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Principles of Anesthesia I - Summer 24 > Exam 2 - Positioning > Flashcards

Exam 2 - Positioning Flashcards

1
Q

What 3 things should we consider r/t positioning?

A
  1. the positioning process from head-toe
  2. proper positioning devices
  3. how much help is needed
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2
Q

What should be used in the abdominal/pelvic area to secure the patient?

How many finger breadths should be underneath these?

A
  • safety belts/straps
  • 2 finger breadths (or nerve damage & decreased flow can happen)
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3
Q

What is the most common surgical position?

A

Supine

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4
Q

Supine

How are the arms positioned?

A
  • arms tucked
  • or out to the side on secured arm boards
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5
Q

Supine Position

Pathophysiologic Considerations

A
  1. Increased venous return, preload, SV, CO
  2. Decreased Vt & FRC
    * FRC = ERV + RV
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6
Q

Supine Position

Why don’t we see the initital pathophysiologic changes?

A
  1. They are transient
  2. d/t mechanoreceptors & baroreceptors sensing the changes and taking the v/s back to baseline
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7
Q

Supine Position

Arms Abduction

A
  1. arms out to the side <90 degrees
  2. padded arm boards secured to the table & pt @ axilla
  3. arms should be supine w/ palms up
  4. elbows padded & arms secured w/ velcro strap
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8
Q

Supine position

Which is better - underpadding or overpadding under gaps?

A

*** over padding **
* under padding leads to problems

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9
Q

Supine Position

Arms Adduction

A
  • tucked alongside the body
  • held via draw sheet - goes up in b/w arm & body and is tucked over the arm
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10
Q

With the arms adducted in the supine position, how should the palms be positioned?

A
  • hand & forearm are supine (palms up)
  • neutral position w/ palms toward the body
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11
Q

What are the 5 complications r/t Supine positioning?

A
  1. backache
  2. pressure alopecia
  3. brachial plexus or axillary nerve injury if arms abducted > 90 degrees
  4. Ulnar nerve injury if hand/arm is pronated (palm down w/ arms adducted)
  5. Stretch injury when neck is extended & head turned away (brachial plexus)
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12
Q

Supine complications

Why do people experience back pain w/ this position?

A
  • lumbar lordotic curvature lost and they lose tone of the paraspinal muscles
    ** extra padding will not help **
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13
Q

Supine complications

What can help pts with kyphosis/scoliosis/back pain Hx?

A

Extra Padding
* support the neck

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14
Q

Supine complications

What causes pressure alopecia?

What can we do to help prevent this?

A
  • decreased flow & excessively long cases
  • lift their head, massage, give their scalp some breathing room
  • use donuts
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15
Q

Supine complications

What is the most common nerve injury with the supine position?

A
  • brachial plexus (keep the arms below shoulder level & 90 degrees)
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16
Q

What is the trendelenburg position?

What is an example surgery it would be used for? (Ericksen mentioned)

A
  • same as supine w/ head tilted down to diff. steepness levels (slight - extreme)
  • Robotics Davinci case
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17
Q

Trendelenburg position

What can we do to prevent the pt from sliding cephalad (toward HOB)?

A
  • use non-sliding matress/pad under the pt
  • mark the sheet to see if the pt slid down
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18
Q

Trendelenburg position

Why do we need to avoid the use of bean bags/shoulder braces?

A
  • they will lead to brachial plexus/compression injuries
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19
Q

Trendelenburg pathophys changes

What happens w/ CO?

A

CO increases d/t increased venous return of blood from lower extremities

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20
Q

Trendelenburg pathophys changes

What happens w/ ICP & IOP?

A
  • increased ICP & IOP
  • pts @ risk for increased ICP - communicate w/ surgeon to minimize trendelenburg steepness
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21
Q

Trendelenburg pathophys changes

What can cause an increase in edema of the face, conjunctiva, larynx, & tongue?

A
  • surgical time & fluid overload - assess the face & oral cavity
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22
Q

Trendelenburg pathophys changes

What does intraabdominal pressure do?

A
  • increases
  • everything pushes up on the lungs & shifts cephalad
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23
Q

trendelenburg pathophys changes

What happens w/ FRC & pulmonary compliance?

A
  • they decrease
  • diaphragm shifts cephalad
  • vent settings may need to be adjusted per pt (esp. if obese)
    – PC vs. VC - they may need higher pressures
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24
Q

Trendelenburg pathphys changes

What increases the risk of endobronchial intubation?

A
  • abdominal contents push the carina cephalad
  • the tube can shift & go R mainstem
    assess the ETT & listen to breath sounds
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25
Q

What is the reverse trendelenburg position?

A
  • same as supine, tilting head of patient up & feet down
  • use non-sliding mattress/pad under pt
  • footrest or something under feet to prevent sliding
    – no risk of nerve injury
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26
Q

Reverse Trendelenburg

Pathophysiologic changes

A
  • HoTN - decreased venous return (pooling in LE)
  • down displacement of abdominal contents & diaphragm
    – good for pts hard to ventilate (increased FRC)
  • decreased perfusion to brain
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27
Q

Reverse Trendelenburg Pathophys Changes

If the pt is in the sitting position or with the head up - where does the arterial line need to be leveled?

A
  • level of the tragus
  • to know they are getting good flow to the brain
28
Q

Sitting Position

What needs to happen with the pts head? How do we do this?

A
  • head stabilized
  • taped to special head rest or use rigid pins (surgeon)
29
Q

Sitting Position

How are the pts hips & feet positioned?

A
  • hips flexed < 90 degrees w/ knees slightly flexed
  • feet are supported to prevent sliding
30
Q

Sitting position

What does having the knees/hips flexed do for the pt?

A
  • prevents nerve compression & decreased flow to LE
  • reduces stretching of the sciatic nerve
31
Q

Sitting Position

What does keeping 2 finger breadths b/w the chin & sternum do?

A
  • reduces flexion of cervical spine
  • need to maintain the head neutral & midline
  • maintains normal blood flow
32
Q

How is beach chair position different from the sitting position?

What cases is beach chair position typically used for?

A
  • beach chair has less hip flexion and only slight leg flexion
    – this gives a reduced risk of sciatic nerve stretching & reduced flow risk
  • commonly used for shoulder surgeries
33
Q

What are 5 major risks associated with the sitting position?

A
  1. Cerebral hypoperfusion & air embolism
  2. pneumocephalus
  3. quadriplegia & spinal cord infarct
  4. cerebral ischemia
  5. peripheral nerve injuries (sciatic nerve injury)
34
Q

Sitting position risks

What can cause an air embolism?

What can an air embolism lead to?

A
  • Neurosurgery - venous sinuses can entrain air (5mL/kg needed to have major issues)
  • Can lead to -
    1. arrhythmias
    2. O2 desat
    3. pulm. HTN
    4. circulatory comprise
    5. cardiac arrest
35
Q

Sitting Risks

What causes a pneumocephalus?

What can that lead to?

A
  • entrainment of air in the subdural or ventricular space
  • can cause pressure on the intracranial structures/sinuses
36
Q

Sitting Risks

What can cause quadriplegia & spinal cord infarct?

A
  • significant flexion of the head forward or to the side
    important to maintain neutrality & normal flow
    – arterial flow & venous drainage
37
Q

Sitting Risks

What can cause cerebral ischemia?

A
  • permissive HoTN
  • reduced CO
  • surgeon will want lower BP in shoulder cases - tell them to screw off
38
Q

Sitting position

What pathophys changes happen?

A
  • HoTN - decreased venous return from venous pooling in LE
  • decreased MAP, CI, & CPP
    – important to maintain normal flow
  • improved ventilation b/c they are sitting up
    – FRC is better
39
Q

Prone position

How are the arms positioned?

A
  • side tucked or outstretched (< 90 degrees)
  • flexion @ elbows
40
Q

Prone position

How is the head positioned?

A
  • head supported face down w/ prone pillow
  • horseshoe headrest
  • rigid fixation w/ pins in neutral position w/o pressure on eyes, nose, mouth, & ears
  • maintain neutrality to prevent occluding jugular veins or any arteries
41
Q

Prone position

We need to avoid compression of the pts ________, ________, & ________.

A
  1. breasts
  2. abdomen
  3. genitalia (men)
42
Q

prone position

How should the legs be positioned?

A
  • padded & slightly flexed @ knees & hips
  • compressions stockings to prevent pooling of blood
43
Q

Prone Images

A
44
Q

What are 5 risks associated w/ the prone position?

A
  1. facial & airway edema
  2. nerve injuries
    – ulnar if elbows not padded
    – brachial if arms abducted > 90 degrees
  3. post-op visual loss (decreased perfusion/ischemia)
    – eye injury r/t head position (maintain neutrality)
  4. ETT dislodgement
  5. loss of monitors & IV lines
45
Q

Prone pathophysiological changes (3)

A
  1. edema of face, conjunctiva, larynx, & tongue
  2. increased abdominal pressure
    – decreased venous return (compression of IVC)
    – decrease CO
  3. improved ventilation
    – ventilation & perfusion in the lungs shift to the dependent areas (dependent areas have better ventilation)
46
Q

Lithotomy Position

A
  • pt lying supine w/ legs up in “padded” or “candy cane” stirrups
  • if using trendelenburg or reverse - need non-sliding mattress
47
Q

Lithotomy position

how are the arms positioned?

A
  • tucked or on arm boards
  • make sure hands are not in crack of bed
  • make mittens for the hands
  • prevent crush injuries
48
Q

Lithotomy position

How are the lower extremities positioned?

A
  • hips flexed 80-100 degrees
  • legs abducted 30-45 degrees from midline, knees flexed
  • lower extremites must be raised/lowered in synchrony - prevents torsion of lumbar spine
  • foot of bed lowered
49
Q

Lithotomy position

If surgery is > 2-3 hours what should we do w/ ROM?

A
  • periodically lower the legs
  • LOL the surgeon ain’t gonna let you do that
50
Q

What are 3 risks associated w/ lithotomy position?

A
  1. back pain
    – similar to supine (loss of paraspinal muscle tone)
  2. nerve injuries
    – brachial plexus, ulnar nerve, common peroneal, lateral femoral cutaneous
  3. compartment syndrome
    – not common (wraps too tight on legs)
51
Q

Lithotomy Pathophysiological Changes

A
  1. increased venous return, CO, ICP
  2. increased intraabdominal pressure
    – displaces diaphragm cephalad
  3. decreased lung compliance & Vt
    – decreased FRC
    – ventilation issues (esp. if large panus/belly)
52
Q

What is the lateral decubitus position?

A

pt lying on non-operative (dependent) side
* requires anterior & posterior support w/ rolls or bean bags
* ex: right lateral decubitus = right side down, left side up

53
Q

Lateral Decubitus position

How should the head be positioned?

A
  • adequate head support needed
  • ensure no pressure on eyes/ears
    – check dependent ear regularly
  • maintain neutrality
54
Q

Lateral Decubitus Position

How should the arms be positioned?

A
  • in front of the pt
  • both must be supported
  • abducted < 90 degrees
  • ax roll placed b/w chest wall & bed, caudal to axilla - @ the nipple line
55
Q

Lateral Decubitis Position

What is the purpose of the axillary roll?

A
  • prevents brachial plexus compression & neurovascular compression
  • prevents “sleeping on the arm/dead arm”
  • maintains normal blood flow to the arm
56
Q

Lateral Decubitus Position

How should the lower extremities be positioned?

A
  • dependent leg should be slightly flexed
  • must place padding b/w the knees
57
Q

Lateral Decubitus - Jack Knife

Where is the ideal location for the bed to be flexed in jack knife or if kidney rest is used?

A

under the iliac crest
* IVC compression can occur
* this also allows for best expansion of the dependent lung

58
Q

Lateral Decubitus

Airway concerns

A
  • ETT dislodgement
  • LMA - iGel is the best option (need it to be seated well)
59
Q

Lateral Decubitus Pathophysiological Concerns

A
  1. venous pooling in LE
    – use compression sleeves
  2. V/Q mismatch d/t inadequate ventilation to dependent lung & decreased blood flow to non-dependent lung
60
Q

What causes most peripheral nerve injuries?

What is the timing that they can occur?

A
  • result of stretch, pressure, and/or ischemia
  • mechanism unclear sometimes - do everything right & still happens
  • can happen in as little as 30 min
61
Q

Are peripheral nerve injuries sensory or motor?

A
  • most are sensory
  • can be motor & sensory
  • temporary or permanent
62
Q

Prevention of Ulnar Nerve Injury (2)

A
  1. avoid excess pressure on postcondylar groove of humerus
  2. keep hand & forearm either supinated or in a neutral position
63
Q

Prevention of Brachial Plexus Injury w/ Trendelenburg

A
  • avoid use of shoulder braces/bean bags
  • avoid abduction of arms when possible
64
Q

Prevention of Brachial Plexus Injury (4)

A
  1. avoid excess lateral rotation of head in supine/prone position
  2. limit abduction of arm to < 90 degrees in supine
  3. avoid high ax-roll placement in decubitus position to avoid neurovascular complications
  4. use US to locate IJ for central line placement
65
Q

Prevention of Spinal Cord and Lumbosacral Nerve/Root/Cord Injury (3)

A
  1. be aware that the fraction of spinal cord injuries is increasing (regional anesthesia)
  2. avoid severe cervical spine flexion or extension when possible
  3. follow current guidelines for regional anesthesia in pts on anti-coagulant therapy
66
Q

Preventionof Sciatic & Peroneal Nerve Injuries (4)

A
  1. minimize time in lithotomy
  2. 2 assistants to coordinate leg movemement to lithotomy
  3. avoid excess flexion of hips, extension of knees, or torsion of lumbar spine
  4. avoid excess pressure on peroneal nerve @ fibular head
67
Q

List the nerve injuries from most common to least common

A
  1. Spinal Cord (25%)
  2. Brachial plexus (19%)
  3. Lumbosacral nerve/root/cord (18%)
  4. Ulnar Nerve (14%)
  5. Sciatic & Peroneal Nerve (7%)

Principles of Anesthesia I - Summer 24 (15 decks)

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