Operative Positioning Flashcards
Who is responsible for making sure no nerve or soft tissue injury and treating physiological changes in OR
Anesthetist
What is primary concern
Patient safety and comfort
Documentation: Describe baseline \_\_ \_\_ \_\_ Describe \_\_ \_\_ Use of \_\_\_, \_\_, \_\_ position \_\_ done and \_\_\_
Range of motion
Infra operative position
Padding, frame, body
Checks, frequency
OR table
Weight limit
Length
136 kg or 300 lbs
80.7 inches
During transfer what is anesthesia responsible for
Head, neck, ivs, monitors
Safety strap
What it doesn’t do
What it does do
Doesn’t hold pt on table
Reminds them if they wake up to stay on table or keeps extremities on table
Most common positions Supine or \_\_ which can go to \_\_ or \_\_ \_\_ \_\_\_\_ Prone or \_\_\_ \_\_ position \_\_\_ \_\_\_ \_\_\_
Supine or dorsal decubitus: trendelenburg or reverse trendelenburg
Lithotomy
Ventral decubitis
Lateral decubitis
Sitting
Supine \_\_ \_\_ operative position Position preferred by \_\_\_\_ Access to \_\_\_, \_\_ for \_\_ and \_\_ Less \_\_\_ changes than other positions
Most common
Anesthesia
Airway, arms for ivs and monitors
Physiologic
Pillow under head in supine Allows proper \_\_\_ position Avoids \_\_\_ extension and \_\_ flexion of neck- avoids plexus stretch or vascular compromise Doughnut shaped pillow avoids \_\_\_\_ No pressure on \_\_\_
Sniffing
Dorsal, lateral
Alopecia
Eyes
Arm boards in supine
Arms abducted __ __ degrees
Hands __ with palm __ not __
Less than 90 degrees
Supination, up, pronated
Arms tucked in supine
__ __ under pt __ or __ not ___
___ padded with palm __
Draw sheet, hip or torso, mattress
Elbow, in
Supine
Feet: heels not __ __ bed, heels __, legs not __
Hanging over
Padded
Crossed
Supine lumbar support Slight \_\_\_ of hips and knees Pillow under \_\_\_ \_\_/\_\_ shouldn't be crossed \_\_ and \_\_ are highest points of spine when supine
Flexion
Knees
Legs/feet
C5 and L3
Mechanisms of peripheral nerve injury
5
Stretching Compression Kinking Ischemia Transection
Brachial plexus
Nerve travels a __ __ course through fixed points
The __ __ fascia
Runs through __, __, and __
Long superficial
Vertebral foramina
Clavicle, scapula, humerus
Brachial plexus
Positioning injury occurs with __ extension, head ___ to __, or sagging ___
Excessive ___ of arm greater than __ degrees
__ or __ __ falls off of table
Neck, turned to side, sideways
Abduction, 90
Arm or arm board
Brachial plexus injury
___ __ shoulders in __ or __ position
Extending arms overhead in __ position
Compression against __ in __ position
Depressed sagging, prone or sitting
Prone
Thorax, lateral
Brachial plexus injury
___ braces
__ __ in cardiac surgery
Deficit if injured
__ or __ arm
Lack of muscle control in __, __, __
Lack of sensation in __ or ___
Shoulder
Sternal retractors
Limp or paralyzed
Arm, hand, wrist
Arm or hand
Radial nerve injury
Due to __ __ of radial nerve on the __ aspect of the __ against: surgical __, __ screen, ___ arm board, repeat __ __
External compression
Lateral, humerus
Retractors, ether, mismatched, BP inflation
Radial nerve deficit
Loss of __ of forearm
Weakness of __
Loss of __ of hand, __ drop, __ affected
Loss of sensation in __ arm, __ forearm, and part of __
Extension
Supination
Extension, wrist, fingers
Lateral, posterior, hand
Most common post op peripheral nerve injury
Ulnar nerve
Ulnar nerve runs in groove between __ of ulna and __ __ of humerus
Olecranon, medial epi condyle
Ulnar nerve
Injury with compression of nerve between the olecranon of __ and medial epicondyle of __ (___ with arm __)
__ with severe elbow ___
Ulna, humerus
Entrapment, extension
Stretch, flexion
Ulnar nerve injury
__ over medial epicondyle with __ of hand causing stretching
Compression against ___
Misplaced __ __
Dislocation, pronation
Bed
BP cuff
Ulnar nerve injury
Inability to __ or __ 5th finger
Loss of __ strength, esp ulnar side
Loss of sensation of __ surface of hand, __ or __ fingers
Eventually leads to atrophy of __ muscle of hand: __ hand
Abduct or oppose
Grip
Palmar, 4th or 5th
Intrinsic, claw
Supine CV changes
Minimal effect on __ and __
Initially have increased __ __. Increased __, __ ___, __, and __. This activates baroreceptors which __ sympathetic outflow and increases __ impulses. Leads to decrease of __ and __ if not blunted by ___
Circulation and perfusion
Venous return. Preload, stroke volume, CO, BP
Decreases, PNS
HR and PVR, anesthetics
Supine CV changes
Have reduced __ __ due to venous pooling in lower extremities
Decreases __ and __
Increases __
Venous return
CO and BP
HR
Supine CV changes
-__ compression by masses, pregnancy, obese abdomen, or ascites __ decrease ___ __ to the __ __ and decrease __ __ even more
IVC May Venous return Right heart Cardiac output
Supine ventilatory changes
__ __ __ decreases +/- ___ ml due to cephalad displacement of the __ and compression of lung bases
Functional residual capacity, 800
Diaphragm
Supine vent changes
Lung volumes reduced by __ __
-loss of chest wall muscle tone with muscle relaxants reduces __ to inherent elastic recoil
-overcome with __ __ __
Muscle relaxants
Opposition
PPV
Supine cerebral blood flow
- __ change due to __ __
- there for ICP ___
Minimal, tight auto regulation
Unchanged
Trendelenberg
- used to treat __ by increasing __ __
- improves __ __ during abdominal and laparoscopic cases
- helps prevent __ __
- facilitates __ during CVL placement
Hypotension, venous return
Surgical exposure
Air embolism
Cannulation
Trendelenburg
Extreme caution with __ __
Place __ from root of neck over the __ __
Shoulder braces
Laterally, acromioclavicular joint
Trendelenberg CV changes
- counteracts hypotension __ __
- increases venous return up to __ __ into central circulation
- increases __ workload
Short term
1 L
Heart
Trendelenberg CV changes
- causes ___ blood flow to lower extremities
- may cause compression of __ by abdomen pushing __
- __ __ congestion
- ___ activated which leads to: peripheral __ and __, decreases __ __ and may make __ __ worse in the long run
Reduced Heart, cephalad Pulmonary vascular Baroreceptors, vasodilation, bradycardia, cardiac output Shock syndrome
Trendelenberg vent changes
-decreased __ __ and ___, increased __ and __ __ __
Lung compliance, FRC
PIP and pulmonary vascular congestion
Trendelenburg vent changes
- with spontaneous vent work of breathing is __
- VQ mismatch with __ exceeding __ in apex of lung
- what can happen to ETT
- risk of __
- what can lead to airway obstruction
Increased Perfusion, ventilation Dislodged into right bronchus Aspiration Face and airway edema
Trendelenburg CBF
How ICP affects CBF
What other pressure changes due to this position
Increased ICP decreases CBF
Intraocular pressure increases
Reverse trendelenburg
Used for surgical exposure of what, 1 specific ex
Variations may be used for 3 other surgeries
Variation of which position in terms of physiologic changes
Upper abdomen
Lap cholecystectomy
Shoulder, neck, intracranial surgery
Sitting position
Reverse trendelenburg
Caution with what
Excessive __ __ of feet can cause __ __ nerve injury which results in what
Plantar flexion
Anterior tibial
Foot drop
Reverse trendelenburg cv changes
- ___ venous return leads to __ preload, __ co (__-__%), and __ BP
- compensatory __ SNS tone, __, and __ by +/- __% which may be blunted by __
Decreased, decreased, decreased, 20-40, decreased
Increased, SVR, HR, 30, anesthetics
Reverse trendelenburg vent changes
- abdomen __ __ impede diaphragmatic excursion, FRC __
- Ventilation is __
Does not
Increases
Easier
Reverse trendelenburg CBF
- CBF __ proportional to the degree of the __ __ (can be up to __%)
- __ decreases
Decreases, head tilt up, 20
ICP
Lithotomy position
- hips flexed __-__ degrees
- legs abducted __-__ degrees from midline
- Lower legs __ to torso
- watch __, __, and __ __ nerves
80-100
30-45
Parallel, femoral, sciatic, lower leg
Lithotomy candy cane stirrups
- __ __ flexion of the knees and or hips
- common injury to __ __ nerve most, then __ and __
More acute
Common peroneal, sciatic, femoral
Lithotomy knee crutch
Watch __ nerve 1st
Then also __ nerve and __ __ nerve
Popliteal
Tibial and common peroneal
Lithotomy
Used for __, __, and __ procedures
Both legs positioned together to prevent __ of __ spine and hip flexion beyond __ degrees
Improper positioning can lead to nerve injuries in 6
Gyn, gu, rectal
Torsion, lumbar, 110
Femoral, sciatic, obturator, lateral femoral cutaneous, saphenous, common peroneal
Most common damaged nerve of lower extremity
Common peroneal nerve
Common peroneal nerve injury
Branch of __
Injury from __ of lateral aspect of knee in __ or __ position
Symptoms: __ __ and inability to __ foot, loss of ability to __ __ toes
Sciatic
Compression, stirrup, lateral
Foot drop, evert, dorsally extend
Sciatic nerve injury
From excessive __ __ of __
Pressure in __ notch from __
Weakness or paralysis of muscles __ knee, __ foot, and __ half of calf.foot __
External rotation, hip
Sciatic, stretching
Below, numbness, lateral
Foot
Femoral nerve injury
From __ at __ brim by __
Or excessive __ of thigh or __ of thighs and __ __ of hips
Compression, pelvic, retractor
Angulation, abduction, external rotation
Femoral nerve injury
Results in loss of __ of hip and loss of __ of knee
Decreased sensation over __ aspect of __
Flexion, extension
Superior, thigh
Saphenous nerve injury
Occurs when __ aspect of lower leg is __ against support bar
Results in __ in __ and __ side of calf
Medial, compressed
Parenthesis, medial, antermedial
Lower extremity compartment syndrome
- occurs when __ to an extremity is inadequate, resulting in __, __, and extensive __ from increased __ pressure
- occurs with long surgical cases >__-__ hours
- occurs with __ and __ __ positions
Perfusion, ischemia, edema, rhabdomyolysis
Tissue
2-3
Lithotomy and lateral decubitus
Lithotomy CV changes
-__ venous return, __ preload to heart with __ increase in __ and increase in __
Increased, increased, transient, CO, BP
Lithotomy CV changes
- perfusion to __ __ reduced
- perfusion pressure changes __ mmHg for each __ cm that a given point varies in vertical height above or below __
Lower extremities
2, 2.5, heart
Lithotomy vent changes
Depending on degree of __ __ abdominal contents may push on diaphragm and impede __ with a decrease of lung __ and decrease __ and __ __
Hip flexion, excursion
Compliance, TV, vital capacity
___ risk increases in lithotomy
Aspiration
Lithotomy cerebral changes
__ __ in cerebral venous blood flow and increase in __ __ with legs elevated
Transient increase, ICP
__ head tongs
Watch for bolt __
Want natural __ alignment
__, __, and __ free from pressure or metal parts touching
Mayfield
Slippage
Neck
Eyes, nose, chin
Prone position
Do what first
Check __ and __ working
__ and __ supported to allow for free __ __ movement and increased __ __
Check lung sounds
IV, a line
Chest and hips, abdomen diaphragmatic
Neck alignment
Head prone position
Head can be turned to side if adequate ___
Caution of obstruction of __ __ drainage and __ __ flow
__, __, and __ free of pressure
Mobility
Jugular venous, vertebral artery
Eyes, nose, ears
Prone position eye injury
Direct __, __ eye, __
Treatment is __ __ and eye patch
Trauma, dry, swelling
Antibiotic ointment
Prone position
Blindness caused by __ __ __ via __ __ or __ obstruction
By sustained direct pressure on eye/__
Leads to visual __, __ or __ blindness
Ischemic optic neuropathy, central vein or artery
Retina
Changes, partial, complete
Risk factors for ischemic optic neuropathy: __ position, operative __, large operative __ __, large __ use
Pt specific risk factors: 6
Inc risk in __ and __ surgery
Prone, hypotension, blood loss, crystalloid
Anemia, smoker, diabetes, male, vascular pathology
Spinal and cardiac
Prone position extremities
Where arms are, abducted how many degrees, extra padding where, prevent shoulders from what
On boards by head, less than 90, at elbow, sagging
Prone position extremities
Watch for __ __ syndrome. If present do what to arms
Legs: __ __ and wear what
Thoracic outlet, arms tucked at sides
Slightly flexed, SCDs or TED hose
Prone position CV changes
__ and __ compression lead to __
__ __ in lower legs leads to ___
In effect these decrease 3
IVC and aortic, hypotension
Venous pooling, hypotension
Preload, CO, BP
Prone position vent changes
- posterior ventilation __ perfusion
- anterior perfusion __ ventilation
- lung compliance __. __ __ pressures increase. __ of __ increases
- use of what frees chest excursion, and __ __ __ overcomes compression
- greater than
- greater than
- decreases. Peak airway. Work of breathing.
- Rolls or bolsters, positive pressure ventilation
Prone position and CBF
-turning head obstructs __ __ leading to __ __ volume and __
Excess flexion or turning obstructs __ __ flow
__ __ injury from stretch
Venous drainage, increased cerebral, ICP
Vertebral artery
Spinal cord
Lateral decubitis position
Used for 4 surgeries
__ support to prevent brachial plexus injury
Limit pressure on dependent __ and __
__ roll placed __ to and __ of __ axillary
Shoulder, hip, kidney, thoracotomy
Head
Eye and ear
Axillary, caudad, outside of lower
Lateral position
Arms: dependent vs non dependent
Legs: padding between legs and flexed __ leg to prevent which nerve injury. Padding on bed to prevent which nerve injury
Dependent arm on padded arm board perpendicular to torso
Non dependent arm supported over folded bedding or suspended w arm rest
Dependent, saphenous nerve. Common peroneal.
Lateral position
__/__ support __ __ or __ posts
Safety strap between __ of __ and __ __
Anterior posterior
Bean bag or hip
Head of femur and iliac crest
Lateral position cv changes
___ change
__ change in CO unless venous return obstructed by __ resting on vena cava
NIBP __ in __ arm
Minimal
No, kidney
Higher in dependent
Lateral position vent changes
Awake and spontaneous breathing: lower lung is __ perfused and __ ventilated, but __, __, and __ increase/decrease
Better, better, FRC/Vc/tv decrease
Lateral position vent changes
Anesthetized but spontaneous breathing
-__ lung better ventilated and __ long is better perfumed
Anesthetized and ventilated
-non dependent lung is __ and dependent lung is __ (__ VQ mismatch)
Non dependent, dependent
Over ventilated, over perfused, worse
Lateral position CBF
__ change unless there is extreme __ of head
Minimal, flexion
Sitting position
Used for 3 types of surgery
Facilitates __ drainage
Cranial, shoulder, numeral
Venous
Sitting position
Head fixed in __ or __
Avoid excessive __ __ which obstructs venous outflow causing __ -or __ __ of brain, stretches __ nerve roots, can obstruct __, and can cause pressure on __
Pins or tape
Flexion, hypo perfusion, venous congestion, cervical
ETT, tongue
Sitting position
Want at least __ __ between mandible and sternum
Avoid rigid __ __ which can lead to __ ischemia
2 finger breadths
Bite block, tongue
Sitting position
Arms: prevent pressure on __ and __ them to prevent pulling on shoulder
Buttocks: positioned in __ of table
__ knees and hips to decrease stretch of __ nerve
Frame, support
Crease
Flex, sciatic
Sitting position CV changes
-pooling of blood decreases __, __, and __
____**
-__ and __ increase to compensate but blunted by anesthetics
-treatment 5
Co, BP, preload
Hypotension
HR and SVR
Ivf, pressers, adjust anesthetic depth, stockings, active leg compression
Sitting position vent changes
Lung __ and __ increase
______ easier
Volume and capacity
WOB
Sitting CBF
CBF __
ICP __
Positioning can impede flow and cause __ or __ __ of brain
Decreased
Decreased
Hypo perfusion or congestion
Sitting venous air embolism
- risk __ __ during procedure when the __ __ is above the level of heart
- inability of __ sinuses to __
Venous air embolism, surgical site
Venous, collapse
Sitting air embolism
Signs: change in __ tones (__ __ murmur) heard via __ placed at ___ border which is __-__ IC space, __ murmur, __, __, __, decreased __, ___ in exhaled gas, circulatory compromise, __ __
Heart, wind mill, Doppler
Parasternal, 2-6th, new, dysrhythmias, hypotension, desat, etco2
Nitrogen, cardiac arrest
Sitting air embolism detected with __ or __ __ ultrasound
TEE or precordial Doppler
Venous air embolism treatment \_\_\_ surgical field with \_\_ Apply \_\_ to cut bony edges Discontinue \_\_ \_\_ Close any open \_\_ Place on \_\_ o2, \_\_\_ \_\_\_ position Aspirate air from \_\_ \_\_ via a \_\_
Flood, NS, Wax Nitrous oxide Vessels 100%, peep Trendelenburg Right atrium, central catheter
