Mar 29, 2012

Leaning To The Left or Right?

An alert reader sent to me the following article published by the American Society of Anesthesiology from their annual meeting of 2011, presented by a Dr. Roger Marks.

From the ASA:
Do Anesthesiologists Lean Toward the Left of the Right?
Roger L. Marks, M.D.,M.P.H.
Univeristy of Miami Miller School of Medicine, Miami, Florida, United States
Some may initially think that the topic of this article is political. However, the purpose is to discuss the placement of the patient in the recovery (rescue) position. This question actually was raised recently at our Passover Seder, the festive meal celebrating the emancipation of the Jews from Egypt. In the Talmud, Pesachim 108a, it is stated that “even the poorest man in Israel must not eat until he reclines” and from here the tradition is brought down that the meaning is to recline to the left, as was the custom of royalty, in order to eat with his right hand. Therefore, a person is required to eat matzah and drink the four cups of wine during the Passover Seder while reclining to the left, as a reminder of his becoming free from slavery on this day. But what about the person whom is left handed? Should he perhaps lean to the right in order to hold his food and drink in his left hand? The majority opinion of the Rabbis is that he must also lean to the left, because leaning to the right may “cause the food to go into the windpipe and thus endanger himself.”


This, I believe, represents the first historical reference to the increased risk of aspiration associated with lying on the right versus lying on the left.


This discussion can also be found in the medical literature in regards to the choice of which side to use when placing a patient in the recovery position. The left lateral decubitus position is the most common recommendation and this is probably due historically to the fact that most ambulances have been designed to have the medical provider located on the right. Therefore, having the patient lying on the left, facing the provider assists in being able to identify and treat problems with the airway, including facilitating laryngoscopy and intubation, buy having the tongue displaced to the left. It is also well known that having a pregnant women lying in the left lateral decubitus position helps avoid pressure on the inferior vena cava and the associated changes in oxygen delivery to the fetus. Also patients with GERD have been shown to have fewer symptoms when sleeping on the left1. From anatomical studies, it has been shown that at the level of vocal cords, the esophageal inlet is in fact displaced slightly to the left of the trachea. Therefore, without any other extenuating circumstances, most anesthesiologists lean to the left.


References:


1. Khoury, RM, Camacho-Lobato, L, Katz, PO, Mohiuddin MA, Castell, DO. Influence of spontaneous sleep positions on nighttime recumbent reflux in patients with gastroesophageal reflux disease. Am J Gastroenterol 1999; 94(8): 2069-73.


Copyright © 2011 American Society of Anesthesiologists
Not that we needed proof in order to sanction our minhag of leaning to the left when we recline at the seder on Pesach, but it is interesting to see when medical science supports our customs, and is far better than trying to justify our customs after finding medical science in opposition...

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