In our September 29, 2009 Patient Safety Tip of the Week “Perioperative Peripheral Nerve Injuries” we noted that peripheral nerve injuries are now among the most common reasons for anesthesia-related malpractice claims.
The American Society of Anesthesiologists has just updated its “Advisory for the Prevention of Perioperative Peripheral Neuropathies”, originally published in 2000. It’s called an “advisory” rather than a guideline because it relies heavily on expert opinion given the relative paucity of an evidence base in the literature for prevention of peripheral nerve injuries during anesthesia or sedation in various settings.
It points out that the preoperative assessment should take into account history of neurological symptoms, diabetes, alcohol use and consider potential risk factors such as body habitus, gender, vascular disease, and arthritis or other deformities. Both extremes of weight are important considerations (remember that many patients who develop peroneal nerve palsies have a history of recent significant weight loss, voluntary or involuntary, with loss of the protective fat pad likely being a contributory factor.) Almost any pre-existing peripheral neuropathy renders nerves more prone to the effects of compression. Some neuropathies, particularly the “hypertrophic” neuropathies where peripheral nerves may be palpably enlarged, render patients even more vulnerable in perioperative settings.
The advisory does do a good job of identifying which peripheral nerves or plexuses are most vulnerable to harm in the perioperative setting. And it provides reasonable recommendations for proper positioning to help reduce the risk of nerve injuries in the upper and lower extremities when the patient must be in various positions (eg. supine vs. prone).
It also has a discussion about the use of padding, arm boards, chest rolls, etc. to minimize the risk to specific nerves. But it does note that padding may also have unintended consequences, particularly if it is applied to tightly. The section on the effects of equipment is also interesting, though almost all the literature is from isolated case reports or small series. However, items such as automated blood pressure cuffs, shoulder braces or rests, Foster frames, self-retaining retractors, leg holders, surgical stockings, pneumatic compression devices, stirrups (particularly when patient is in the lithotomy position), slings, continuous passive motion machines, etc. have all been implicated in peripheral nerve injuries.
We refer you back to our September 29, 2009 Patient Safety Tip of the Week “Perioperative Peripheral Nerve Injuries” for many other examples of peripheral nerve injuries occurring in the perioperative setting.
While there is no good evidence base on the practice, we advocate that the need for positioning or repositioning to be discussed during the pre-surgical huddle (or the surgical timeout) and that the duration of the procedure be announced periodically so that consideration can be given to repositioning the at-risk patient. At any rate, now is a good time to review your perioperative procedures for preventing peripheral nerve injuries.
The American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies presents an updated report of the Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies. Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies: An Updated Report by the American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. Anesthesiology 2011; 114(4): 741-754