Exam 2 Positioning (6/13/24)

Question 1

Increase or decrease in the following when laying supine for surgery?

Tidal Volume
Preload
Stroke Volume
Cardiac Output
Venous Return
Functional Residual Capacity

Answer 1

• Tidal Volume: Decreased
• Preload: Increased
• Stroke Volume: Increased
• Cardiac Output: Increased
• Venous Return: Increased
• FRC: Decreased

These are initial changes and are transient.

Question 2

Safety belts/straps must be used in the ___ and ___ area to secure the patient in addition to the securing of extremities

Answer 2

Abdominal and Pelvic

Question 3

What is the most common surgical position?

Answer 3

Supine

Question 4

Describe Abduction of the arms for surgery:

Answer 4

• Out to the side, < 90 degrees
• Padded arm boards secured to the table and patient at the axilla
• The arms should be supine (palms up)

Question 5

Describe Adduction of the arms for surgery:

Answer 5

• Tucked alongside the body
• Arms held along the side of body via draw sheet under the body and over the arm
• Hand and forearm are supine (palms up) or neutral position (palms toward body)

Question 6

Complications of Supine positioning for surgery:

Answer 6

• Stretch Injury (Brachial Plexus)
• Ulnar Nerve Injury (if pronated)
• Pressure Alopecia
• Backache (Loss of tone from paraspinal muscles)
• Brachial Plexus or Axillary nerve injury (if arms abducted > 90 degrees)

Question 7

What position is this patient in?

Answer 7

Trendelenburg

Question 8

True or False:

In trendelenburg position, it is preferred to use bean bags and shoulder braces to prevent patient from sliding cephalad.

Answer 8

FALSE

Avoid using bean bags or shoulder braces

Question 9

Pathophysiologic Considerations in the trendelenburg position:

Select All That Apply:
Which of the following are increased while in the trendelenburg position for surgery?

A. Intra-abdominal Pressure
B. Venous Return
C. Cardiac Output
D. FRC
E. Intra-Ocular Pressure
F. Pulmonary Compliance

Answer 9

A. Intra-abdominal Pressure
B. Venous Return
C. Cardiac Output
E. Intra-Ocular Pressure

Question 10

This pathophysiologic consideration for the trendelenburg position can increase with surgical time and in presence of fluid overload.

Answer 10

Edema of face, conjunctiva, larynx, and tongue

Question 11

Why does the patient’s FRC and pulmonary compliance decrease in the trendelenburg position?

Answer 11

Because the diaphragm shifts cephalad

Question 12

What is one consideration regarding vent management for the trendelenburg position?

Answer 12

May need higher pressures in ventilated patients for adequate ventilation

Question 13

There is an increased risk of ___ because abdominal contents push the carina cephalad in the trendelenburg position.

Answer 13

Endobronchial intubation

Question 14

What dis is?

Answer 14

Reverse Trendelenburg

Question 15

Pathophysiologic considerations for the Reverse Trendelenburg Position for surgery:

Answer 15

• Hypotension risk (Decreased Venous Return)
• Downward displacement of abdominal contents and diaphragm
• Decreased perfusion to brain

Question 16

For a patient in the reverse trendelenburg and sitting positions, where should place the transducer level of an arterial line to ensure accurate blood pressures and accurate cerebral perfusion pressures?

Answer 16

Tragus

Question 17

While in the sitting position for surgery, you want to ensure at least ___ fingers distance between the chin and the sternum.

Answer 17

2

Question 18

In the sitting position, how should the hips be positioned?
What does this help reduce?

Answer 18

Hips should be flexed < 90 degrees.

This helps to reduce stretching of the sciatic nerve.

Question 19

The use of Compression stockings/wraps helps maintain ___ in the sitting position.

Answer 19

Venous Return

Question 20

Frequent Positon for Shoulder cases?

Answer 20

Beach Chair Position

Less severe hip flexion and slight leg flexion

Question 21

Risks of the Sitting position for surgery:

Answer 21

• Cerebral hypoperfusion and air embolism
• Pneumocephalus
• Quadriplegia and spinal cord infarction
• Cerebral ischemia
• Peripheral nerve injuries
• Sciatic Nerve Injury

Question 22

True or False:

Hypotension, decreased cardiac index, and decreased cerebral perfusion pressure are common pathophysiologic changes in the sitting position for surgery.

Answer 22

TRUE

Question 23

There is no information on this card…

Answer 23

This is straight out of a horror movie… wtf

Question 24

Three places, specifically mentioned in lecture, in which we should avoid compression while in the prone position.

Answer 24

1. Breasts
2. Abdomen
3. Genitalia

Question 25

Risks from prone position for surgery:

Answer 25

* Facial/Airway Edema * Ulnar/Brachial plexus Nerve injury * Post-op vision loss secondary to decreased perfusion/ischemia * ETT Dislodgement * Loss of monitors and IV Lines

Question 26

Select All that Apply: Which of the following are decreased while the patient is in the prone position for surgery? A. Ventilation B. Facial Edema C. Abdominal Pressure D. Cardiac Output E. Venous Return

Answer 26

D. Cardiac Output E. Venous Return There is actually improved ventilation in the prone position.

Question 27

Compression of this structure can cause a decrease in venous return in the prone position.

Answer 27

Inferior Vena Cava

Question 28

Describe the Lithotomy position:

Answer 28

* Patient laying supine with legs up in padded or “candy cane" stirrups * Hips flexed 80 -100 degrees and legs abducted 30 - 45 degrees from midline, knees flexed * Lower extremities MUST be raised and lowered in synchrony together (Prevents lumbar injury)

Question 29

If the patient is undergoing a surgery that is > 2-3 hrs in the lithotomy position, what should we do?

Answer 29

Periodically Lower the Legs

Question 30

Various nerves that are at a high risk of injury in the lithotomy position.

Answer 30

* Brachial Plexus * Ulnar Nerve * Common Peroneal * Lateral Femoral Cutaneous

Question 31

Aside from the various nerve injuries, there are 2 other risks while in the lithotomy position:

Answer 31

Back Pain Compartment Syndrome

Question 32

Pathophysiological Considerations in the lithotomy position:

Answer 32

* Increase VR, CO, ICP, Abdominal Pressure * Decreased lung compliance and Tidal Volume

Question 33

In the lateral decubitus position, which side of the patient is down? Operative vs. Non-Operative Dependent vs. Independent

Answer 33

Non-Operative Dependent

Question 34

If the patient is in the Left lateral Decubitus postion, what side of the body is the operation occuring on?

Answer 34

Right

Question 35

Describe the placement and use of an axillary roll while in the lateral decubitus position:

Answer 35

Placed between chest wall and bed, caudal to axilla. Used to prevent brachial plexus compression.

Question 36

# Lateral Decubitus If bed flexed or kidney rest used, the break in the bed needs to be placed under the ____.

Answer 36

Iliac Crest

Question 37

Lateral Decubitus Pathophysiological Considerations:

Answer 37

* Venous Pooling in lower extremities * V/Q Mismatching (inadequate ventilation to dependent lung and decreased blood flow to the nondependent lung)

Question 38

Peripheral Nerve injuries are usually a result of ___.

Answer 38

Stretch, Pressure and/or ischemia

Question 39

Peripheral Nerve injuries can occur in as little as___.

Answer 39

30 minutes.

Question 40

True or False: So long as optimal positioning is performed peripheral nerve injuries will not occur.

Answer 40

FALSE: 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**

Question 41

Which two positions does compression of the inferior vena cava occur?

Answer 41

Prone Lateral Decubitus

Question 42

For which position should we be cautious with using an LMA due to dislodgement risk?

Answer 42

Lateral Decubitus