In this issue, Warner al. and fellow members of the American Society of Anesthesiologists’ (ASA) Task Force on Prevention of Perioperative Peripheral Neuropathies, present a practice advisory generated through a five-step process. Intended as a source of guidance and not a formal set of practice guidelines, the advisory focuses on such preventive strategies as perioperative patient positioning, use of protective padding, and avoidance of contact with hard surfaces or supports that may apply direct pressure on susceptible peripheral nerves.
The 10-member task force first conducted a review of the published literature, initially identifying 509 articles that addressed topics related to seven evidence linkages. After a review of the articles, 427 were eliminated because they did not provide direct evidence. Second, consultants who practice in various academic and private practice settings and who have particular expertise in identified subject areas were surveyed regarding their opinions of the effectiveness of positioning and protective strategies to prevent perioperative peripheral neuropathies. These consultants were also asked to comment on the task force’s initial draft report. Third, the task force collected responses from 429 of 1,500 ASA members selected at random to complete surveys regarding their opinions of the advisory’s elements. Fourth, the task force held an open forum at a major national anesthesia meeting to solicit additional input regarding the draft advisory. Finally, all available information was used to build consensus within the task force on the advisory.
The task force found strong agreement among surveyed consultants and ASA members that a focused preoperative physical assessment may identify patients with an increased risk of development of peripheral neuropathies during the perioperative period. Eighty-eight percent of the responding consultants and 80% of the ASA member respondents agreed with this statement. In the area of specific positioning strategies for the upper extremities, 92% of the consultant respondents and 96% of the ASA members agreed that limiting abduction of the arms in a supine patient may decrease the risk of brachial plexus neuropathy. There was some disagreement regarding the upper limits of abduction, with 93% of the consultants advising limiting abduction to 90°, and 7% indicating an upper abduction limit of 60°. Further advisories regarding preventive positioning strategies addressed ulnar neuropathies in supine patients with arms on arm boards, with arms tucked at the side, or with the elbow flexed. The task force also addressed specific positioning strategies for the lower extremities, the use of protective padding, automatic blood pressure cuffs, and shoulder braces.