PRONE  -  Andrew's Frame

DESCRIPTION:
A specialized prone kneeling frame that facilitates surgical access to the lumbar and cervical, and occipital areas.

Used for:

  • Back or neck procedures (cervical to sacral)
  • Procedures of the occipital or postero-lateral cranium
  • Sacral, perianal & perineal procedures


 


POSITIONING STEPS:

  1. Note preoperatively, any patient limitations in positioning (neck or arms).  The patient is anesthetized and intubated, and the endotracheal tube is secured, while patient is lying in the supine position, on either a stretcher or bed.  This is accomplished by moving the OR table to one side, so the patient (on stretcher or bed) can be pulled into position for induction, near the anesthesia machine and needed equipment. The OGT, EGS and humidifier should be placed at this time.

  2. After intubation and induction are accomplished, the anesthesia provider gives permission for other OR team members to assist in moving the OR table back, next to the stretcher or bed, aligning both in front of the anesthesia machine.  The anesthetist frees and secures all lines ( IV, Art-line, Central-lines, etc.) in preparation for turning of the patient. (Please note: There should be a draw sheet on the OR table before moving patient onto it, for later positioning of the patient arms.)

  3. With multiple assistants, the anesthesia circuit is briefly disconnected by the CRNA as he or she simultaneously commands the head, with one hand securing the airway (or ETT), and attends to the position of all lines.  At the command or 1-2-3count of the CRNA, the patient is carefully flipped prone onto the OR table.

  4. While other OR team members assist in the prone positioning of the patient, the CRNA continues to maintain the airway, reconnects the circuit, ensures proper functioning of the ventilator (or ability to hand ventilate patient in the case of a LMA), and checks and secures lines.

  5. Parallel thoracic or chest rolls (made from tightly rolled sheets and blankets or manufactured gel rolls) are placed under the thorax, lateral to the breasts, following the long line of the body to free the abdomen from compression.  Care is given not to compress the breasts with the rolls or cause undue pressure under the axilla.

  6. The head is positioned prone, with face placed in a foam prone-cutout pillow (with ETT, OGT and EGS exiting out the side), in a skull-pin head clamp, or in a rocker-based face/forehead rest.  It can alternatively be placed laterally, using a gel donut, pillow or blankets, while avoiding forced rotation of the pronated head .  Eyes, ears, and nose should be checked to assure that these areas are free from pressure.  Most important:  *The C-spine should be in neutral alignment (check for neutral position of the neck in all 3 planes).  The tube should be free without kinking or undue traction, and the anesthesia provider should be able to visually see or reach in and check all connections.

  7. The arms are padded and positioned usually cephalad to prevent nerve stretch or compression.  The arms are secured to prevent accidental movement causing dislocation or trauma.

  8. Legs are maintained in the long axis of the body.  The bed is then broken to put the patient in a kneeling position. The knees are padded and a padded support rest is placed against the buttocks.  There should be a 90-degree angle at the hips, knees, and ankles, with all pressure points padded.

  9. The patient is secured to the table with tape or a belt across the thighs immediately under the buttocks and over the iliac crests.


EQUIPMENT:

POTENTIAL COMPLICATIONS: 

  • Compression ulcers:  orbital, ears, nose, elbows, iliac crests, knees, breasts and toes
  • Nerve damage:  axillary, brachial plexus, radial, ulnar,  popliteal, long thoracic
  • Thoracic outlet syndrome
  • Cervical Spine Injury
  • Breast trauma
  • Unstable chest wall
  • Venous congestion
  • Conjunctival edema

PRONE ARM POSITIONS:

POSITIONING VARIATIONS: