Mid-calf position—an improved technique to place neuraxial anaesthesia
Editor—Optimal patient positioning with minimal movement during placement of neuraxial anaesthesia may increase the ease and speed of the block procedure. Several studies have shown that alterations in patient positioning1 2 can affect the difficulty of placing neuraxial anaesthesia. While the sitting position is widely used, there have been no published reports describing variants of the sitting position. To optimize spine flexion for midline neuraxial block placement, patients are often asked to assume a ‘mad cat’ or ‘cooked shrimp’ position. However, directing patients, especially parturients in labour, to assume this position for epidural or spinal placement can be challenging. We report a modification of the sitting position for neuraxial anaesthesia placement: the mid-calf position. While using this position, we have noticed that patients easily assume a stable, flexed posture with minimal coaching. This position has been an effective positioning tool for several body types including obese parturients.In the mid-calf position, the patient rests the lower legs (mid-calf), rather than the knees, on the edge of the bed, sitting somewhat further back on the bed than in the conventional sitting position. As a result, the knees are slightly flexed with the patient’s back nearer to the practitioner. The patient’s neck is flexed forward and the arms are crossed in front of the body (Fig. 1).
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One advantage of the mid-calf position is that the patient naturally assumes an ideal position for placement of a neuraxial block with little instruction. The shoulders fall forward and the flexed position achieved appears to optimally open the spaces between the spinous processes.
Another advantage of the mid-calf position is that the legs provide two additional points of stability. This prevents excessive forward flexion at the hips, so the torso does not move away from the practitioner during the procedure. Patients in this position are less inclined to lean forward, backward or tilt laterally. The patient’s centre of gravity shifts away from the forward edge of the bed, increasing stability and requiring less physical assistance by nursing staff, tables or commercial support devices.
A number of techniques have been used to improve the success of neuraxial anaesthesia placement including ultrasound visualization of the spinous processes3 or microdrip identification of the epidural space.4 However, we feel a simple variation of the sitting position can optimize patient position for neuraxial anaesthesia placement. If one elects the sitting position for midline neuraxial anaesthesia placement, we believe the mid-calf position provides superior conditions to the conventional sitting position.
Durham, NC, USA
*E-mail: Moeen.K.Panni{at}uth.tmc.edu
References
1 Stone PA, Kilpatrick AW, Thorburn J. Posture and neuraxial anesthesia catheter insertion. The relationship between skill, experience and maternal posture on the outcome of neuraxial anesthesia catheter insertion. Anaesthesia 1990; 45:920–3[Web of Science][Medline]
2 Hamza J, Smida M, Benhamou D, Cohen SE. Parturient's posture during neuraxial anesthesia puncture affects the distance from skin to neuraxial anesthesia space. J Clin Anesth 1995; 7:1–4[CrossRef][Web of Science][Medline]
3 Grau T, Leipold RW, Horter J, Conradi R, Martin E, Motsch J. The lumbar neuraxial anesthesia space in pregnancy: visualization by ultrasonography. Br J Anaesth 2001; 86:798–804
4 Hirabayashi Y, Matsuda I, Inoue S, Shimizu R. A new technique of identifying the neuraxial anesthesia space "dripping infusion method". J Anesth 1989; 3:105–8[Medline]
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