An elderly patient placed on a fracture table

Question

Outline the risks associated with the following positions, and the actions you would take to ameliorate them. Provide rationales for your responses.
What will be an ideal response?

Answer 1

Answer:
Risks
The incidence of perioperative complications is increased in the elderly due to loss of functional reserve and general organ decline. Elderly patients experience more postoperative complications related to the increased number of comorbidities present. The most common complications are cardiac or pulmonary, which place elderly patients at greater anaesthetic and surgical risk. An elderly patient placed on a fracture or traction table is exposed to the following risks:
risk of pressure injury and damage to skin integrity
injury to genitalia, pudendal and perineal nerves resulting in faecal incontinence and loss of perineal and genital sensation
loss of dignity due to exposure
inadvertent perioperative hypothermia (IPH)
increased VTE risk
distress, disorientation and postoperative delirium.

Actions
Some orthopaedic procedures require the use of a specialised fracture table. Indications for use include correcting fractured neck of femurs, as well as performing some femoral procedures, because the table permits rotation and manipulation of the operative limb. Frail elderly patients with hip fractures are frequently unable to tolerate a general anaesthesia and are therefore required to undergo positioning on the fracture table and surgery under a regional anaesthesia.
Use of a pressure-relieving mattress or gel overlay on OR table.
Rationale: Pressure ulcer prevention is paramount for all patients, but the elderly patient is particularly vulnerable. Careful assessment of the patient's skin integrity preoperatively and after positioning should be communicated to team members and documented in the perioperative nursing record. Diligent pressure area care enhances prevention.
Preoperative assessment and confirmation of correctly placed, well-padded perineal post with surgical team members.
Rationale: The patient is placed supine on the fracture table with the pelvis stabilised against a well-padded perineal post and the foot of the operative limb placed into a traction boot. Traction is gradually applied to the limb to aid in the reduction of the hip or femoral fracture. A poorly placed or inadequately padded perineal post can result in genital injury, pudendal and perineal nerve damage with resultant faecal incontinence, and loss of perineal and genital sensation.
Extreme care should be taken when manipulating the elderly patient's lower limbs and placing the foot of the operative limb in the traction boot. The lower limb and foot should be covered by cast padding or ‘Webril type' bandages.
Rationale: Traction is achieved by restraining the injured limb in a well-padded, boot-like device that is part of the table's movable traction arm. Pressure areas can develop when the traction boot comes into contact with unprotected skin. Additionally, an elderly patient is at risk of skin damage related to friction and shearing forces. Patients should not be dragged down the OR table on a draw sheet (intentionally or inadvertently) when attempting to achieve traction because friction and shear-related skin injury may occur. Skin tears can also occur when handling and positioning the elderly patient's limbs.
Team members should provide instruction, support and reassurance and ensure that the patient's dignity is maintained during positioning and surgery.
Rationale: The patient is at high risk of compromise to dignity and psychological discomfort related to the surgical positioning. Preservation of patient privacy, confidentiality and dignity is a must. The patient will be positioned legs apart, with a perineal post in position and unable to wear underwear. When regional anaesthesia is used, patients are aware of positioning and procedural activities, and minimising exposure and using discretion are a high priority.
Maintenance of normothermia (36°C) for the elderly patient through the pre-, intra- and postoperative phases of surgery.
Rationale: The elderly patient who is to be positioned on a fracture table is at significant risk of IPH for the following reasons: administration of anaesthesia, limb placement away from the trunk of the body, preoperative trauma, age, small body mass and potential immunocompromised status. Therefore, the following strategies must be employed:
Monitor the patient's temperature regularly in the pre-, intra- and postoperative phases of surgery.
Apply active pre-warming preoperatively if the patient is not normothermic.
Provide the patient with a minimum of one sheet and two blankets.
Ensure all limbs are covered.
Use active warming devices, such as forced-air warming devices (FAWD), warming mattresses, heated gel pads and circulating water garments.
Use fluid warmers for IV fluids (including blood) when >500 mL is to be administered.
Warm irrigation fluids intraoperatively.
Increase the ambient OR temperature to 21°C or above while active warming is being established.
Use of graduated compression stocking and an intermittent pneumatic compression device on non-operative limb should be applied for the elderly patient at risk of VTE.