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JW: Principles of Anesthesia I > Exam 2- Positioning (6/15/23) > Flashcards

Exam 2- Positioning (6/15/23) Flashcards

1
Q

What is the most common surgical position?

A
  • 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?

A
  • ↑ Venous return
  • ↑ Preload
  • ↑ SV
  • ↑ CO
  • ↓Tidal volume
  • ↓ FRC
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3
Q

Describe arm abduction positioning

A
  • Arm 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)
  • Elbows padded and arm is secured with a Velcro strap
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4
Q

Describe arm adduction positioning

A
  • Arm 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)
  • Elbows are padded
  • May tuck one arm if surgeon must stand on side of patient
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5
Q

Complications of the supine position

A
  • Backache
  • Pressure alopecia
  • Brachial plexus or axillary nerve injury if arms abducted > 90 degrees
  • Ulnar nerve injury if hand/arm is pronated (palm down)
  • Stretch injury when neck is extended and head turned away (brachial plexus)
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6
Q

What position is this patient in?

A
  • Trendelenburg (head down)
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7
Q

Safety/general considerations with Trendelenburg position.

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

Pathophysiological considerations with Trendelenburg position.

A
  • ↑ CO, ↑ Venous Return from lower extremities
  • ↑ ICP, ↑ IOP, Facial Edema
  • ↑ Intraabdominal Presure
  • ↓ FRC and ↓ Pulmonary Compliance
  • May need higher pressure in ventilated patients
  • Risk of endobronchial intubation as abdominal contents push the carina cephalad
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9
Q

What position is this patient in?

A
  • Reverse Trendelenburg (head up)
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10
Q

Safety/general considerations with Reverse Trendelenburg position.

A
  • Use a non-sliding mattress/pad to prevent the patient from sliding
  • Use a footrest or something under the feet to prevent the patient from sliding
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11
Q

Pathophysiological considerations with Reverse Trendelenburg position.

A
  • Risk of Hypotension (↓ Venous Return, Venous pooling)
  • Downward displacement of abdominal contents/ diaphragm (better ventilation)
  • ↓ Perfusion to the brain
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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
  • Shoulder Cases

Beach chair position will have less severe hip flexion 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

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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16
Q

Sitting position risk

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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17
Q

Pathophysiological consideration of the sitting position?

A
  • Hypotension d/t ↓ venous return.
  • ↓ MAP
  • ↓ Cardiac Index
  • ↓ Perfusion Pressure
  • Improved ventilation in non-obese patients
18
Q

What position is the patient in?

A
  • Prone
19
Q

Describe the prone position.

A
  • Patient lying on stomach
  • Arms at side tucked or outstretched (< 90 degrees), with flexion at elbows
  • 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
  • Avoid compression of breasts, abdomen, and genitalia
  • Legs padded and slightly flexed at the knees and hips
  • Compression stockings for lower extremities to prevent pooling
20
Q

Why do you not turn a prone patient’s head to one side or the other?

A
  • Risk of jugular occlusion or carotid occlusion
21
Q

Risk of prone position

A
  • Facial and airway edema
  • Ulnar nerve injury if elbows are not padded
  • Brachial plexus injury if arms are abducted > 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
22
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
23
Q

What position is the patient in?

A
  • Lithotomy
24
Q

Describe the Lithotomy position

A
  • Patient laying supine with legs up in padded or “candy cane” stirrups
  • Arms tucked or on arm boards
  • If using Trendelenburg or reverse Trendelenburg, need non-sliding mattress
  • 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
  • Foot of the bed is lowered, must protect the hands and fingers from crush injury
  • Surgery > 2-3 hours, periodically lower the legs
25
Q

Lithotomy risk

A
  • Back pain
  • Brachial plexus injury
  • Ulnar nerve injury
  • Common peroneal injury
  • Lateral femoral cutaneous injury
  • Compartment syndrome
26
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
  • Peroneal
27
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
  • Lateral femoral cutaneous
28
Q

Pathophysiological considerations for the lithotomy consideration.

A
  • ↑ Venous return, ↑ CO, and ↑ ICP
  • ↑ Intraabdominal pressure
  • Displaces diaphragm cephalad
  • ↓ Lung compliance and ↓ tidal volume
29
Q

What position is the patient in?

A
  • Lateral Decubitus Position
30
Q

Describe the Lateral Decubitus position.

A
  • Patient lying on non-operative (dependent) side and requires anterior and posterior support w/ rolls or bean bags
  • Adequate head support… no pressure on eyes or ears
  • Neutral position
  • Dependent ear should be regularly checked
  • Dependent leg is slightly flexed
  • Arms are in front of the patient and both must be supported and abducted < 90 degrees
  • Axillary roll placed between chest wall and bed, caudal to axilla to prevent brachial plexus compression
  • 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
32
Q

Safety/general considerations for the lateral decubitus position

A
  • If bed flexed or kidney rest used, needs to be placed under iliac crest
  • Inferior vena cava compression can occur
  • Consider proper positioning to allow the best possible expansion of the dependent lung
  • 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

Pathophysiological considers for the Lateral Decubitus position

A
  • Venous pooling in lower extremities (use compression stockings/devices)
  • V/Q mismatch due to inadequate ventilation to dependent lung and decreased blood flow to the nondependent lung
34
Q

Peripheral nerve injury can be caused by what factors?

A
  • Stretch
  • Pressure
  • Ischemia

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

35
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.

36
Q

Which AANA standard relates to patient positioning?

A
  • Standard 8: Patient Positioning
37
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
38
Q

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

A
  • Brachial plexus
39
Q

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

A
  • Trendelenburg
40
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 Circle of Willis

This will represent arterial pressure at the base of the brain.

41
Q

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

A
  • The patient should be positioned in a head down/Trendelenburg and left lateral decubitus position (Durant position).
  • This aims to trap air in the right atrium and ventricle, thus minimizing the entry of air emboli into the right ventricular and pulmonary artery.
42
Q

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

A
  • Prevent torsion and injury to lower spine

JW: Principles of Anesthesia I (64 decks)

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