Minimally invasive total hip arthroplasty

AORN Journal,  June, 2004  by Sharon E. Hohler

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ANESTHESIA INDUCTION

After the circulating nurse and scrub person have prepared the room, including performing the first sponge and sharp counts, the circulating nurse verifies that all needed staff members are ready and returns to the preoperative area to transport the patient to the OR. Several staff members help the patient move onto the OR bed. The circulating nurse helps the anesthesia care provider initiate ECG, pulse oximeter, and blood pressure monitoring. The anesthesia care provider performs other monitoring, such as placing an arterial line, depending on the patient's health status. The anesthesia care provider may administer general anesthesia, epidural anesthesia, or a combination of both.

POSITIONING

The MITHA procedure can be performed via a single or double incision. Patient positioning differs depending on which approach is used. No matter which position is used, preoperative assessment of the patient includes

   ... age, height and weight, skin condition,
   nutritional status, preexisting
   conditions which complicate the
   patient's risks and mobility limits....
   The perioperative nurse should be
   actively involved in patient positioning....
   evaluate that the positioning of
   [the] patient maintains optimal safety
   and function of the respiratory, circulatory,
   neurologic, musculoskeletal and
   integumentary systems ... and then
   document the positioning to include
   the preoperative assessment, type and
   location of position and/or padding
   devices, names/titles of persons who
   position the patient, and postoperative
   outcome evaluation. (16 (p341-346))

For example, the circulating nurse notes that Mrs H is 82 years old, 5 ft 3 inches tall, weighs 102 lbs, and has osteoarthritis, osteoporosis, fragile skin, and poor nutritional status that is confirmed by hypoalbuminemia. A cervical neck x-ray report on Mrs H's chart shows no instability, but the circulating nurse ensures that a flexible intubating laryngoscope is readily available in case the anesthesia care provider encounters difficulty with intubation because of the patient's osteoporotic condition. The anesthesia care provider and perioperative staff members work cooperatively to position Mrs H gently, placing gel padding, which distributes pressure over larger surface areas than does foam padding, to protect bony prominences and pressure points on the patient's dependent side. (16 (p342))

SINGLE-INCISION POSITIONING. For a single-incision procedure, the patient is placed in a secure lateral position (Figure 3). A pelvic-stabilizing device, such as a McGuire or Montreal hip holder, is used to hold the patient securely in position. The desired position is to place the patient perpendicular to the floor with no anterior/posterior or proximal/distal tilt. The anesthesia care provider places a gel roll under the patient's dependent axilla to minimize stretching or compression of the patient's brachial plexus. Gel padding is placed under the entire body, including the lateral aspect of the patient's dependent knee to protect the peroneal nerve, which is located superficially over the head of the fibula. Staff members place padding and pillows between the patient's knees, ankles, and feet before the patient's surgical leg is prepped and draped. The circulating nurse flexes the patient's lower arm on an armboard, with the dependent shoulder brought slightly forward to relieve pressure. The anesthesia care provider helps place the patient's upper arm on an elevated armboard or pillows. The circulating nurse and anesthesia care provider work cooperatively after positioning the patient and throughout the procedure to monitor the patient's radial pulses to ensure adequate circulation. Staff members use wide tape and other positioning equipment to secure the patient's position. The circulating nurse also assesses the patient's lower extremity pulses and documents their status before and after positioning and after the procedure.