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Intro to Anesthesia: Part A > Patient Positioning > Flashcards

Patient Positioning Flashcards

1
Q

Supine Position:

  1. Indications
  2. Risks
  3. Cardiovascular Changes
  4. Respiratory Changes
  5. Cranial Changes
A
  1. Provides easy access to airway, IVs, less physiological changes
  2. Pillow under head; avoid felxion or extension of neck due to brachial plexus stretch (35 degrees in sniffing position); arms abducted <90 degrees, SUPINATED; slight leg flexion (watch DVTs if pillow under knees)
  3. Minimal overall; Will have initial increased VR, then increases parasympathetic compensation ( 🔽 HR, PVR) Eventual reduced VR due to pooling; careful for IVC compression in pregnant, ascites, obese
  4. FRC decreases 800ml due to diaphragm displacement; decreases lung volumes, diaphragmatic excursion; use PIP to help overcome loss of chest wall tone from NMB
  5. Minimal; auto regulation tight
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2
Q

Trendelenburg Position:

  1. Indications
  2. Risks
  3. Cardiovascular Changes
  4. Respiratory Changes
  5. Cranial Changes
A
  1. Can prevent air embolism; short term hypotension tx;
    upward displacement of abd cavity contents; CVC
    placement
  2. Brachial plexus injury; shoulder brace lateral over
    acromioclavicular joint; reduced LE perfusion;
    face/airway
    edema; ASPIRATION RISK
  3. Increases VR up to 1L; baroreceptors activates, may
    make shock worse in long term; only use short term for
    shock; increases heart workload
  4. Decreases compliance, PIP, FRC; VQ mismatch at apex
    (perfusion>ventilation); risk of ASPIRATION; pulmonary
    vasculature congestion; ETT may shift to RMB
  5. Increases ICP; intraocular pressure
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3
Q

Reverse Trendelenburg:

  1. Indications
  2. Risks
  3. Cardiovascular Changes
  4. Respiratory Changes
  5. Cranial Changes
A
  1. Enhances view of upper abd contents (laparoscopy,
    cholesystectomy)
  2. Watch for foot drop and excessive plantar flexion
    (damages ANTERIOR TIBIAL NERVE)
  3. Reduces VR; preload, CO, BP; compensatory mech
    blunted by anesthetics; increased work on heart
  4. Ventilation easier; increases FRC and diaphragmatic
    excursion
  5. Blood flow decrease, ICP down 20%
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4
Q

Lithotomy Position:

  1. Indications
  2. Risks
  3. Cardiovascular Changes
  4. Respiratory Changes
  5. Cranial Changes
A
  1. GYN, GU, rectal procedures; abduct legs 30-45 degrees, flex 80-100; lower legs parallel to torso, place in stirrups simultaneously to avoid torsion
  2. Avoid flexion beyond 110; common perineal nerve most commonly damaged lower extremity nerve; LE compartment syndrome; move hips/legs simultaneously
  3. Leg elevation increases VR; perfusion change 2 mmHg per every 2.5cm above heart; transient VR/CO increase; when take legs down, hypotension (CHECK BP)
  4. Depending on amount of flexion, decreases diaphragm excursion; ⬇️ compliance, TV, VC; increase aspiration risk
  5. Transient increase in blood flow
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5
Q

Prone Position:

  1. Indications
  2. Risks
  3. Cardiovascular Changes
  4. Respiratory Changes
  5. Cranial Changes
A
  1. Usually cranial surgery; Have Wilson frame (free-hanging
    abd); prepare pt on stretcher before transfer; recheck
    on line placement
  2. Check breath sounds first; Neck alignment, pressure on
    eyes, nose; corneal abrasion/pressure, blindness;
    line/ET displacement; always tape eyes closed; ischemic
    optic neuropathy/intaoptical pressure
  3. Thoracic outlet syndrome; IVC and aortic compression
    hypotension; ⬇️ CO and BP, especially on initial move,
    pooling in LE causes hypotension
  4. VQ mismatch; post vent>perf; ant perf>vent; ⬆️ PIP,
    work of breathing, decrease compliance; have free
    chest excursion and use PPV to overcome effects
  5. Obstruct venous outflow if head turned; increases ICP;
    normal ICP otherwise
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6
Q

Nerve Damage:

  1. Most common overall
  2. Second most common
  3. Most common lower extremity
A
  1. Ulnar
  2. Brachial Plexus
  3. Common Peroneal Nerve
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7
Q

Common Brachial Plexus Injury Mechanisms (5 items)

A
  1. Neck extension
  2. Arm abduction >90
  3. Arm falling of table
  4. Depressed shoulders (prone/reverse Tren)
  5. Compression against thorax (lateral)
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8
Q

Radial Nerve:

  1. Anatomy
  2. Injury Mechanisms
  3. Symptoms
A
  1. Innervates lateral aspect of UE
  2. Compression usually against humerus; Surgical retractors, ether screen, BP inflation
  3. Loss of extension of forearm, wrist drop (loss of hand extension), loss of sensation in lateral arm/posterior forearm
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9
Q

Ulnar Nerve Compression:

  1. Anatomy
  2. Injury Mechanisms
  3. Symptoms
A
  1. Runs in grove between olecranon and medial epicondyle of humerus
  2. Most commonly injured nerve; compression between olecranon and medial epicondyle; severe stretch (arm falling off table); compression against bed; misplaced BP inflation
  3. Loss of grip, inability to abduct or feel on palmar side of 4/5th finger; atrophy (claw hand)
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10
Q

Common Peroneal Nerve

  1. Anatomy
  2. Injury Mechanisms
  3. Symptoms
A
  1. Branch of sciatic, innervates outer calf; most common lower extremity injury
  2. Compression of lateral knee (lithotomy or lateral)
  3. Foot drop; inability to evert foot or dorsiflex toes
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11
Q

Popliteal Nerve Injury

  1. Anatomy
  2. Injury Mechanisms
A
  1. Branch of sciatic that innervates back of knee

2. Compression behind knee (lithotomy); especially in Knee-Crutch style stirrups

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12
Q

Sciatic Nerve

  1. Anatomy
  2. Injury Mechanisms
  3. Symptoms
A
  1. Runs from buttock through lower limb, comes off L1 and S1
  2. Excessive rotation of hips; pressure on sciatic notch (posterior buttocks)
  3. Paralysis or weakness of muscles below knee; foot
    drop; lateral calf and foot numbness
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13
Q

Femoral Nerve Injury

  1. Anatomy
  2. Injury Mechanisms
  3. Symptoms
A
  1. Runs length of internal thigh; branches from L2-L4
  2. Compression at pelvic brim; excessive angulation/abduction (>45) of thighs and external rotation (lithotomy); flexion > 110 degrees
  3. Loss of flexion at hip; loss of extension of knee; decreased thigh sensation
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14
Q

Saphenous Nerve Injury

  1. Anatomy
  2. Injury Mechanisms
  3. Symptoms
A
  1. Medial aspect of the thigh and calf; branch of
    femoral nerve
  2. Compression of medial aspect of leg against support bar (lithotomy)
  3. Parathesia medial and antemedial part of calf
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15
Q

Lower Compartment Syndrome

  1. Occurrence
  2. Symptoms
  3. Treatment
A
  1. Typically long lithotomy/lateral cases (>2-3 hours)
  2. Ischemia, edema, rahbdomyolysis
  3. Fasciotomy
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16
Q

Thoracic Outlet Syndrome

  1. Definition
  2. Test
A
  1. Poor circulation in vessels between upper extremities and trunk
  2. Extend pt hands over head for 1 minute; check perfusion
17
Q

Lateral Position:

  1. Indications
  2. Risks
  3. Cardiovascular Changes
  4. Respiratory Changes
  5. Cranial Changes
A
  1. Kidney, lung shoulder, hip surgery
  2. Neutral head support, pressure on dependent eye/ear
    Axillary Roll placed just below axilla; knee padding to
    prevent saphenous injury, on bed to prevent common
    peroneal injury
  3. Minimal; no change in CO unless VR obstructed; BP will
    be different in arms
  4. VQ mismatch (see other slide)
  5. Minimal unless extreme flexion
18
Q

Lateral Position VQ Mismatch:

  1. Awake/Spontaneous Breathing
  2. Anesthetized/ Spontaneous Breathing
  3. Anesthetized/ Mechanical Ventilation
A
  1. Dependent lung: better perfused and ventilated (lower lung volumes)
  2. Dependent lung: better perfused, Nondependent lung: better ventilated (VQ Mismatch)
  3. Dependent lung: overperfused; Nondependent lung: overventilated (worse VQ mismatch)
19
Q

Sitting Position:

  1. Indications
  2. Risks
  3. Cardiovascular Changes
  4. Respiratory Changes
  5. Cranial Changes
A
  1. Cranial, shoulder, humeral procedures
  2. Avoid excessive neck flexion (2 FB between mandible and sternum); flexion can cause venous congestion, cervical nerve stretch, tongue swelling; ET tube kink; flex knees; support arms so no downward pulling to preven brachial plexus injury; flex knees to prevent sciatic injury
  3. Pooling of blood in LE; HYPOTENSION; HR and SVR usually blunted by anesthetics; check BP often
  4. Lung volumes and capacities increased; compliance increases; work of breathing decreases
  5. ICP and cerebral blood flow decreased
20
Q

Venous Air Embolism

  1. Risk
  2. Detection
A
  1. Anytime surgical field above level of heart
  2. TEE (higher sensitivity) or prerecordial Doppler
    (parasternal border, 2-6 ICS)
21
Q

Venous Air Embolism Treatment (5 items)

A
  1. Flood surgical field with NS, apply wax to bones, close
    any open vessels
  2. D/C N20
  3. Place on 100% and PEEP
  4. Durant Maneuver: place pt in L Lat decubitus and
    T-berg
  5. Aspirate air via CVC
22
Q

5 Nerve Injury Mechanisms

A
  1. Compression
  2. Stretching
  3. Trans-section
  4. Ischemia
  5. Knotting/Kinking
23
Q

Brachial Plexus:

  1. Anatomy
  2. Injury Mechanisms
  3. Symptoms
A
  1. C5-T1; runs through vertebral foramina fasciaa, under clavicle, over first rib, to the humerus (contains ulnar, median, and radial nerve)
  2. Sagging at shoulders (sitting), neck flexion/extension, lateral compression against thorax (lateral), abducting arms >90 (supine/prone)
  3. Second most common injury: loss of motor control, paralysis/parathesia of UE
24
Q

Position Documentation (4 items)

A
  1. Baseline ROM
  2. Inta-op position
  3. Use of padding, frames
  4. Checks done and frequency
25
Q

OR Table:

  1. Weight Limit
  2. Height Limit
  3. Patient Position
A
  1. 136kg (300 lbs)
  2. 80.7 inches (6’7”)
  3. Body centered under central column
26
Q

Ischemic Optic Neuropathy Risk Factors (7 items)

A
  1. Prone position
  2. Operaitve hypotension
  3. Operative blood loss
  4. Large crystaloid use
  5. Anemia
  6. PVD (diabetes/smoking)
  7. HTN
27
Q

Venous Air Embolism Sypmtoms (6 items)

A 
1. Mill wheel murmur (constant, machine like murmur @
    parasternal border 2-6 IC space)
2. Dysrhythmias, 
3. decreased ETCO2, 
4. Hypotension, 
5. Desaturation, 
6. Nitrogen in exhaled gas

Intro to Anesthesia: Part A (6 decks)

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