Abstract SNACC-60

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Prone positioning for paediatric spinal surgery: how well do we consent our patients? How well do we document what we do in order to keep them safe?

1Fiandeiro C, 2Avanis M, 1Cernovsky J
1Royal National Orthopaedic Hospital, Middlesex, , UK; 2Great Ormond Street Hospital, London, , UK

Introduction

Prone positioning during anaesthesia is associated with well-documented complications, including rare but potentially disastrous visual loss, with an incidence of up to 0.2%. 1 Most can be anticipated and minimised with appropriate safety measures. However, the patient population at our institution often have comorbidities that make positioning them prone very challenging.

In the UK, there is currently no standard consent process for prone positioning or guidance on the appropriate intraoperative safety measures and required documentation.

We therefore performed a study in order to examine:
(1)the consent process for prone positioning by the surgical and anaesthetic teams
(2)the intraoperative documentation of safety measures undertaken.

Methods
A retrospective review of 100 case notes of paediatric patients undergoing spinal surgery in the prone position between June and December 2013 was performed.

Results
The average age of patient was 14.8 years (10 – 18); 75 were female. The main reason for surgery was scoliosis correction. The mean duration of surgery was 204 minutes (90 – 360).

None of the surgical consent forms mentioned prone positioning, although 14 documented the risk of visual loss. Anaesthetic consent was documented in 40 cases; this varied from ticking the phrase ‘prone positioning’ to listing the various potential complications eg nerve and ocular damage, soft tissue swelling and pressure sores.

Anaesthetic chart documentation of prone positioning and the various safety measures undertaken was variable; 4 did not have the patient’s position documented. The most commonly documented measures undertaken were (a) the use of a prone-view (73%) (b) the use of a Montreal mattress (70%) (d) eye care (62%) and (e) pressure points padded (63%). Additional measures included, positioning and padding of the legs (22%) and arms (4%) and maintaining a neutral head and neck position (21%). Difficult patient positioning was documented on 6 occasions. Seventeen charts had documentation of regular intraoperative checks. Of note, the anaesthetists who documented initial consent went on to document a greater number of safety measures intraoperatively.

Discussion and Conclusion
Consent and documentation for prone positioning was inadequate in the majority of the cases examined and when present was very varied. Procedural consent and intraoperative positioning is a multidisciplinary responsibility; in the current litigious culture of the NHS both surgeons and anesthetists must be encouraged to document the process of communication and safety measures undertaken.

We are in the process of redesigning our anaesthetic charts in order to improve and standardise both the consent and the safety precautions performed and documented for prone positioning.


References:
1. Edgecomb H et al. Anaesthesia in the prone position. Br. J. Anaesth. (2008) 100 (2): 165-183.

2. Adams J. Quality and outcomes in anaesthesia: lessons from litigation. Br. J. Anaesth. (2012) 109 (1): 110-122.


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