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Intro Nurse Anesthesia > Patient Positioning > Flashcards

Patient Positioning Flashcards

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1
Q

Mechanism of injury for PNI

A

Stretching, compression, ischemia

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2
Q

Most common PNI

A

Brachial plexus

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3
Q

When do PNI typically present?

A

24-48 hr later

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4
Q

Advantages to supine position

A

Access to airway
Access to arms for IV/monitors
Hemodynamic reserve is maintained

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5
Q

How are arms positioned on arm boards in supine?

A 
Secured to OR table.
Abducted <90 degrees
Padded
Safety straps
Hands supinated
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6
Q

How are arms tucked in supine position?

A

Draw sheet placed under pt hip or torso.
Elbows padded
Palm in.
Make sure IV is dripping before case starts

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7
Q

What 2 mechanisms can cause brachial plexus injury?

A

Avoid abduction >90 degrees

Avoid direct compression at neck

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8
Q

How can we prevent an ulnar PNI in supine position?

A

Hands and forearms supinated, or, neutral position w palms towards body

Proper padding at elbow

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9
Q

Potential complications of supine position

A

Pressure alopecia
Backache
PNI
Aortacabal syndrome (compression of IVC preventing blood flow returning to heart)

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10
Q

Trendelenburg Reasons needed

A
  • Improves exposure during abdominal and lap sx.
  • Used during central line placement to prevent air embolism
  • Can help increase venous return during hypotension
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11
Q

CV and respiratory consequences of trendelenburg?

A

Increase venous return
Decrease FRC
Decrease pulmonary compliance

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12
Q

How does trendelenburg impact cerebral blood flow?

A

INCREASE intracranial vascular congestion with gravity.
Causes INCREASED ICP
DECREASED CBF

Also see intraocular pressure increase

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13
Q

How to prevent cephalad slide?

A 
Anti-skid pads
Flexion of knees
Shoulder braces (try to NEVER use)
Beanbag cradling
Cross-torso straps
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14
Q

If using shoulder braces, where should they be positioned to minimize injury

A

Laterally AWAY from root of neck over the arcomioclavicular joint

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15
Q

Anesthestic concerns with using trendelenburg position?

A

Swelling of face, tongue, larynx

Stomach is above glottis

“Migration” of ETT

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16
Q

Purpose of reverse trendelenburg

A

Facilitates upper and sx (shifts abdominal contents caudad)

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17
Q

Anesthetic concerns for reverse trendelenburg

A

Caudal slipping
Decreased venous return
Cerebral perfusion pressure decrease

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18
Q

Lithotomy position hips flexed at? Legs abducted at?

A
  • Hips flexed 80-100 degrees
  • Legs abducted 30-45 deg from midline
  • Knees flexed until lower legs parallel with torso.
  • legs must be raised at SAME time
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19
Q

Which PNI can be caused by improper positioning of lithotomy position?

A 
Femoral
Sciatic
Obturator
Lateral femoral cutraneous
Sphenoid
Common peroneal
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20
Q

Concerns with use of candy can stirrups

A

More acute flexion of knees/hips

Injury to common peroneal nerve, femoral, sciatic

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21
Q

Concern of knee-crutch style lithotomy position

A 
Popliteal nerve (tibial nerve and common peroneal nerve)
Sciatic
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22
Q

What to watch for in lithotomy position?

A

Fingers! Major risk for crush injury when table is lowered if arms are tucked in

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23
Q

Cv consequences with lithotomy

A

Legs elevated increases venous return

Transient increase in co

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24
Q

Respiratory consequences for lithotomy

A

Cephalad displacement of abd contents
Decreased lung compliance
Decreased TV
Increased peak pressure

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25
Q

Limit for legs in air for lithotomy and why?

A

Legs need to be lowered if sx extends >2-3 hr.

Concerned for compartment syndrome

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26
Q

Decrease in arterial pressure for each cm above RA?

A

0.78 mmHg

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27
Q

At what pressure would a decompressive fasciotomy be performed?

A

30 mmHg

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28
Q

At what point is there irreversible muscle damage from compartment syndrome?

A

50 mm Hg

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29
Q

Risk factors for compartment syndrome in lithotomy

A 
High BMI, 
peripheral vascular dx
Hypotension
Reduced cardiac output
Smokers
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30
Q

Lateral decubitus position is used during…

A

Thorax sx,
Retroperitoneal sx
Hip

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31
Q

What do we need to pay attention to with lateral decubitus position?

A

Head neutral, in line with spine with pillows
Arms abducted <90
Dependent ear is flat
Dependent eye is free from material

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32
Q

What do we use in lateral decubitus position to decrease risk of auxiliary PNI?

A

Axillary roll.

Between chest wall and bed, just caudal to dependent axilla.

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33
Q

What do we need to be checking in dependent arm in lateral decubitus?

A

Pulse in dependent arm.
Know that the NIBP will be higher in dependent arm.
Padding all bony prominences

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34
Q

How are the legs placed in lateral decubitus

A

Lower leg (dependent leg) flexed with pillows between legs.

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35
Q

Pulmonary consequences of lateral decubitus

A

In mechanically ventilated, paralyzed pt- dependent lung is compressed by weight of mediastinum and cephalad pressure of abd contents.

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36
Q

Unanesthetized patient ventilation/perfusion in non dependent vs dependent

A

Non dependent lung had decreased ventilation and perfusion.

Dependent lung has increased ventilation and perfusion.

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37
Q

Anesthetize patient v/q in non dependent and dependent lung?

A

Non dependent lung has increased ventilation but decreased perfusion

Dependent lung has decreased ventilation, but increased perfusion

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38
Q

Ventilation/perfusion in awake and spontaneous breathing patient

A

Dependent (lower) lung is both better perfused and better ventilated.

LUng volumes (FRC, VC, TV decreased)

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39
Q

V/Q mismatch in anesthetize but spontaneous breathing

A

Non dependent lung between ventilated and dependent lung better perfused

40
Q

V/Q mismatch in anesthetized, mechanically ventilated pt

A

Nondependent lung OVERventilated and dependent lung OVERperfused (wise v/q mismatch)

41
Q

Prone position alternative name

A

Ventral decubitus

42
Q

Anesthetic concerns with positioning for prone position

A

Thoracic outlet syndrome
PNI- posterior fossa, post spine, perirectum, lower extremities

INTUBATE IN STRETCHER!

Eye care!
Secure ETT well

You are responsible for head.

43
Q

What do we do to legs in prone position?

A

Flex and pad legs

44
Q

What do we do with face in prone position?

A

Can be neutral or turned to side. Do not turn head if any cervical issues, CVA hx, carotid dx etc

45
Q

Positioning of arms in prone position?

A

Superman or tucked at sides. Arms remain <90

46
Q

What do we assess immediately after turning to prone position?

A

Breath sounds!

47
Q

Concerns for mayfield head tongs/pins

A

Watch for bolt slippage
Need neutral neck alignment
Eyes, nose chin free of pressure

48
Q

Huge concern for prone position?

A

Vision loss, ischemic optic neuropathy

49
Q

What can increase risk for ischemic optic neuropathy

A 
Intraoperative hypotension
Anemia
Increased crystalloid use
Large blood loss
Long duration of sx
Head down leading to increased IOP
50
Q

What do we need to do to abominable in prone position?

A

Elevate abdomen to decrease compressure.

Increased abdominal pressure impedes venous return

Increased abdominal pressure can cause “back bleeding” from increased abdominal pressure pushing blood through epidural arteries.

51
Q

What will abdominal pressure in prone position cause in regards to respiratory status?

A

Decreased FRC, decreased pulmonary compliance, increased peak airway pressure

Place rolls or bolsters clavicle to iliac crest.

52
Q

Cardiovascular changes in prone position

A

IVC and aortic compression can cause hypotension
-venous pooling in lower extremities and cause hypotension
- hypotension can occur with move to prone position.
(Prolonged hypotension in addition to pressure on face/eyes may lead to blindness)

53
Q

Prone position impact on cerebral blood flow?

A

Turning head obstructs venous drainage, may lead to increase ICP and increase cerebral volume

Excessive flexion or turning, obstructed vertebral artery flow

May cause spinal cord injury from stretch

54
Q

Where do we place breast in regards to Wilson frame

A

Medial

55
Q

Concerning populations for prone position

A

Morbidly obese
Respiratory compromise
Repositioning difficulty

56
Q

Sitting position advantages

A

Excellent surgical field for post cervical spine and post fossa.

Dec blood in operative field
Reduced perioperative blood loss

57
Q

Surgical disadvantages to sitting position

A

Venous and paradoxical air embolism

58
Q

Anesthesia advantages to sitting position

A

Superior access to airway
Reduced facial swelling
Improved ventilation

59
Q

Anesthetic concerns for sitting position

A

Head may be pinned/ taped
Arms need to be supported
Knees slightly flexed to reduce stretching on sciatic nerve
Feet supported and padded

60
Q

Hemodynamic effects with sitting position?

A

Drastic effects
Pooling of blood causes hypotension.
- use IVF, Vasopressors, adjustment of anesthetic depth, leg compression devices to promote V.R.

61
Q

What happens when head/neck flexed in sitting position

A

Impendance of blood flow
Causes hypoperfusion/venous congestion of brain

Can block ETT
Create pressure on tongue
Medcervical tetraplegia (makes someone quad by pulling/stretching of cervical spine)

Anesthesia ROB is 2 FB d/t mandible and sternum

62
Q

Beach chair position advantages

A

Superior access to shoulder compared to lat dec position.

Better mobility/manipulation of joint

63
Q

Anesthetic concerns for beach chair position

A

Significant Neuro and CV alterations

Decreased venous return
Reduced CPP
Reduced preload, CO, BP
Hypotension (deliberate or permissive)
Failure to compensate for height of head!
64
Q

Ventilator changes with sitting position?

A

Lung volume and capacities increase
Compliance increase
Work of breathing easier

Mechanical and spontaneous ventilation easier

65
Q

Huge risk in sitting position?

A

Elevation of sx field above heart and open rural sinuses might cause VAE

66
Q

Signs of venous air embolism

A

Change in hear tones (wind mill murmur)

  • can be heard via Doppler at parasternal border,
  • dysrhythmia
  • hypotension
  • desaturation
  • decreased ETCO2
  • nitrogen in exhaled gas
  • circulatory compromise and cardiac arrest
67
Q

Treatment of VAE

A 
Flood sx 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 RA via a catheter.
68
Q

Anesthetic considerations in sitting position

A

Monitor BP in reference to level of brain

  • Avoid and rapidly treat hypotension or bradycardia
  • Careful position of head to prevent occlusion of cerebral vessels,
  • monitor CPP if available
69
Q

Brachial plexus injury can be caused by:

A

Positioning injury

  • neck extension, head turned to side/sagging sideways
  • excessive abduction of arm >90 deg
  • arm/arm board falls off table
  • depressed sagging shoulders in prone/sitting position
  • extended arms overheard in prone
  • compression plexus against thorax
  • shoulder braces
  • sternum retractors in cardiac sx
70
Q

Deficit noted in brachial plexus injury

A

Limp/paralyzed arm
Lack of muscle control in arm/hand/wrist
Lack of sensation in arm/hand

71
Q

Ulnar nerve deficits

A

Inability to abduct or oppose 5th finger
Loss of grip strength- esp ulnar side
Loss of sensation palmar surface of hand 4th,5th fingers.
Eventually leads to claw hand

72
Q

Radial nerve injury cause

A

Due to external compression of radial nerve on lateral aspect of humerus against:

  • sx retractors
  • ether screen
  • mismatched arm board
  • repeated BP inflation
73
Q

Deficit of radial nerve if injured:

A

Loss of extension of forearm
Weakness of supination
Loss of extension of hand, wrist drop and fingers
Loss of sensation in lateral arm, posterior forearm, part of hand

74
Q

Where does ulnar nerve run?

A

Between olecranon of ulna and medial epicondyle of humerus

75
Q

What causes ulnar nerve injury?

A

Compression of nerve b/w olecranon of ulna and medial epicondyle of humerus (entrapment with arm extension)

Stretch with severe elbow flexion

Dislocation over medial epicondyle with pronation hand causing stretching

Compression against bed

Misplaced BP cuff

76
Q

Common peroneal nerve injury cause

A

Compression of lateral aspect of knee against stirrup or lateral position

77
Q

Common peroneal nerve injury symptoms

A

Foot drop
Inability to evert foot
Loss of dorsal extension of toes

78
Q

Sciatic nerve injury cause

A

Excessive external rotation in hips

Hyperextension of knee

Pressure in sciatic notch from stretching

79
Q

Sciatic nerve injury symptoms

A

Weakness/paralysis of muscles below knee

Numbness of foot and lateral half of calf

Foot drop

80
Q

Femoral nerve injury causes

A

Injured with compression at pelvic brim by retractor or excessive angular ion of thigh and external rotation of hips

81
Q

Femoral nerve symptoms

A

Loss of flexion hip and loss of extension of knee

Decreased sensation over superior aspect thighs

82
Q

Saphenous nerve injury cause

A

Occurs when medial aspect of lower leg is compressed against support bar

83
Q

Saphenous nerve injury symptoms

A

Parenthesis medial and antermedial side of calf

84
Q

Lower extremity compartment syndrome

A
  • Occurs when perfusion to extremity is inadequate, results in 1)ischemia
    2) edema
    3) extensive rhabdomyolysis

Occurs with long sx procedures >2-3 hrs

Occurs with lithotomy and lateral decubitus position

Treatment fasciotomy

85
Q

Radial nerve location, etiology of nerve damage and presentation.

A

Passes along spiral groove at lateral aspect of humerus (3FB above lateral epicondyle)

Etiology:

  • External compression IV pole
  • Excessive cycling of NIBP cuff
  • UE tourniquet
  • Sheets too tight if arms tucked

Presentation:
Inability to extend the hand at the wrist.

86
Q

Median nerve

A

Type of injury fairly uncommon

Etiology:
IV placed in AC space
Carpal tunnel syndrome
Elbow hyperextension
Forced elbow extension during positioning after NDNB administered

Presentation:
-Reduced sensation over palmar
surface of thumb, index finger, middle finger, lateral aspect of ring finger
-Inability to oppose thumb

87
Q

Ulnar nerve location, boundaries, mechanism for injury, risk factors, presentation

A

Ulnar n emerges from cubical tunnel between numeral head and ulnar heads of flexor carpi ulnaris

Boundaries

1) medial epicondyle of humerus
2) olecranon process of elbow
3) cubical tunnel retinaculum

Mechanism

1) external compression
2) elbow flexion

Risk factors

1) male
2) preexisting ulnar neuropathy
3) extremes of body habitus
4) prolonged bed rest

Presentation

1) impaired sensation of 4th and 5th digit
2) inability to abduct or oppose 5th digits

88
Q

Brachial plexus stretch injury

A

Stretch injury due to fixed anatomical locations (cervical vertebrae and axillary fascia)

Asa general rule, risk of stretch is highest when arms abducted >90 degree and head rotated to one side

89
Q

Brachial compression injury

A

Occurs when brachial plexus compressed as it passes b/w clavicle and 1st rib or by an external force

Sternotomy retractors may compress the brachial plexus under the first rib

90
Q

Brachial plexus injury presentation

A

Following non cardiac sx, motor deficit in upper and middle nerve roots may be experienced (median and radial nerve)

Following cardiac sx- deficit presents in lower nerve roots (ulnar nervE) and is sensory related

91
Q

Obturator nerve injury etiology, presentation, prevention

A

Excessive flexion of thighs towards groin
Excessive traction during lower abd surgery
Forceps delivery

Presentation
Inability to ADDUCT the leg
Reduced sensation over medial aspect of thighs

Prevention
Minimize hip flexion

92
Q

Femoral nerve etiology, presentation

A

Etiology
Excessive traction during lower abd sx

Presents
Impaired knee extension and hip flexion
Reduced sensation over anterior thigh and anterolateral aspect of leg

93
Q

Saphenous etiology, prevention, presentation

A

Etiology- medial aspect of leg leans against supporting cradle of lithotomy position

Prevention
Place padding b/w leg and stirrups

Presentation
Reduced sensation over anteromedial aspect of leg

94
Q

Common peroneal etiology, presentation, prevention

A

Branch of sciatic

Etiology
Highly susceptible to injury when pt placed in stirrups
Nerve wraps around fibulae head and compromised when lateral aspect of leg makes contact with stirrup bar

Presentation
Foot drop
Inability to ever foot
Inability to extend toes dorsal

Prevention
Place padding b/w leg and stirrup
Place padding under fibulae head
Knees flexed with min rotation

95
Q

Sciatic nerve etiology, prevention, presentation

A

Etiology
External rotation of leg
External rotation of knee

Prevention
Appropriate padding under buttocks
Avoid extreme rotation of hip
Flex table at knees

Presentation
Foot drop

Intro Nurse Anesthesia (5 decks)

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