Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 39:
Anesthesia for Microsurgery
  Every anesthetized patient must be carefully positioned on the operating table, and this aspect of patient care is especially important in prolonged surgical procedures. The two most common complications related to positioning are pressure necrosis and peripheral neuropathy. With careful planning, properly placed protective padding, and constant observation of the patient, such complications should be rare. Nevertheless, each position presents specific problems.

Supine Position. A four-inch-thick foam mattress ("egg crate type") is placed over the usual operating table mattress and covered with a cloth sheet or soft paper sheet. A soft, contoured foam pillow provides good support and stability for the head and neck. Occipital alopecia has resulted from prolonged pressure on the head caused by resting on a very firm pillow covered with the usual conductive rubber often used in the operating room: Peripheral nerve complications can occur in the supine position. In a series of 72 postoperative neuropathies, 33 occurred in the supine position.13 Fourteen of these involved the brachial plexus and the ulnar nerve. These injuries can be prevented by proper positioning and padding. Foam rubber elbow pads can be used to protect the ulnar nerve in its superficial position just lateral to the medial epicondyle. To avoid stretch injury to the brachial plexus, the arms should not be abducted to more than 90. Miller14 suggests palpating the pectoralis major muscle because, if it is relaxed, there should be no tension on the brachial plexus.

  Pressure necrosis and pressure neuropathies have been caused by metal frames, ether screens, instrument stands, and other commonly used pieces of equipment.

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