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Principles > Perioperative Positioning > Flashcards

Perioperative Positioning Flashcards

1
Q

Standard 8

A

Patient positioning - collaborate with the surgical/procedure team to position, assess, and monitor proper body alignment

Use protective measures to maintain perfusion and protect pressure points/nerve plexus

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2
Q

What is the most common nerve injury

A

Ulnar and brachial plexus nerve

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3
Q

What are the seven positioning goals

A
  1. Safety
  2. Optimize surgical exposure
  3. Preserve patient dignity
  4. Maintain hemodynamics stability
  5. Maintain cardio respiratory function
  6. No ischemia, injury, or compression
  7. Prevent pressure ulcers
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4
Q

How do volatile agents effect CO/BP

A

Decrease

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5
Q

How do NMBs affect the cardiac system?

A

Decreased muscle tone = decreased venous return

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6
Q

What is the concern for anatomy cephalad to heart

A

Risk for hypoperfusion/ischemia

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7
Q

How does gravity effect the pulmonary system

A

Ventilation - non dependent = dead space
Perfusion - dependent = shunt
Loss of HPV?

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8
Q

What are the ways in which nerves can be injured

A

Compression, transaction, stretch, traction

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9
Q

Risk factors for pressure ulcers

A

Elderly, diabetes, PVD, surgical time, chronic hypotension, increased body temp (?), body habitus

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10
Q

Supine positioning mechanics

A

Lying on back
Arms - secured with arm boards, padding, straps, laterally or abducted (<90 degrees with supinated forearm)
Legs - flat, uncrossed, heel padding
Consider lumbar support

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11
Q

Supine arm positioning/nerve concerns

A

Avoid brachial plexus injury by keeping arms abducted <90
Avoid ulnar nerve compression by padding elbows and avoiding pronation

(Brachial nerve compression/stretch at shoulder/axial level and ulnar nerve compression at AC/elbow level)

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12
Q

How does the supine position effect the respiratory system

A

Reduced TLC and FRC
Diaphragm shifts cephalad
General anesthesia and NMBs enhance respiratory effects

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13
Q

Prone mechanics

A

Head/neck = neutral
Often intubated
Arms abducted but <90
Body/trunk support to keep abdomen from being compressed

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14
Q

How to facilitate proning in OR

A

Intubate and get lines and everything on the stretcher
Flip on anesthesia’s count - and anesthesia maintains airway
Before anything else - ensure that you still have your airway
Make sure you have enough help and that everyone is sharing the same “mental model”

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15
Q

What types of surgery would you use prone for

A

Spine, butt, rectum, ankle, intracranial, etc

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16
Q

CV considerations of prone positioning

A

Pooling of blood in dependent extremities
Compression of inferior vena cava
Epidural engorgement

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17
Q

Respiratory considerations of prone positioning

A

Decreased compliance if chest/abdomen not freely hanging
Increased FRC
-improved posterior lung ventilation may increase oxygenation

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18
Q

Post op vision loss causes

A 
Prolonged prone position
Central retinal artery occlusion
Central retinal vein occlusion
Ischemic optic neuropathy (89% cause)
Cortical blindness
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19
Q

Ways to prevent POVL

A 
Surgical duration <6h
10-15 degree head up (to reduce orbital edema)
Bp 20% of preop baseline and MAP > 70
Maintain Hct >25
Avoid prolonged targeted hypotension
Avoid head and neck flexion
Avoid direct pressure on the eye
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20
Q

Ischemic optic neuropathy

A

Most common type of POVL
Associated with extended surgical time and extensive blood loss
Not associated with globe pressure
RF = obseity, male, Wilson frame (blood pools in the face because it is dependent d/t frame)

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21
Q

Equation for ocular perfusion pressure

A

OPP = MAP-IOP

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22
Q

Central retinal artery occlusion clinical signs and symptoms

A

Sudden, profound vision loss
Painless
Monocular

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23
Q

Etiology of CRAO

A

“Eye stroke”

Embolism, vasculitis, vasospasm, sickle cell, trauma, glaucoma

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24
Q

Diagnosis of CRAO

A

Retinal pallor, macular cherry red spot, +/- afferent pupillary defect

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25
Q

Treatment of CRAO

A

Consult optho and neuro
Case reports of intra-arterial TPA
Limited evidence for treatment - possibly digital massage and lowering IOP

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26
Q

Central retinal vein occlusion “eye dvt” signs and symptoms

A

Variable - blurred vision to sudden vision loss
Painless
Monocular

27
Q

CRVO etiology/ risk factors

A 
“Eye dvt”
Typical stroke risk factors
Hypercoagulable states
Glaucoma
Compression of vein in thyroid or orbital tumors
28
Q

Diagnosis of CRVO

A

Optic disk edema

Diffuse retinal hemorrhages “blood and thunder”

29
Q

Treatment of CRVO

A

Consult optho and neuro

No specific treatment

30
Q

Nerve Compression

A

Force nerve against bony prominence or some other hard surface (can be a surgical surface like the OR table or positioning tools)

31
Q

Nerve Transection

A

Nerve is cut

32
Q

Stretched nerve

A

Nerves are pulled tightly

33
Q

Nerve traction

A

Nerve stretched over or under something that is immovable

34
Q

Nerve sheath ischemia direct vs indirect

A

Direct - d/t something like compression of the nerve itself

Indirect - compartment syndrome

35
Q

Lithotomy mechanics

A 
Legs abducted and elevated
Keep fingers free of footboard
Keep legs free to save peroneal nerve
Hip flexed
Facilitates access to perineum/gyn/urology

***ensure adequate padding

36
Q

Nerve considerations for lithotomy

A

Peroneal nerve injury d/t stirrups

Sciatic obturator stretch and femoral nerve palsy d/t hip flexion

37
Q

Respiratory considerations of lithotomy

A

20% reduced FRC
Reduced vital capacity
Hypoventilation if breathing spontaneously

38
Q

Cv considerations of lithotomy

A

Increased (shifted) central blood volume

Auto Transfusion of 250-300ml/leg when raised

39
Q

Mechanics of lateral positioning

A

Head and neck neutral and supported
Shoulders, hips, head, legs aligned in same plane
Eyes, ears, and face should be pressure free
Chest and hip supports
Dependent arm on padded arm board - perpendicular to torso <90
Non dependent arm should be supported - flexion at elbow, padded, secured
Axillary roll should be in use under dependent side of thorax
There should be knew flexion with pillows between knees

REGULARLY assess perfusion

40
Q

Jack-knife position

A

Lateral position with the use of a kidney rest

41
Q

lateral positioning used for

A

Kidney, shoulder, orthopedic (THA/hip), thorax surgeries

42
Q

CV considerations of the lateral position

A

Minimal changes (euvolemic)

Kidney rest elevated may compress great vessels and decrease venous return

43
Q

How to place kidney rest

A

Slowly under iliac crest

44
Q

Resp considerations of lateral position

A

V/Q mismatch possible

In anesthetized patients:
- FRC is increased in non dependent lung and decreased in dependent lung because diaphragm relaxes and rises to compress dependent lung
In awake patients:
- you have enhanced VQ matching and you do not get the compression of diaphragm

Dependent lung lower than left atrium so its prone to atelectasis and fluid accumulation

45
Q

Sitting position used for

A

Cerivical spine surgery, shoulder surgery, posterior fossa, breast reconstruction

46
Q

Sitting mechanics

A 
HOB 30-90 degrees
OR table flexed and backrest elevated
Head secured
Pad heels and flex legs
Secure arms

Dislodge head from headrest with vigorous surgical manipulation is possible so be careful

47
Q

How do you prevent sciatic stretch in the sitting position

A

Pad heels and flex legs

48
Q

Potential complication of Sitting position

A

VAE
Pneumocephalus
Quadriplegia

49
Q

Pneumocephalus and the sitting position

A

Associated with Neuro procedures, often benign

Air enters open dura, CSF drainage, surgical decompression

50
Q

Quadriplegia and sitting position

A

Spinal cord stretch when head is flexed combined with loss of auto regulation associated with general anesthesia

Ensure 2 fingerbreadths to limit strain at C5 vertebrae

51
Q

Cv effects of sitting position

A

Reduced SV and CO (up to 20%)
Decreased MAP and CVP
Lower extremity venous pooling
Decreased CPP

52
Q

Respiratory considerations of sitting position

A

Increased FRC and compliance

53
Q

Rise in cm to drop in MAP conversion

A

Every 1 cm rise = 0.75mmHg drop in MAP

So

A map of 65 degrees on an arm BP cuff at level of heart correlates to a MAP of 50 in the brain (if your head is 20cm away from the level of the cuff)

54
Q

Trendelenburg

A

Patient is lying in one plane with the head down

55
Q

Shoulder braces with trendelenburg can cause

A

Plexus nerve stretch and compression

Stretch if placed to laterally
Compression if placed too medically

Avoid shoulder pads if possible

56
Q

Pressure changes with trendelenburg

A

Patient will have increased ICP, IOP, and CVP

57
Q

Hemodynamics and T-burg

A

Degree of T-burg = degree of dependent edema and therefore hemodynamic impact

58
Q

Reverse t-burg

A

Body is in same plane, bed flat, head up

59
Q

Physiologic considerations of reverse T-burg

A

Increased pulmonary compliance and FRC

Decreased ICP, IOP, CPP, BP

60
Q

Brachial plexus considerations in supine

A

Make sure arms are abducted less than 90 and make sure humeral head is not rotated

61
Q

Signs of brachial plexus injury

A

Weakness in the arms, decreased reflexes and corresponding sensory deficits

62
Q

Lateral decubitus considerations for brachial plexus injuries

A

Can cause stretch, traction, tension

And dependent compression via chest

63
Q

Res Ipsa Loquitor

A

The thing speaks for itself

Provider presumed negligent if cause of injury is under providers control and issue would not occur without negligence

Stay vigilant

Principles (11 decks)

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