E2- Positioning Flashcards
What is the most common surgical position?
- Supine
Arm boards must be secure if in use.
What are initial transient physiological changes to be expected when moving from sitting to supine?
Heart::
* * ↑ Venous return
* ↑ Preload
* ↑ SV
* ↑ CO
Lungs ::
* ↓Tidal volume
* ↓ FRC
Describe arm abduction positioning
- Arm out to the side, < 90 degrees
- Padded arm boards secured to table + pt at axilla
- arms = supine (palms up)
- Elbows = padded
- arm secured with Velcro strap
Describe arm adduction positioning
- Arm tucked alongside the body
- via draw sheet under the body and over the arm
- Hand + forearm = supine (palms up) .. OR.. neutral position (palms toward body)
- Elbows are padded
- May tuck one arm if surgeon must stand on side of patient
5 Complications of the supine position
* Backache**
*** Pressure alopecia**
* Brachial plexus / axillary nerve injury = arms > 90 degrees
* Ulnar nerve injury = hand/arm is pronated (palm down)
* Stretch injury= neck extended + head turned away (brachial plexus) **
What is the most common nerve positioning injury?
Brachial Plexus
What position is this patient in?
- Trendelenburg (head down)
Safety/general considerations with Trendelenburg position.
- non-sliding mattress/pad to prevent the patient from sliding cephalad
- Avoid using bean bags or shoulder braces
- **making mark at level of patient’s head **on the sheet =determine if patient has slid
Pathophysiological considerations with Trendelenburg position.
Heart ::
* ↑ CO, ↑ Venous Return from lower extremities
- ↑ ICP, ↑ IOP
*Edema - face, conjunctiva, larynx, tongue - ↑ Intraabdominal Presure
Lungs ::
* ↓ FRC + ↓ Pulmonary Compliance
* May need higher pressure in ventilated patients
* Risk of endobronchial intubation as abdominal contents push the carina cephalad
What position is this patient in?
- Reverse Trendelenburg (head up)
Safety/general considerations with Reverse Trendelenburg position.
- non-sliding mattress/pad to prevent patient sliding
- footrest under feet to prevent patient sliding
Pathophysiological considerations with Reverse Trendelenburg position.
- Risk of Hypotension (↓ Venous Return, Venous pooling)
- Downward displacement of abdominal contents/ diaphragm (better ventilation)
- ↓ Perfusion to brain
ART LINE @ TRAGUS !!
Opposite Trendelenburg = good heart, bad lungs, bad brain
Name the positions
- Left Picture: Beach Chair Position
- Right Picture: Full Sitting Position
When will the patient be in the Beach chair position?
- Shoulder Cases
Beach chair position will have less severe hip flexion and slight leg flexion.
Describe the set-up of the full sitting position
- Head = stabilized – taped or rigid pins
- Hips = flexed < 90 degrees
knees = slightly flexed for balance + reduce stretching of the sciatic nerve - Feet are supported – prevent sliding
* Compression stockings to maintain venous return - Keep at least two finger’s distance between the chin and sternum
Sitting position 5 risk
- Cerebral hypoperfusion and air embolism - venous sinuses»_space; pulm htn, arrythmia, arrest
- Pneumocephalus- accumulation of air in subdural + inrtraventricular space, pressure on the intracranial structure
- Quadriplegia and spinal cord infarction- hyperflexion of the neck
- Cerebral ischemia
- Peripheral nerve injuries (Sciatic nerve injury)
NEURO + sciatic
Pathophysiological consideration of the sitting position?
Heart ::
* * Hypotension d/t ↓ venous return.
* ↓ MAP
* ↓ Cardiac Index
* ↓ Cerebral Perfusion Pressure - art tragus
Lungs ::
* Improved ventilation in non-obese patients
What position is the patient in?
- Prone — with Wilson frame
Describe the prone position.
- Patient lying on stomach
- Arms = side tucked or outstretched (< 90 degrees), with flexion at elbows
- Head supported face down using —- prone pillow, horseshoe headrest, or rigid fixation
- Avoid compression of breasts, abdomen, and genitalia
- Legs = padded + slightly flexed @ knees + hips
- Compression stockings for lower extremities to prevent pooling
SPECIAL:
* Intubate supine
* EKG leads on back
* Wilson Frame !!
Why do you not turn a prone patient’s head to one side or the other?
- Risk of jugular occlusion or carotid occlusion
Risk of prone position
- Facial + airway edema
- Ulnar nerve = elbows are not padded
- Brachial plexus injury = arms > 90 degrees
- Post-op visual loss secondary to decreased perfusion/ischemia
* Eye injuries r/t head position - ETT dislodgement biggest complication, document
- Loss of monitors and IV lines
Visual loss / eye injury + lines
Pathophysiological considerations for prone patients
- Edema of face, conjunctiva, larynx, and tongue
Heart ::
* ↑ Abdominal pressure
* ↓ Venous return through compression of inferior vena cava
* ↓ CO
Lungs ::
* Improved ventilation + perfusion in the lungs d/t shift to the dependent areas
What position is the patient in?
- Lithotomy
Describe the Lithotomy position
- Patient laying supine with legs up = padded or “candy cane” stirrups
- Arms = tucked or on arm boards
- If using Trendelenburg or reverse Trendelenburg = non-sliding mattress
- Hips = flexed 80 -100 degrees
- legs = abducted 30 - 45 degrees from midline, knees flexed
- Lower extremities MUST be raised and lowered in SYNCHRONY together
- prevent torsion injury to lumbar
- Foot of the bed is lowered, mustprotect hands and fingers from crush injury
- Surgery > 2-3 hours, periodically lower the legs
