Hey everyone, I'm Brandon Odo.
And I'm Brian Bulling.
And this is Critical Care Scenarios, the podcast where we use clinical cases, narrative storytelling,
and expert guests to unpack how critical care is practiced in the real world.
Hello everyone, it is Brandon back with another turbo.
I think today is going to sound a little bit boring, but it's one of those little things
that I think having understanding of really improves your practical perspective on critical
care medicine.
The little things that just kind of when you assemble them all together, sometimes they
make the difference between things going right and things going wrong.
That topic is the patient's position in the bed.
Now I'm not actually talking about the position of the head of the bed, which you hear about
a little more.
This comes up because an elevated head of bed has been shown to reduce the risk of things
like aspiration and ventilator associated pneumonia.
So it's considered part of routine good care unless there's some contraindication for it.
What gets talked about a little less though is regardless of the position of the head
of the bed where the patient is actually found in the bed.
Beds are bigger than humans, therefore the human can move about within the bed.
It sometimes matters where they are positioned.
Let me give you a few examples.
One of the most common things you'll see is a patient where the head of the bed is elevated
and they have slid downwards, scooted towards the foot of the bed from what you might call
the anatomic position, which would be where the hips fold being right where the bed folds.
Their position matches the bed's position.
People tend to slide down.
That is probably because when you sit them up, gravity is pushing them in that direction.
It is a little better if rather than just lifting the head of the bed, you also lift the knees
to some extent.
You fold twice and that creates more of a cute angle at the hips that tends to hold onto
them rather than letting them slide down.
Pretty much all hospital beds will do this, but we don't always bend them in that way
and some patients don't like it.
Patients tend to migrate downward.
What does this matter?
It affects the position of their body because rather than them being folded neatly at the
hips, they end up folded somewhere along their spine, essentially, whereas their hips are
not bent.
If you can imagine a patient who is having difficulty breathing, for instance, maybe
you're trying to get them off a ventilator.
You're like, maybe we can extubate this person today, but they're a little borderline and
I really want to make sure that their respiratory milieu is optimized.
One being breathes best when we're upright and mobile and not laying in bed all scrunched
up and flat, so you want them sitting up, but if you just go and lift the head of their
bed, if you step back, you may realize you haven't actually sat them up very much.
If they've scooted down in bed, which they so often do, all you've done is kind of created
a fold or a cathosis of sorts somewhere in their low to mid back or even their upper
back depending on how far they've gone, which is probably not helping their breathing.
They're not really particularly upright.
It's maybe even made it worse because now you've scrunched their chest or even scrunched
their neck, which is not good for an airway and someone you might have to re-intubate
or who's at risk of occluding their airway.
But none of these things are good.
The worst of all is if they have a very large belly, a large or taut abdomen, and particularly
one that's not so much spread out but is kind of a big tight ball, like somebody who
has a siteease, for instance.
These bellies can really compress the lungs easily and their position is heavily affected
by this.
This is why you could even sit these patients up and perhaps even worsen their breathing
if you compress that belly against their chest.
So, what does this all mean?
It means that if you really want to properly sit somebody upright, you usually need to
reposition them in the bed.
You've got to give them the scooch, get some help, usually lower the head to make it easy,
slide them upwards so that their hip is at that fold in the bed.
Or realistically, this usually means their head is about at the top of the mattress.
If you're a little too far, that's okay.
They will sort of equilibrate once you sit them up.
Then you sit them up and you will find that they are actually in a more upright position.
If they do have a larger belly, a good supplement to this is to take their legs and rather than
having them together, adducted, and to display them out a little bit.
Give them a little bit of a frog leg which gives that belly somewhere to go.
It helps prevent it from being compressed by the legs and hips.
It opens up a space for it.
Patient like this who's really sat up pretty upright and then got room for their belly,
you've done most of what you can do for their breathing.
What else might you need to adjust somebody in the bed?
Well, procedures are a common time for this because you need to be able to get to the
patient and depending on where you're going, their position can really impact this.
If you're going to intubate a patient, you're generally going to want them pretty much as
far to the top of the bed as you can because you need to get at their mouth and you don't
want to have to reach over a great deal for it.
This is more important if you're doing direct laryngoscopy because you need to actually
exert some force on their head and neck and this is more and more difficult to do the
more you have to reach over.
You really want them pretty close to your core so you can apply that force along the
axis of your spine in an efficient way.
If you have to reach forward a great deal, you're going to need a huge amount of strength
because you're making a longer lever arm.
For video, not quite so important but you generally still don't want to reach a huge
amount.
You can also ask the question of where you want the head of the bed for this, right?
Any anesthesiologists are used to patients being flat for intubation because that's
how they tend to be in the OR.
I generally favor having the head of bed at least somewhat elevated.
I think it improves the compliance of their chest because you're not squishing as long
as much.
You're probably going to have a longer time until they desat and having at least a little
bit of head of that elevation reduces aspiration risk, even just passive aspiration.
If you're paralyzing, they're probably not going to actively vomit on you.
But being completely flat, there's no gradient to prevent gastric contents from flowing up
the esophagus if the tone of the esophageal sphincters is poor.
But even a small amount of elevation helps prevent that.
Of course, the more you elevate the head, the more difficult it could be to get to the
mouth until if they're super upright, you end up having to stain on the back of the bed
or things like that.
But in most cases, a small amount of head of bed elevation is a good idea.
If you're going to do vascular access at the neck, you'll also want them positioned pretty
far up.
If you're going to place a center line into perhaps one of the internal jugular veins,
you really want them as far as you can because the IJs are always a little bit of a pain
to get to.
But the more you have to reach over, the harder it's going to be.
You can try to get around this by standing at the side of the bed instead of behind the
head.
This is, we've talked about it in the past, this can be a little bit trickier depending
on if you can figure out the ergonomics and depending on which side you are.
But in that case, you're going to want them perhaps not quite so far to the head, that's
not so necessary, but you're going to want them closer to the side of the bed where you're
on.
If you're into doing peripheral IVs in the EJ, the external jugular, you're also going
to want them towards the top.
The move here is to try to get extension of the neck.
It's ergonomically tricky to get a catheter into an EJ if the neck is not extended because
the catheter itself, the back part of it tends to run into them.
It's like you almost can't get it flat enough to advance it very far, especially if you
have a longer catheter, like a longer butt end.
So you could even drop their head off the back of the mattress a little, allowing it
to extend past the plane of the bed, or you can pad behind their neck with a towel roll
or something like that.
If you need to get at the lower part of their body, you're going to have similar issues.
Ultrasound of the heart is a classic one.
If you go into the echolabs, you'll see these patients being positioned well to really optimize
their windows.
We could often do better at that, but even just a cursory effort can make a big difference.
You're trying to get something like a apical IV chamber view of the heart, or to some extent
even a peristernal window, is tending to help if you roll the patient to their left,
at least somewhat.
In the ICU, a bedbound patient, this often just means putting a wedge beneath them.
The nurses use these wedges to turn the patients every couple hours left and right to redistribute
the pressure points, reduce the risk of ulcers.
You can wedge them towards their left.
It brings that heart closer to the wall of the left thorax, and even to the anterior wall
to some extent.
Then, if you can bring their left arm upward somewhat, that'll help open up the rib spaces.
You can even get it behind their head in an ideal world.
If you're going to do something like a fast exam, an abdominal study, you're also going
to need to ideally position them.
The most common thing is going to be trying to get at the more posterior windows of the
abdomen.
It's going to be a distance to get at the kidneys, or if you're doing a left upper quadrant portion
of a fast exam, which involves a spleen from a fairly posterior view.
Sometimes this even applies if you're looking at the chest, things like pleural effusions.
Maybe you even want a drain one, do a thoracentesis.
A lot of this involves getting pretty posteriorly.
That can be hard in a patient who is in the bed.
You need to try to open up your access.
Move the arms if you need to.
Move things like pillows and wedges.
Occasionally, it's even helpful to move the patient closer to the edge of the bed so that
the mattress is not so much in your way.
A final point that's probably worth mentioning is what you do when there is a lot of tissue
in the way.
Patients that are fairly obese can start to present a challenge to procedures just because
the abdomen can start to get in the way.
If you're going to be doing something like a femoral line, venous or arterial, in a patient
who's larger, and it doesn't have to be all that big of a patient for this to present
problems, that pain is really folds over that crease of the groin where people will
tend to access these sites.
You can try to access a little more distally to get away from some of that, which is nice
when you could pull it off.
The vessels do get deeper.
Typically, if you're going here, this applies somewhat to the axillary site as well.
If you're doing an axillary arterial line, not so much for venous lines because either
a subclavian, more in the chest, or upper arm veins where you're doing a midline or
a pic or a long IV, these get away from the folds.
Big enough patient, there can be a lot of tissue right at the axilla where people tend
to do axillary lines.
Either they're just proximal and they're on the chest or they're just a distal and they're
on the upper part of the arm.
People will usually call both of those axillaries, but there can be a lot of tissue there as
well.
Just like the femoral sites, you usually need to try to move this tissue out of the way.
You can ask somebody to hold it for you, hold the panace, but that's a huge burden on them.
Frankly, it can be less than reliable.
What tends to work best is tape.
You need to tape this tissue out of the way.
Find fairly wide tape, like cloth tape is usually best.
Stick it to the skin and use it to apply tension, pull that tissue out of the way, and then
secure it to something.
Usually this will be one of the rails of the bed.
This is a little bit of an art.
You're almost always going to need multiple pieces.
Sometimes I find it helpful to put a piece down kind of transversely on the skin to give
a surface for the long pieces to stick onto.
Then you often have to hold things in place until you get several pieces down, because
one is usually not enough to hold the weight.
Once you have several in place, that kind of network of them can be pretty reliable.
But you've got to fine tune until you have a setup that exposes your site well and you
feel like it's reliable because you don't want these tapes to come out when you're in
the middle of the procedure.
A patient who's at all awake, you want to talk to them about this, that's probably not super
pleasant for them to have their adipose tissue pulled and taped in various directions.
You should give some thought if that's the kind of site you're accessing, how clean you're
going to be able to keep it if it's deep in a recess of tissue.
There are certainly times when this is necessary.
Again, in something like a femoral site, it almost seems like the rarity to have a patient
that wears completely exposed.
You don't need much of a panace there to start to cover up at least that very first part of
the femoral crease.
The only other thing I'll say about positioning today is that wherever you position a patient,
try to make sure it's optimized not just for the patient's physiology or what you're trying
to do to them, but also for your comfort if you're going to be in here doing something
like a procedure because it is easy to say that it's no big deal, this will be over in
a few minutes.
But if you're going to make a career out of standing at the bedside of patients, you don't
want to have your career curtailed because you spent a lot of that time in weird non-ergonomic
positions.
You're going to start having pain in your back or your neck or your extremities.
Put the patient in a position that is comfortable to you even if it takes a few more minutes.
Raise the bed as much as you need to, move them to the right part of the bed.
It's worth your time in a way that you will not appreciate until you get a little older
and you do more of these and then you wish you'd done it differently from the beginning.
That's enough for today.
I'll talk to you guys next time.
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