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Health Assessment > Operative Positioning > Flashcards

Operative Positioning Flashcards

0
Q

Patient Safety

A
  • Team Approach
  • Anesthetist needs to use vigilance (patient is unconscious, loss of sensation, muscle relaxation)
  • establish positions gradually, particularly at the conclusion of long surgeries
  • documentation (describe baseline range of motion, intra-operative position, use of padding, frame, body position, checks done and frequency)
  • liability (avoided by responsible, vigilant care and documentation)
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1
Q

Purpose of Operative Positioning

A
  • Comfort
  • Patient Safety
  • Surgical Exposure and/or Surgical Access

*Positioning may evoke undesirable physiological changes and injuries. The Anesthetist is responsible for supervising and assuring no nerve or soft tissue injury and to minimize physiological changes. Litigation can occur.

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2
Q

OR Table

A

Weight limit: 136 kg (300 lbs)
Length: 80.7 inches

  • base/center/column to keep weight evenly balanced similar to a see saw
  • torso over column
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3
Q

Transfer to OR table

A
  • Stretcher along side OR table- BOTH locked
  • Make sure OR table has draw sheet
  • Staff members on stretcher side AND bed side
  • Patient transfers self or moved by staff (head and neck aligned with spine and watch extremities)
  • Then apply safety strap
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4
Q

Most Common Operative Positions

A
  • Supine or Dorsal Decubitus Position
  • Trendelenburg
  • Reverse Trendelenburg
  • Lithotomy
  • Prone or Ventral Decubitus Position
  • Lateral Decubitus
  • Sitting
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5
Q

Supine Position

A
  • Most common operative position
  • Position preferred by anesthesia providers
    • access to airway
    • access to arms for IVs/monitors/alines
    • less physiologic changes than in other positions
  • Pillow under head
  • *allows proper sniffing position
  • *avoids dorsal extension and lateral flexion of neck
  • *doughnut shape pillow (avoids alopecia)
  • *no pressure on eyes
  • Arms
  • *tuck arm
    • draw sheet under pt hip or torso, not mattress;
    • elbow padded; palm in
  • *arm boards
    • properly secured to the OR table
    • most ideal
    • abducted <90 degrees, avoids stretch brachial plexus
    • padded
    • safety straps
    • hands -supinated (palm up) NOT pronated (can cause ulnar nerve damage- palm up to prevent it)
  • Feet
  • *Heels not hanging over the bed
  • *heels padded (pressure points should be padded)
  • Lumbar support
  • *back pain is a common problem after anesthesia. maintain natural curvature in back.
  • *slight flexion hips and knees
  • *pillow under knees (caution)
  • *legs/feet should not be crossed
  • *elastic compression stockings and SCDs increase venous return and decrease risk of DVT
  • SAFETY STRAP
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6
Q

Nerve Injuries occur due to:

A

incorrect positioning, length of procedure, obesity and other pathological conditions such as diabetes and smoking

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7
Q

Mechanisms of Nerve Injuries

A
  • Stretching (move an extremity in a way its not use to being moved and elongates the nerve and messes with the pathway of the nerve)
  • Compression
  • Kinking (between two objects)
  • Ischemia (prolonged stretching/compression or hypotension)
  • Transection
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8
Q

Brachial Plexus Injury in Supine position

A

-Long superficial course through two fixed points (the vertebral foramina fascia and the axilla)

  • Injury occurs with
  • *neck extension, or head turned to side
  • *excessive abduction of arm > 90 degrees
  • *arm/ arm board falls off table
  • *(mostly stretching injuries)
  • *shoulder braces push down on the clavicle, shoulder sagging while sitting, arm is smooched in lateral position, and use of retractors
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9
Q

Brachial Plexus Injury deficit:

A
  • electric shocks, or burning sensation shooting down arm

- numbness or weak arm function

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10
Q

Radial Nerve Injury in Supine Position

CAUSED FROM:

A

Injury due to external compression of the radial nerve on the lateral aspect of the humerus against

  • surgical retractors
  • ether screen
  • mismatched arm board (“step off”) -mattress and arm board are uneven
  • repeat BP inflation
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11
Q

Radial Nerve Injury

RESULTS IN

A

wrist drop
weakness in abduction of the thumb
numbness 1,2, ring fingers
inability to extend elbow

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12
Q

Ulnar Nerve Injury in Supine Position

A

Most common postoperative peripheral nerve injury

In cubital tunnel at elbow groove- compression of the nerve between the olecranon of ulna and medial epicondyle of humerus (entrapment with arm extension)

injured by 
stretch with severe elbow flexion
dislocation with pronation hand
nerve dislocation over medial epicondle w/ stretching
compression against bed

3x more common in men

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13
Q

Claw Hand

A

Long term problem associated with ulnar nerve injury

  • inability to abduct or oppose 5th finger
  • weak grip ulnar side of fist
  • loss sensation palmar surface 4th or 5th fingers
  • leads to atrophy of intrinsic muscle of hand
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14
Q

Ulnar Nerve: To reduce risk of injury

A
  • pad arm boards
  • avoid downward compression by strap
  • assure surgical personnel do not compress patients arm
  • place BP cuff proximally so that it does not impose on ulnar groove or cubital tunnel
  • avoid prolonged flexion of elbow

**if you had to hyperflex the elbow for surgery than you need to remember time- every so often let the arm down

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15
Q

Supine: CV changes

A

-minimal effects on circulation and perfusion

  • initially, have increased venous return to heart
  • increased preload, stroke volume, co, and bp
  • activates baroreceptors which decrease sympathetic outflow and increases parasympathetic impulses
  • compensatory decreases HR, PVR
  • reduced venous drainage from lower extremities
  • uncross legs
  • pad heels
  • pillow beneath knees
  • flexed hips and knees
  • all to improve venous return

-IV compression by masses, pregnancy, obese abdomen or ascites may decrease venous return to the right heart and decrease CO

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16
Q

Supine: Ventilatory Changes

A

FRC decreases +/- 800 ml
related to cephalad placement of the diaphagram and compression of lung bases

lung volumes are further reduced by muscle relaxants

  • loss of chest wall muscle tone with muscle relaxants-reduces opposition to inherent elastic recoil of pulmonary tissues
  • overcome with positive pressure ventilation
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17
Q

Supine: Cerebral Blood Flow

A

minimal change related to tight autoregulation

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18
Q

Trendelenberg

A

Used to treat hypotension by increasing venous return

improves surgical exposure during abdominal and laparoscopic surgery (pulls abdominal content towards the head to work on the pelvis- gyn surgery)

helps prevent air embolism

facilitates cannulation during central line placement

use extreme caution with shoulder braces

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19
Q

Shoulder Braces

A

If they must be used they should be well padded and placed laterally away from the root of the neck over the arcomioclaviular joint

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20
Q

Trendelenburg: CV changes

A
  • used to counteract hypotension (controversial and short term)
  • increases venous return to the heart- up to 1 L into central circulation
  • causes reduced blood flow to the lower extremities
  • may cause compression of heart by abdominal contents pushing cephalad
  • baroreceptors activated– peripheral vasodilation and bradycardia may make shock syndromes worse in the long run
  • hypotension may occur when the supine position is resumed
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21
Q

Trendelenberg: Ventilatory Changes

A

Contents of the abdomen displaced cephalad impeding diaphragmatic excursion, compresses lung bases, decreases lung compliance, decreases FRC, PIP increases

With spontaneous ventilation, work of breathing is increased

V:Q mismatch with perfusion exceeding ventilation in the apex of the lung

ETT is easily shifted into right mainstem bronchus as abdominal/thoracic contents shift cephalad.

risk of aspiration

face and airway edema can lead to airway obstruction

22
Q

Trendelenberg: Cerebral Blood Flow

A

Increases intracranial vascular congestion-GRAVITY
Increased intracranial pressure
Intraocular pressure increases

glaucoma, CNS dz or pt with already increased pressure would NOT be a good candidate for this position

23
Q

Reverse Trendelenberg

A
  • Utilized to enhance surgical exposure of the upper abdomen by shifting the abdominal contents caudad
  • ex: laparoscopic cholecystectomy
  • Variations of this position may be used for shoulder, neck, intracranial surgery
  • This is a variation of the sitting position in terms of physiologic changes
  • Caution with foot board
  • excessive plantar flexion of the feet for extended periods of time
  • anterior tibial nerve injury
  • results in foot drop
24
Q

Reverse Trendelenberg: CV Changes

A
  • Reduced preload
  • Reduced CO (20-40%)
  • lowered BP

Increased SNS tone, SVR, and HR +/- 30% (may be blunted by anesthetics)

Activation of the renin-angiotensin- aldosterone system

Venous pooling in the lower extremities- compression stockings should be used

resume the position slowly to prevent a large drop in BP

25
Q

Reverse Trendelenberg: Ventilatory Changes

A

Abdomen does not impede diaphragmatic excursion, FRC increases

Ventilation is easier

26
Q

Reverse Trendelenberg: Cerebral Blood Flow

A
  • decreases proportional to the degree of head up tilt (can be up to 20%).
  • intracranial pressure decreases
  • helps patients with high ICP
  • measure blood pressure close to the circle of willis (make sure the transducer is parallel with their head)
27
Q

Lithotomy Position

A
  • “Calf support” stirrups
  • Hips flexed 80-100 degrees
  • Legs abducted 30-45 degrees from midline
  • Lower legs parallel to torso
  • Watch femoral, sciatic, lower leg nerves
  • “candy” cane stirrups
  • usually more acute flexion of the knees and/or hips
  • watch injury to common peroneal nerve, sciatic, femoral
  • “knee crutch style”
  • watch popliteal nerve (tibial nerve and common peroneal nerve)
28
Q

Lithotomy -Lower extremity nerve injury

A

78% common peroneal nerve
15% sciatic
7% femoral

most common with

  • low body mass
  • prolonged surgery
  • recent cigarette smoking
  • PVD
  • DM
  • obesity
29
Q

Lithotomy

A

-Commonly used for GYN, GU, and rectal procedures

  • Both legs are positioned into stirups together to avoid torsion of the lumbar spine and hip flexion beyond 110 degrees is avoided
  • flexed at hip and knee & simultaneously elevated and separated

improper positioning may lead to the following nerve injuries:
femoral, sciatic, obturator, lateral femoral cutaneous, saphenous, COMMON PERONEAL

30
Q

Common peroneal nerve injury

A
  • most frequently damaged nerve of lower extremity
  • branch of sciatic, lateral to neck of fibula
  • injury from:
  • *compression of lateral aspect of knee against stirrup or lateral position
  • symptoms:
  • foot drop
  • inability to evert the foot
  • loss of dorsal extension of toes
31
Q

sciatic nerve injury

A
  • excessive external rotation hips
  • pressure in sciatic notch from stretching

symptoms:

  • weakness or paralysis of muscles below the knee
  • numbness of foot and lateral half of calf
  • foot drop
32
Q

Femoral Nerve Injury

A
  • Injured with compression at pelvic brim by retractor or excessive angulation of thigh/abduction of thighs and external rotation of hips
  • results in loss of flexion hip and loss of extension of knee
  • decreased sensation over superior aspect of thigh
33
Q

Saphenous Nerve Injury

A
  • Occurs when medial aspect of lower leg compressed against support bar
  • results in paresthesias medial and antermedial side of calf
34
Q

Lower extremity Compartment Syndrome

A
  • Occurs when perfusion to an extremity is inadequate, resulting in ischemia, edema, and extensive rhabdomyolysis from increased tissue pressure
  • occurs with long surgical procedures ( > 2-3 hours)
  • occurs with lithotomy and lateral decubitus positions
35
Q

Lithotomy: CV Changes

A

-Elevation of legs increases venous return/increases preload to heart with transient increase in CO and increase in BP

  • Perfusion to the lower extremities is reduced
  • perfusion pressure changes 2 mmHg for each 2.5 cm that a given point varies in vertical height above or below the reference point (heart).
36
Q

Lithotomy: Ventilatory Changes

A
  • Depending on the degree of hip flexion, abdominal contents may push up on the diaphragm and impede excursion, with a reduction of lung compliance and decrease TV and decrease in vital capacity.
  • Aspiration risk increases.
37
Q

Lithotomy: Cerebral changes

A

-Transient increase in cerebral venous blood flow and increase in intracranial pressure with legs elevated

38
Q

Prone position

A

Wilson Frame: use something under the patient to get the pressure off the abdomen to allow vena cava perfusion or Jackson Table: Spins the patient if they need the patient in prone and supine position

Head rest

  • watch eyes, nose, airway, neck alignment, watch bony structures of face
  • head may be turned to side if adequate mobility
  • neck is neutral alignment, not excessive flexion or extension
  • if head is turned to the side check ears free of pressure
  • you can have stretch of the brachial plexus when you turn head side to side and venous obstruction to lympathics and blood flow to the neck

On stretcher you will

  • standard induction/intubation
  • line placement
  • NGT/OGT
  • Foley
  • eye protection

Secure everything

  • Check breath sounds again
  • Monitors on and working
  • check IV and Aline working
  • check for excessive pressure on
  • eyes, nose, upper extremities, breasts, genitals, anterior iliac crest
  • chest and hips supported to allow for free abdomen for diaphragmatic movement and increased venous return
  • check neck alignment
39
Q

Prone position

EYE INJURY

A

-Corneal abrasions
*direct trauma, dry eye, swelling
*treatment antibiotic ointment, eye patch
-Blindness
*ischemic optic neuropathy
via central vein or artery obstruction
via sustained, direct pressure on the eye/retina
*visual changes/partial or complete blindness
*risk factors include:
prone position
operative hypotension
large operative blood loss
large crystalloid use
anemia
smoker
diabetic
patients with vascular pathology or htn, male

-CAUTION in spinal surgery and cardiac surgery

could be from edema compressing the optic nerve or hypoperfusion; prevent this by doing good eye care, using lubricant, constantly checking pressure, well hydrated, normal hct

40
Q

Prone Position- Extremities

A 
Arms:
on boards by head
abducted less 90 degrees
extra padding at elbow
prevent shoulders from sagging
watch for thoracic outlet syndrome
tucked at sides

Legs:
slightly flexed
elastic compressed stockings/SCD

41
Q

Thoracic outlet syndrome

A

Arms above head can cause this due to compressing lympathics and blood flow

test for it by putting arms above the head for a couple minutes and check for numbness or tingling of fingers & check for pulses

if they have it: tuck arms at the side

42
Q

Prone: CV Changes

A

IVC and Aortic compression: HYPOTENSION
-rolls or similar devices free the abdomen and chest improving flow

Venous pooling in lower extremities: HYPOTENSION

  • leads to decreased preload, CO, and BP
  • elastic compression stockings/SCDs

Hypotension associated with the move to prone position must be anticipated, monitored, and treated as necessary
*prolonged hypotension in addition to pressure on the face/eyes may lead to blindness

43
Q

Prone: Ventilatory Changes

A
  • VQ Mismatch:
  • posterior ventilation > perfusion
  • anterior ventilation > ventilator

-Cephalad displacement of diaphgragm. lung compliance decreases. peak airway pressure increase. work of breathing increases.

  • use rolls/bolsters- frees chest excursion
  • positive pressure ventilation overcomes compression effect
44
Q

Prone: Cerebral Blood Flow

A
  • Turning head obstructs venous drainage leading to increased cerebral volume and ICP
  • Excess flexion or turning- obstruction of vertebral artery flow
45
Q

Lateral Decubitus Position

A
  • Used for thoracotomy, kidney, shoulder, and hip surgery
  • requires special positioning:
  • head support- neutral position- avoid misalignment of cervical spine, stretch brachial plexus
  • limited pressure on dependent eye and ear
  • axillary roll (chest roll or chest support)- placed caudad to and outside of lower axilla (NOT under axilla)

ARMS

  • dependent arm on padded arm board perpendicular to torso
  • non dependent arm supported over folded bedding or suspened with armrest

LEGS

  • padding between knees and flexed dependent leg (saphenous nerve injury)
  • padding on bed (common peroneal nerve injury)

Anterior/posterior support- beanbag/hip posts
Safety strap- b/w head of femur and iliac crest

46
Q

Lateral position: CV changes

A
  • minimal change
  • no change in CO unless venous return is obstructed (kidney rest against vena cava)
  • noninvasive BP cuff measurements will be different in two arms
  • higher in dependent arm and lower in nondependent arm
47
Q

Lateral position: Ventilatory changes

A

Awake and spontaneous breathing
-dependent lung is both better perfused and better ventilated, but lung volumes (FRC, VC, TV decrease)

Anesthetized but spontaneous breathing
-nondependent lung better ventilated and dependent lung is better perfused (VQ mismatch)

Anesthetized and mechanically ventilated patient
-nondependent lung is overventilated and dependent lung is overperfused (worse VQ mismatch)

48
Q

Lateral Position: cerebral blood flow

A

minimal change unless there is a extreme flexion of the head

49
Q

Sitting Position

A

“beach chair”

  • to prevent nerve injury try to get sciatic nerve and bottom in the bend
  • Used for cranial surgery, shoulder, and humeral procedures ; ex: plastic surgery
  • facilitates venous drainage
  • excellent surgical exposure/access
  • less blood loss

Head

  • fixed in pins or taped in place
  • avoid excessive cervical flexion
  • obstructs venous outflow causing hypoperfusion or venous congestion in the brain, stretch cervical nerve roots, can obstruct ETT, can place pressure on the tongue and compress lympathics of tongue (swelling)
  • want atleast 2 FB between mandible and sternum
  • avoid rigid bite block-tongue ischemia

ARMS

  • avoid pressure on frame
  • support arms- avoid traction pulling down on shoulders (brachial plexus injury)

BUTTOCKS- positioned in break of table

Flex Knees & hips- decrease stretch of sciatic nerve

Use elastic compression stockings/SCD

Feet Supported and padded

50
Q

Sitting: CV Changes

A

Pooling of blood into lower extremities decreases preload, CO and BP
Hypotension
HR and SVR increase as a compensatory measure (blunted by anesthetics)

Treatment: IVF, vasopressors, adjustments of anesthetic depth, elastic stockings and active leg compression devices

Try to measure blood pressure at the circle of willis

51
Q

Sitting: Ventilatory Change

A

Lung volumes and capacities increase
Lung compliance increases
Work of breathing easier

Mechanical ventilation and spontaneous ventilator easier in this position

52
Q

Sitting: Cerebral Blood Flow

A

Gravity
Cerebral Blood Flow decreased
intracranial pressures decreased
watch positioning which can impede arterial and venous blood flow, causing hypoperfusion or venous congestion of the brain

53
Q

Sitting Position: Venous Air Embolism

A
  • A risk ANYTIME the surgical site is above the level of the heart
  • Inability of venous sinuses to collapse
  • potentially lethal complication
  • symptoms:
  • change in heart tones (wind mill murmur) heard via doppler placed at the parasternal border (2nd-6th IC space)
  • new murmur
  • dysrhythmias
  • hypotension
  • desaturation
  • decreased EtCO2!!!!!!!!
  • nitrogen in exhaled gas
  • circulatory compromise
  • cardiac arrest

-detection of entrained air with TEE or precordial doppler ultrasound

treatment

  • flood surgical field with NS, apply wax to cut bony edges, close any open vessels
  • d/c nitrous oxide
  • place on 100 o2, peep
  • t-berg position
  • aspirate air from right atrium via a catheter

Health Assessment (4 decks)

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