the head and below the knees, place arms at a maximum angle of 90º with the body, keep legs uncrossed, pay attention with hyperextension of the feet; prone -protect face, eyes and chin, favor access to tubes and monitoring lines, maintain neck alignment, place roll cushion from the collar bone to the iliac crest and under the legs and feet, leave genitals free, protect feet against hyperflexion; lateral -maintain spinal alignment, observe ears, place a support under the head, armpit region and between the legs, keep leg in contact with the table flexed in the hip region and the superior leg stretched; lithotomy -maintain arms in arm holders at a maximum angle of 90º, pad hip, buttocks and body sides, use the lowest leg elevation for the shortest possible time and minimize the hip abduction degree.ConclusionThe conclusion of this integrative literature review evidences the importance of nursing actions in surgical positioning, including the prevention of complications deriving from this procedure, the assessment of each patient's needs and the availability of adequate equipment and devices.Nurses should become consumers of research results and/or conduct studies in response to daily problems, and should also seek strategies to put available evidence in clinical practice.In the authors' opinion, this will imply the consolidation of Evidence-Based Practice.
Table 1 displays the descriptors used to conduct the integrative review.

Table 2 -
Synthesis of research with experimental and quasi-experimental research design

Table 3 -
Synthesis of research with non-experimental research design

Table 4 -
Synthesis of expert opinion and experience report researchThe Association constructed practical recommendations in six standards, which are: I.Preoperative assessment of patient's special surgical positioning needs, II.Devices to support positioning should be available, clean and preferably maintain normal capillary interface pressure, III.The nurse should monitor the patient's body alignment and tissue integrity based on physiological principles, IV.After the positioning, the nurse should assess the patient again, V. Positioning documentation should follow "AORN Recommended practices for documentation of perioperative nursing care", VI.Institutional standards and procedures table are clean and safe, move patient carefully, place and fix him/her in the desired position, take care with pressure points, as skin injuries can be caused by long stay on the table, based positioning and/or inadequate moving, associated with factors like age, weight, nutritional state and temperature control.