Position: Prone, Left Lateral, Right Lateral, arms free at side, arms extended and flexed (“superman”)
Time: 5-30 min (very short)
Blood Loss: Very Low (5-10 ml)
Post-op Pain: Minimal (1-3)
Maintenance Paralytic: No

Anticipate high stimulation – Initial access to the inside of the bone will be moderately stimulating. The aspiration of bone marrow is VERY stimulating. Make sure to give adequate sedation 1- 2 minutes prior to these events.

Approach – the positioning depends on the approach. By experience, these are usually done in the lateral position with a MAC. Some report to be doing these under GETA and in the prone position and ‘superman’ positioning of the arms. If GETA is used, it is very common for these patients to be very hypotensive, so be ready with pressors/fluids.

Prone Position (general considerations): Maintain cervical neutrality. Keep IV’s out of the antecubital space. The patients arms are typically flexed, which will kink the IV. Eye protection should be used as the prone position heightens the risk of corneal abrasion and/or traction on the globe (which can result in blindness). Check the patients eyes/ears/nose regularly throughout the case to ensure they are free of pressure. Positioning of the leads is typically high on the posterior and posterolateral back (somewhere free of pressure and out of surgical borders). Keep your connections and tubing where you’ll have fast access.

Lateral position (general considerations): If an ETT has been placed, make sure ETT is secure with extra tape.  Unhook anesthesia circuit while turning lateral and be especially careful to keep patient’s head neutral and aligned with body to avoid neck injury. Once lateral, use pillows/blankets/foam headrest to keep the patient’s head in neutral position. The most common nerve injury for orthopedic lateral procedures are neurapraxias of the brachial plexus. These are motor and/or sensory loss for 6-8 weeks due to pressure on the contralateral (dependent) axilla. To prevent this, place an axillary roll under the patient (caudad to the axilla, on the rib cage, and NOT in the axilla). Check routinely to make sure the axillary roll does not migrate into the axilla. If the non-dependent arm is placed on a board, check padding and reposition regularly to avoid radial nerve compression. If a bean bag is employed, check the hard edges to ensure that unnecessary pressure isn’t being put on soft tissues. Pad all dependent bony prominences such as the fibular head (to prevent peroneal nerve injury), and place pillows between the knees and ankles (to prevent saphenous nerve injury). If anterior hip supports are in place, ensure they are properly padded or neuropraxias and/or occlusions of large blood vessels may result.