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Principles of Anesthesia I > E2 - Positioning > Flashcards

E2 - Positioning Flashcards

1
Q

What is the most common surgical position?
A. Sitting
B. Beach chair
C. Supine
D. Prone

A

C. Supine

Arm boards must be secure if in use.

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2
Q

What are initial physiological changes to be expected when moving from sitting to supine? Select 3
A. decreased SV
B. increased VR
C. increased SV
D. increased tidal volume
E. decreased VR
F. decreased FRC

A

B. ↑ Venous return
↑ Preload
C. ↑ SV
↑ CO
↓Tidal volume
F. ↓ FRC

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3
Q

When positioning arms abducted, what should you NOT do?
A. Put arms supine (palms up)
B. Put arm out to the side, > 90 degrees
C. Pad Elbows and secure arm with a Velcro strap
D. Secure padded arm boards to the table and patient’s axilla

A

B. put arm out to the side, > 90 degrees

*arms should be abducted LESS than 90 degrees *

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4
Q

What is important to remember about arm adduction positioning? select 2.
A. hands and forearm cannot be supine (palms up)
B. pad elbows
C. tuck arms alongside the body
D. arms held along the side of body via draw sheet over the body and under the arm
E. do not tuck arms if surgeon needs to stand on side of pt

A

B. Elbows are padded
C. Arm tucked alongside the body

Arms held along the side of body via **draw sheet under the body and over the arm **

**May tuck one arm **if surgeon must stand on side of patient

Hand and forearm are supine** (palms up) or neutral position (palms toward body)***

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5
Q

Two specific complications of the supine position include:
A. increased ICP
B. pressure alopecia
C. headache
D. increased facial edema
E. stretch (brachial plexus) injury when neck is extended and head turned away

A

B. Pressure alopecia
E. Stretch injury when neck is extended and head turned away (brachial plexus)

Others: Backache, Brachial plexus or axillary nerve injury if arms abducted > 90 degrees, Ulnar nerve injury if hand/arm is pronated (palm down)

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6
Q

What position is this patient in?

A
  • Trendelenburg (head down)
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7
Q

What is a consideration with Trendelenburg position? Select 2.
A. Use a non-sliding mattress/pad to prevent the patient from sliding cephalad
B. Avoid using bean bags or shoulder braces
C. Arms should not be abducted
D. There will be a decrease in cardiac output

A

A. Use a non-sliding mattress/pad to prevent the patient from sliding cephalad
B. Avoid using bean bags or shoulder braces

Also, consider making a mark at the level of the patient’s head on the sheet or pad so you can determine easily if the patient has slid

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8
Q

What are 2 vent/airway considerations with Trendelenburg position? Select 2.
A. increased pulm compliance
B. may need higher pressure in ventilated patients
C. risk of ETT going right mainstem
D. decreased RV
E. increased ICP
F. increased facial edema

A

B. May need higher pressure in ventilated patients
C. Risk of endobronchial intubation as abdominal contents push the carina cephalad

Also: ↑ CO, ↑ Venous Return from lower extremities
↑ ICP, ↑ IOP, Facial Edema
↑ Intraabdominal Presure
↓ FRC and ↓ Pulmonary Compliance

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9
Q

What position is this patient in?

A
  • Reverse Trendelenburg (head up)
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10
Q

What is a consideration with Reverse Trendelenburg position?
A. use a sliding pad so its easier to move patient’s head up
B. use a footrest or something under feet to prevent pt from sliding
C. brachial plexus injury is common
D. upward displacement of abd contents and diaphragm

A

B. Use a footrest or something under the feet to prevent the patient from sliding

and Use a non-sliding mattress/pad to prevent the patient from sliding

also … Downward displacement of abdominal contents/ diaphragm (better ventilation)

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11
Q

What is a major risk associated with reverse trendelenburg?
A. possible self-extubation risk
B. increased aspiration risk
C. decreased perfusion to the brain
D. patient could slide off the table
E. risk of hypertensive crisis

A

C. Risk of Hypotension (↓ Venous Return, Venous pooling) = ↓ Perfusion to the brain!

make sure CBF is adequate by leveling art line to level of TRAGUS to get accurate MAP readings

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12
Q

Name the positions

A
  • Left Picture: Beach Chair Position
  • Right Picture: Full Sitting Position
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13
Q

When will the patient be in the Beach chair position?
A. Knee surgeries
B. C sections
C. Shoulder cases
D. Toe amputations

A

C. Shoulder Cases

Beach chair position will have less severe hip flexion (than sitting) and slight leg flexion.

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14
Q

Describe the set-up of the full sitting position

A
  • Head must be stabilized – taped to special headrest or rigid pins
  • Hips are flexed < 90 degrees and knees slightly flexed for balance to reduce stretching of the sciatic nerve
  • Feet are supported – prevent sliding
  • Compression stockings/wraps to maintain venous return
  • Keep at least two finger’s distance between the chin and sternum
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15
Q

Sitting position risks

A
  • Cerebral hypoperfusion and air embolism
  • Pneumocephalus- accumulation of air in subdural space, pressure on the intracranial structure
  • Quadriplegia and spinal cord infarction- hyperflexion of the neck
  • Cerebral ischemia
  • Peripheral nerve injuries (Sciatic nerve injury)
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16
Q

Pathophysiological considerations of the sitting position include: (select 2)
A. hydrocephalus
B. hypotension
C. increased ICP
D. decreased cerebral perfusion pressure
E. brachial plexus injury

A

B. Hypotension d/t ↓ venous return = ↓ MAP = ↓ Cardiac Index

D. ↓ cerebral Perfusion Pressure

and improved ventilation in non-obese patients

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17
Q

What position is the patient in?

A
  • Prone
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18
Q

What things should we avoid compression of when we prone the patient? Select 3.
A. nose
B. breasts
C. elbows
D. shoulders
E. knees
F. genitalia

A

A. Head supported face down using a prone pillow, horseshoe headrest, or rigid fixation with pins in a neutral position without pressure on eyes, nose, mouth, and ears

B. Avoid compression of breasts, abdomen, and genitalia

And: Legs padded and slightly flexed at the knees and hips

Compression stockings for lower extremities to prevent pooling

19
Q

What should the patient’s arms be like when they are proned?

A. Arms at side tucked or outstretched (< 90 degrees), with flexion at elbows
B. Arms at side tucked or outstretched (> 90 degrees), with flexion at elbows
C. Arms at side tucked or outstretched (< 90 degrees), with extension at elbows
D. Arms outstretched (> 90 degrees), with extension at elbows

A

A. Arms at side tucked or outstretched (< 90 degrees), with flexion at elbows

20
Q

What are some risks that are sort of specific to prone position? Select 2.
A. sciatic nerve injury
B. post-op visual loss
C. ETT dislodgement
D. brachial plexus injury if arms abducted < 90 degrees

A

B. Post-op visual loss secondary to decreased perfusion/ischemia
C. ETT dislodgement biggest complication, document

Others:
Eye injuries r/t head position
Facial and airway edema
Ulnar nerve injury if elbows are not padded
Brachial plexus injury if arms are abducted > 90 degrees
Loss of monitors and IV lines

21
Q

Pathophysiological considerations for prone patients

A
  • Edema of face, conjunctiva, larynx, and tongue
  • ↑ Abdominal pressure
  • ↓ Venous return through compression of the inferior vena cava
  • ↓ CO
  • Improved ventilation and perfusion in the lungs d/t shift to the dependent areas
22
Q

What position is the patient in?

A
  • Lithotomy

Patient laying supine with legs up in padded or “candy cane” stirrups + Arms tucked or on arm boards

23
Q

What are some key points for Lithotomy position? Select 2.

A. brachial plexus injury is not as common in this position
B. Hips flexed 80 -100 degrees and legs abducted 30 - 45 degrees from midline
C. Periodically lower the legs if the surgery is > 1 hr
D. Lower extremities MUST be raised and lowered in synchrony together
E. Foot of the bed is lowered so don’t worry about crushing hands or fingers

A

B. Hips flexed 80 -100 degrees and legs abducted 30 - 45 degrees from midline, knees flexed
D. Lower extremities MUST be raised and lowered in synchrony together

And: Foot of the bed is lowered, must protect the hands and fingers from crush injury

Surgery > 2-3 hours, periodically lower the legs

If using Trendelenburg or reverse Trendelenburg, need non-sliding mattress

24
Q

Lithotomy risks

A
  • Back pain
  • Brachial plexus injury
  • Ulnar nerve injury
  • Common peroneal injury
  • Lateral femoral cutaneous injury
  • Compartment syndrome

BBUCCL

25
Q

For the Lithotomy Position, the_______ nerve is particularly prone to injury as it lies between the fibular head and compression from the leg support.

A. Common peroneal
B. Lateral femoral cutaneous
C. Sciatic
D. Medial femoral cutaneous

A

A. common Peroneal

26
Q

For the Lithotomy Position, branches of the ____________nerves often pass directly through the inguinal ligaments and can be impinged and become ischemic within the stretched ligament.

A. Peroneal
B. Lateral femoral cutaneous
C. Sciatic
D. Medial femoral cutaneous

A

B. Lateral femoral cutaneous

27
Q

Pathophysiological considerations for the lithotomy consideration.

A
  • ↑ Venous return, ↑ CO, and ↑ ICP
  • ↑ Intraabdominal pressure
  • Displaces diaphragm cephalad… ↓ Lung compliance and ↓ tidal volume
28
Q

What position is the patient in?

A
  • Lateral Decubitus Position

Patient lying on non-operative (dependent) side and requires anterior and posterior support w/ rolls or bean bags

29
Q

In the Lateral Decubitus position, where do we place the axillary roll? Select 2
A. cephalad to axilla
B. between chest wall and bed
C. caudal to axilla
D. between rib 10 and bed

A

B. between chest wall and bed
C. caudal to axilla to prevent brachial plexus compression

30
Q

What are some considerations for lateral decubitus position regarding arm placement, padding, and dependent side?

A
  • Adequate head support… no pressure on eyes or ears
  • Neutral position
  • Dependent ear should be regularly checked
  • Dependent leg = slightly flexed
  • Arms are in front of the patient and both must be supported and abducted < 90 degrees
  • Must place padding between the knees
31
Q

For right Lateral Decubitus, what side of the patient will be down?

A

RIGHT lateral decubitus = RIGHT side down

make sure to check that right ear regularly

32
Q

What are some safety/general considerations for the lateral decubitus position?

A. Inferior vena cava compression does not commonly occur with this position
B. position pt to allow for best expansion of dependent lung
C. ETT dislodgement rarely occurs
D. ulnar nerve injury can occur if arm is abducted

A

B. Consider proper positioning to allow the best possible expansion of the dependent lung

  • Inferior vena cava compression can occur
  • Ulnar nerve injury can occur if elbows are not padded
  • Brachial plexus injury can occur if arms are abducted > 90 degrees
  • ETT dislodgement; caution with use of LMA
33
Q

If kidney rest is used (or bed is flexed), where must it be placed?
A. under the greater trochanter
B. under the iliac crest
C. above the iliac crest
D. above the greater trochanter

A

B. under the iliac crest

34
Q

What are the likely reasons for ulnar nerve injury and brachial plexus injury?

it’s been on like every slide

A

Ulnar nerve injury can occur - if elbows are not padded
Brachial plexus injury can occur - if arms are abducted > 90 degrees

35
Q

In lateral decubitus position, what is the V/Q mismatch due to?

A. inadequate ventilation to dependent lung and increased blood flow to the nondependent lung
B. adequate ventilation to dependent lung and decreased blood flow to the nondependent lung
C. inadequate ventilation to dependent lung and decreased blood flow to the nondependent lung
D. adequate ventilation to dependent lung and increased blood flow to the nondependent lung

A

C. V/Q mismatch due to inadequate ventilation to dependent lung and decreased blood flow to the nondependent lung

Also watch out for venous pooling in lower extremities (use compression stockings/devices)

36
Q

Peripheral nerve injury can be caused by what factor?
A. stretch
B. ischemia
C. pressure
D. all of the above

A

D. all of the above
(SIP)

Peripheral nerve injury can occur in as a little as 30 minutes

37
Q

Can nerve injury occur even when optimal positioning is performed?

A
  • Yes

Overall, cases of nerve injuries have decreased, but are still a major legal cause to professional liability claims and can still occur even when optimal positioning is performed.

38
Q

Which AANA standard relates to patient positioning?

A
  • Standard 8: Patient Positioning
39
Q

A patient is supine with the neck extended and the head turned to the right, away from surgical site. Which positioning complication may occur?

A
  • Brachial plexus nerve injury
40
Q

Shoulder braces used during Trendelenburg increases the risk of compression injury to the _______.

A
  • Brachial plexus
41
Q

What position is contraindicated in a patient with an increased ICP?

A
  • Trendelenburg
42
Q

If an arterial line is used for pressure monitoring in a patient placed in Reverse Trendelenburg, the transducer should be zeroed at _________.

A

The tragus!

This will represent arterial pressure at the base of the brain/Circle of willis

based on what she said in class…

43
Q

What position should the patient be placed in if there is a suspected cerebral air embolism?

A

Trendelenburg and left lateral decubitus position (Durant position).

traps air in the right atrium and ventricle, thus minimizing the entry of air emboli into the right ventricular and pulmonary artery.

44
Q

When placing a patient in a lithotomy position, why must the legs be raised and lowered synchronously?

A. to prevent compartment syndrome
B. to prevent sciatic nerve injury
C. to prevent the drop in VR
D. to prevent torsion and injury to lower spine

A

D. Prevent torsion and injury to lower spine

increased VR in this position

and common peroneal and lateral femoral cutaneous nerve injuries are more likely (not sciatic)

Principles of Anesthesia I (27 decks)

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