The purpose of this study was to determine whether different body positions-Fowler's, supine, and left lateral-as compared with a sitting position can prevent postprandial drops in blood pressure in older adults. Participants included 32 persons 65 or over who had experienced postprandial drops in systolic blood pressure of more than 15 mm Hg in a pilot study. This study employed a within-subject repeated measures design using random order allocation of different body positions. To protect against a carryover effect, blood pressures in the different positions were taken at intervals of 1 week. Blood pressure and heart rate were both measured before lunch and at 15-min intervals for 120 min after lunch. Descriptive statistics, repeated measures ANOVA, and paired t-tests with a Bonferroni adjustment were used to analyze the data. No significant differences were observed in the magnitude of blood pressure drops regardless of the position taken after a meal. Therefore, different body positions alone do not adequately prevent PPH or attenuate drops in blood pressure for older adults with PPH. Nurses should carefully monitor falls in blood pressure even in persons on bed rest to prevent the complications of postprandial hypotension.

Pressure ulcers pose significant negative individual consequences and financial burden on the healthcare system. Prolonged sitting in High Fowler's position (HF) is common clinical practice for older adults who spend extended periods of time in bed. While HF aids in digestion and respiration, being placed in a HF may increase perceived discomfort and risk of pressure ulcers due to increased pressure magnitude at the sacral and gluteal regions. It is likely that shearing forces could also contribute to risk of pressure ulcers in HF. The purpose of this study was to evaluate the effect of a low-tech and time-efficient Trunk Release Manuever (TRM) on sacral and gluteal pressure, trunk displacement and perceived discomfort in ambulatory older adults.A randomized controlled trial was used. We recruited community-living adults who were 60 years of age and older using posters, newspaper advertisements and word-of-mouth. Participants were randomly allocated to either the intervention or control group. The intervention group (n = 59) received the TRM, while the control group (n = 58) maintained the standard HF position.The TRM group had significantly lower mean (SD) PPI values post-intervention compared to the control group, 59.6 (30.7) mmHg and 79.9 (36.5) mmHg respectively (p = 0.002). There was also a significant difference in trunk displacement between the TRM and control groups, +3.2 mm and -5.8 mm respectively (p = 0.005). There were no significant differences in perceived discomfort between the groups.The TRM was effective for reducing pressure in the sacral and gluteal regions and for releasing the trunk at the point of contact between the skin and the support surface, but did not have an effect on perceived discomfort. The TRM is a simple method of repositioning which may have important clinical application for the prevention of pressure ulcers that may occur as a result of HF.

Functional endoscopic sinus surgery (FESS) is a surgical procedure, during which all necessary manipulations are performed while using a fibreoptic camera. The endoscope is inserted together with the surgical instruments, through the nasal cavity. During the surgery, bleeding has to be minimized, since even a small amount of blood may completely obstruct vision via the endoscope. Various approaches have been used to secure a dry operating field; among them are: topical vasoconstrictors, Fowler's position, alpha-and beta-adrenergic blockade, and preoperative steroids. All these methods are far from being effective and are associated with significant side effects. The recently approved approach to this problem is to combine total intravenous anaesthesia using propofol and remifentanil, together with esmolol. With the heart rate reduced to 60 bpm, excellent operative conditions can be achieved with moderate hypotension (MAP 65 mm Hg-8.7 kPa). Altered microcirculation and a low cardiac output are the principal underlying mechanisms in these cases.

Although blood pressure (BP) differences from supine to sitting position have long been recognized, limited data are available on other commonly used body positions. We performed a cross-sectional study to compare BP values obtained in supine, sitting, and Fowler's positions in essential hypertensive subjects.Systolic BP (SBP) and diastolic BP (DBP) were recorded using an automatic oscillometric device. Nine measurements were taken: three measurements, in random order, in supine, Fowler's, and sitting position. Two generalized estimating equations models were used to evaluate potential predictors of SBP and DBP adjusting for heart rate and measurement order.The sample consisted of 250 subjects (mean age 66.3 ± 13.4 years; 44.4% males). Measured in supine, Fowler's, and sitting position, mean SBPs were 139.3 ± 14.0; 138.1 ± 13.8; 137.2 ± 13.7 mm Hg, respectively, and mean DBPs 80.1 ± 9.1; 81.9 ± 9.4; 83.0 ± 9.6 mm Hg, respectively. At multivariate analysis, mean SBP significantly decreased if measured in Fowler's and sitting positions, as compared to supine. In contrast, DBP significantly increased. A relevant proportion of subjects showed large differences (≤ or ≥10 mm Hg) in mean SBP across positions: i.e., 30.0% comparing supine vs. sitting SBP. An even higher prevalence of large differences was observed according to the measurement order within the same positions, with no univocal direction (random variation).Fowler's position may represent a valid alternative to sitting and supine positions for BP measurement in clinical practice. BP random variability was found to be large regardless of body position, reinforcing the need for operators to closely follow current guidelines that recommend ≥2 recordings at each measurement.

The Fowler position, widely used in surgery and obstetrics for patient placement, marks a fraction of 19th-century Brooklyn surgeon George Ryerson Fowler's prodigious accomplishments. Fowler was a pioneer who refined the appendectomy, performed the first lung decortication, advocated for sterile techniques, introduced first aid in the US Army, and helped start a precursor to Annals of Surgery. His publications include the first US textbook on appendicitis--ironically, the disease that killed him.

Combined spinal and general anesthesia block (CSGAB) and combined epidural and general anesthesia block (CEGAB) in laparoscopic cholecystectomy were compared.Forty patients were randomly selected (ASA physical status I-II) to receive sevoflurane plus 10 to 15 mg of bupivacaine weighed at 0.5% and 20 microg of fentanyl (CSGAB) or sevoflurane plus 150 mg of ropivacaine and 1 microg/kg of fentanyl (CEGAB). Blood pressure, heart rate, oxygen and carbon dioxide saturation, drug doses and sevoflurane MAC (minimum alveolar concentration) were evaluated during surgery. Anesthesia recovery time and pain intensity and duration were evaluated during the first two postoperative hours. Frequency of incisional or referred pain, dyspnea, headache, cramping, nausea and vomiting were evaluated 24 hours after surgery. Statistical analysis was carried out using the Chi-square test and Student t test. Relative risk, absolute risk reduction and number needed to treat (NNT) for adverse reactions were determined.Systolic and diastolic arterial pressures posterior to semi-Fowler's position were lower in the CSGAB group than in the CEGAB group. (94 +/- 16 vs. 110 +/- 18 mmHg; p < 0.01 and 59 +/- 8 vs. 69 +/- 12, mmHg; p < 0.01, respectively). Anesthesia recovery time (32 +/- 17 vs. 61 +/- 29 minutes; p < 0.01) and pain duration (26 +/- 42 vs. 83 +/- 46 minutes; p < 0.01) were shorter in the CSGAB group. NNT was 8 for postoperative pain, 8 for nausea, and 95 for vomiting.CSGAB was more efficacious for rapid anesthesia recovery and had a shorter post-operative pain duration than CEGAB.

A partial sitting position has been reported to increase functional residual capacity (FRC) in lean subjects, whereas FRC does not change with position in the morbidly obese. The effects of positioning in the subgroup of overweight and mildly to moderately obese subjects have not been examined. We hypothesized that a change in FRC may be related to adipose tissue distribution.We investigated the hypotheses that a 30 degrees Fowler's position would increase the FRC and decrease the closing-capacity-to-FRC ratio in subjects with a body mass index in the 25.0-39.9 kg/m(2) range. We tested whether body fat distribution, measured by waist circumference and waist-to-hip ratio, correlated with the lung-volume changes.The 30 degrees Fowler's position did not improve the FRC, when compared to the supine position (n = 32). The closing-capacity-to-FRC ratio was > 1 in 5 of 7 subjects while sitting, and in all 7 subjects while supine or in the 30 degrees Fowler's position. The waist-to-hip ratio was correlated with closing capacity in all positions, and correlated with closing-capacity-to-FRC ratio in the supine position.Standard position changes purported to increase FRC are ineffective in the overweight and mildly to moderately obese, a subpopulation represented by almost 67% of Americans. Bedside caregivers may need to modify current practices when the clinical goal is to improve resting lung volumes in sedentary patients.

Prolonged exposure to pressure is the primary etiologic factor of a pressure ulcer (PU) and effective preventive interventions must avoid or minimize this exposure. Therefore, frequent repositioning of the patient has long been recommended as a means of preventing PU.To review the evidence on the efficacy of repositioning as a PU prevention intervention.A systematic review of electronic databases MEDLINE and CINAHL, from January 1960 to July 2008, was undertaken. Studies were limited to prospective randomized clinical trials or quasi-experimental studies that compared repositioning to any other preventive interventions or any study that compared various techniques of repositioning such as turning frequency. Only those studies that measured the primary outcome of interest, PU incidence, were included in our review.Limited evidence suggests that repositioning every 4 hours, when combined with an appropriate pressure redistribution surface, is just as effective for the prevention of facility- acquired PUs as a more frequent (every 2 hour) regimen. There is insufficient evidence to determine whether a 30 degrees lateral position is superior to a 90 degrees lateral position or a semi-Fowler's position.The current regulatory and legal environment has focused increased attention on PU prevention. Pressure redistribution methods and the frequency of application are among the first factors scrutinized when a PU develops. Our clinical experience validates that regular movement of the immobilized patient is important, but evidence defining the optimal frequency of repositioning or optimal positioning is lacking.

Patients with deep neck infections, especially those with Ludwig's angina, may die as a result of airway management mishaps. Skillful airway management is critical, but a safe method of airway control in these patients is yet to be established. We subjected patients with deep neck infections to fiberoptic tracheal intubation by using topical anesthesia to provide general anesthesia for surgical interventions. Patient characteristics and techniques for intubations were recorded on a special data-collection form. Of the 26 patients, 17 had Ludwig's angina, and 9 had other types of deep neck infections. Three patients were tracheally intubated while in the sitting position, 2 in Fowler's position, and 21 in the supine position with the head up 10 degrees-15 degrees. Tracheal intubations were successful in 25 patients: 19 nasally and 6 orally. After surgery, seven patients were kept tracheally intubated, and five patients had tracheostomies. Complications were limited to three cases of mild epistaxis and four oversedations with transient hypoxemia. Twelve patients remembered part of the procedure, and two considered it unpleasant. Tracheal intubation with a flexible bronchoscope by using topical anesthesia is highly successful in adult patients with deep neck infections. Tracheostomy using local anesthesia is recommended if fiberoptic intubation is not feasible, if the clinician is not skillful in the use of awake fiberoptic intubation, or if intubation attempts have failed.