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HA > Position > Flashcards

Position Flashcards

1
Q

position general

A
  • crna responsible, done for safety and comfort,
  • slow changes at end of case
  • can evoke undesirable physiological changes
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2
Q

documentation 5 positioning

A
  • ROM prior to case
  • intra op position
  • frame/padding
  • actually position
  • frequent checks
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3
Q

transfer to OR table

A
  • stretcher and OR table next to each other both locked
  • OR table has draw sheet
  • staff on both sides
  • self transfer or assistance
  • head aligned and watch extremities
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4
Q

Supine

A 
most common
-less physiological changes that others 
-has access to airway and arms (IVs)
-no pressure on eyes
-pillow under head: for better sniffing position and avoids dorsal extension/lateral flexion of neck
(doughnut shaped pillow--avoids alopecia
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5
Q

Supine arms, feet, lumbar

A
  • arms tucked- palm in, pad elbow, use draw sheet to tuck arms under torso (not mattress)
  • Arm board-abduct less than 90 to avoid brachial plexus stretch, hands Palm Up SUPINATED (protects ulnar nerve)
  • Feet: heels not hanging off bed and padded
  • Lumbar: (all this improves venous return) hips and knees flexed, pillow under knees (caution for DVTs, but helps with low back pain)
  • Legs not crossed, compression stockings/SCDs
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6
Q

CV changes in Supine

A

minimal effects

  • initially increase venous return to heart,
  • *increased preload, SVR, CO, BP which activates baroreceptors and PSN outflow so compensatory decrease HR and PVR
  • Decreased venous drainage for lower extremities
  • *IVC compression by masses: preg (put on L), ascities, obesity–may decreased venous return to heart and decreased CO
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7
Q

Ventilatory changes in Supine

A

FRC decreased 800ml

  • diaphragm displacement and compression of lung bases
  • and Muscle relaxant: decrease lung volume and loss of chest wall muscle tone.
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8
Q

Cerebral blood flow changes in Supine

A

minimal–tight autoregulation

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9
Q

mechanisms of nerve injuries 5 and diseases

A

STICK

  • Stretching
  • Transection
  • Ischemia
  • Compression
  • Kinking
  • Obesity, DM, Smoking
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10
Q

Brachial plexus injury (supine) cause and deficits(general)

A

-neck extension or head turned to side
-excessive abduction of arm >90
-arm falls of table
Deficits:
-electric shocks or buring sensation shooting down arm
-numbness or weakness in arm

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11
Q

1 and 2 injured

A

1 ulnar #2 brachial

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12
Q

Radial nerve injury (supine)

A

-external compression to radial nerve on lateral aspect of humerus from:
–surg retractor
–ether screen
–uneven arm boards
–repeat BP
Result:
-wrist drop
-weakness in abduction of them
-numbness in 1,2,3 digit
-inability at extending elbow

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13
Q

Ulnar injury

A
  • most common injury
  • in cubital tunnel in elbow groove
  • Compression btwn olecaron and medial epicondyle–entrapment with arm extension
  • Stretch with severe arm flexion
  • Stretch with dislocation with pronated hand (dislocated over medial epicondyle)
  • 3Xmore common in men
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14
Q

Ulnar injury symptoms

A

Claw hand

  • inability to abduct or oppose 5th finger
  • weak grip on ulnar side of fist
  • Loss of sensation on palmer side of 4th and 5th finger
  • eventually leads to atrophy of intrinsic muscles of hand
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15
Q

Reduce rick of Ulnar injury

A
  • pad arm board
  • avoid compression with strap
  • assure surg personnel dont compress
  • make sure BP cuff is Proximal (not in ulnar groove)
  • Avoid prolonged elbow flexion
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16
Q

Trendelenberg

A
  • used to treat hypotension by increasing venous return
  • improves surg exposure in abd and lap surg
  • *helps prevent air embolism with central line placement
  • shoulder braces- used with EXTREME caution–away from the neck over AC joint
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17
Q

CV changes in trendelenberg

A
  • short term for hypotension, increased Venous return..up to 1L
  • decreased blood flow to lower extremities
  • compression of heart
  • activation of Baroreceptors: peripheral vasodilation and decreased HR (can make shock worse)
  • *return to supine: slowly, decreased BP, venous pooling
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18
Q

Vent changes in Trendelenberg

A
  • abd contents displace: impeding diaphragm
  • -compressing lung bases
  • -decreased lung compliance
  • -decreased FRC and increase PIP
  • Increase WOB (spot breathing)
  • V/Q mismatch– increase perfusion in apex
  • aspiration risk
  • facial/airway edema
  • ETT can become R mainstem
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19
Q

Cerebral blood flow Trendelenberg

A
  • *IICP
  • IIOP
  • increased vascular congestion-gravity
  • *CNS disease pt- NOT good candidate
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20
Q

Reverse Trandelenberg

A

Enhance surgical exposed of upper abd–shifting content down ex lap chole

  • -Variation of this position use for Neck, shoulder and intracranial surg
  • for physiological change– its a variation of sitting
  • FOOT board: caution- excessive planter flexion for extended period of time– can cause Anterior tibial nerve injury–FOOT Drop
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21
Q

CV changes in Reverse Trendelenberg

A

decreased CO(20-40%), Preload, BP
-compensatory increase SNS tone, SVR and HR(30%) **this may be blunted by anesthetics
-Activation of renin-angiotensin-aldosteron system
-Venous pooling in lower extremities (compression stockings)
Return to supine: increased CO secondary to increased venous return

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22
Q

Lithotomy position

A

-calf support stirrups
-hips flexed 80-100degrees
-Legs abduct 30-45 degrees
-lower legs parallel to torso
-can Pinch femoral
-or Stretch sciatic
-or compress peroneal nerve
-Used for:
GYN, GU, Rectal procedures
*both legs in stirrups to avoid torsion of lumbar
-AND hip flex beyond 110 is avoided
-when positioning: elevate together then separate

23
Q

Candy cane stirrups

A

usually more acute flexion of hip and knees

watch for nerve injuries: femoral, sciatic, peroneal

24
Q

Knee crutch

A

can injury the popliteal nerve
common perennial
tibial

25
Q

Lower extremity nerve injury

A 
1 in 3608 pt
78% common peroneal.. most common lower 
15% sciatic
7%femoral
-Most common with low BMI, prolonged surg, smoking, DM, PVD, obesity
26
Q

Improper positioning in Lithotomy can lead to

A

nerve injuries: femoral, sciatic, obturator, lateral femoral cutaneous, saphenous, common peroneal

27
Q

Common Peroneal Nerve Injury

A

-most frequent lower nerve damaged
-branch of sciatic, on lateral side of fibula
*injury for compression to lateral side of leg to stirrup
Symptoms: foot drop, inability to evert foot, loss of dorsal extension of toes

28
Q

Sciatic nerve injury

A

-Excess external rotation of hips
-S/S: weakness or paralysis of muscles below the knee, numbness of foot and lateral 1/2 of calf
Get foot drop

29
Q

Femoral Nerve injury

A 
Compression at pelvic brim by retractor 
-excessive angulation of thigh abduction
-external rotation of hips
S/S loss of extension of knee
-decreased sensation over superior aspect thigh
30
Q

Saphenous Nerve injury

A

-medial aspect of lower leg compressed against support bar

S/S: parasthesia of medial an antermedial side of calf

31
Q

Lower extremity compartment syndrome

A
  • When perfusing of an extremity is inadequate
  • Results in ischemia, edema,
  • Externsive rhabdomyolysis from increased tissue pressure
  • occurs with long cases (>2-3hrs)
  • occurs with lithotomy and lateral decubitus position
32
Q

CV changes with Lithotomy

A

increased venous return
-increased preload
-transient increase in CO and BP
perfusion in lower extremities is decreased
**each 2.5cm vertically above heart needs 2mmhg more pressure to perfuse.

33
Q

Vent changes in Lithotomy

A

-depends on the degree of hip flexion–can displace abd content up therefore
-decreasing lung compliance
decrease TV and vital capacity
-aspiration risk

34
Q

Cerebral flow changes in lithotomy

A
  • transient increase in cerebral venous blood flow

- increase in ICP with legs elevated

35
Q

Prone position

A
  • wilson frame
  • jackson table
  • head rest with mirror- can watch eyes, airway, neck, nose
  • Horseshoe head rest- Watch bony structures of face
  • Mayfield head tongs and pins: watch for slippage, neck alignment, nose—touching metal components
36
Q

Prone: On stretcher you…8

A
  • intubate
  • line placement
  • NGT/OGT
  • esoph steth,
  • bite blocks
  • foley
  • good eye protection
  • To disconnect or not to disconnect monitors??
  • Anesthesia is in charge of the head/airway
37
Q

Prone: on Table

A
  • **Check Breath Sounds FIRST, have help and can flip them back over if need to
  • monitors on and working
  • Check IV and aline
  • check for excessive pressure on eyes, nose, upper extremities, breast, genitals, ant. iliac crest.
  • chest an abd support to allow for free abd–helps diaphragmatic mvmt and increased venous return
  • Neck in neutral alignment, no excessive flexion or extension
  • can turn head to side if pt has mobility to do so
  • eye, nose, ears free of pressure
38
Q

Prone: eye injury

A

-corneal abrasions: direct trauma, dry eyes, swelling TX: abx, eye patch
-Blindness: ischemic optic neuropathy
–via central vein or artery obstruction
–via sustained, direct pressure on eye/retina
-can result in visual changes or complete blindness
Risk factors other than prone: operative hypotension, lg OP blood loss, anemia, smoker, DM, HTN, male,
**caution in cardiac and spinal surg

39
Q

Prone: extremities

A
  • Arms: on boards by head, padding, including the elbow, abduction less than 90, prevent shoulders from sagging
  • Legs: slightly flexed, SCDs
40
Q

Thoracic Outlet syndrome

A

at risk in prone,
-Check by having pt put hands behind head for 2 minutes—see if numbness or tingling, check pulse–if yes to numbness than must tuck arms.

41
Q

CV changes in Prone

A
  • ICV and aorta compression–Hypotension
  • -Rolls to free abd and chest will improve flow
  • Venous pooling in lower extremities–hypotension, SCD, elastic compression
  • Hypotension associated with the move must be anticipated and tx if necessary
42
Q

Vent changes in Prone

A

V/Q mismatch:

  • Post vent>perf
  • Anterior perf>vent
  • cephalad diaplacement of diaphragm
  • lung compliance decreased
  • increased peak airway pressure
  • Increased WOB
  • use rolls
43
Q

Cerebral blood flow change in prone

A
  • turning head obstructs venous return leading to increased cerebral volume and IICP
  • excess flexion or turning-obstruction of vertebral artery flow
44
Q

Lateral decubitus Position (lots-o-info, arms, legs)

A

used for: thoracotomy, kidney, hip, shoulder surg
-requires: head support-neutral position (avoid, misalignment of cervical spine and stretch of brachial plexus)
-Limited pressure on dependent eye and ear
-Axillary roll- placed ciudad to outside of lower axilla **keep axilla clear
ARMS: dependent arm on padded arms board perpendicular to torso
–non-dependent supported with blankets or suspended with armrest
LEGS: -padding in btwn knees and flexed dependent leg (saphenous nerve injury)
-padding on bed common peroneal nerve injury
ANTERIOIR/POSTERIOR support:
-bean bags, hip post
-safety strap btwn head of femur and iliac crest

45
Q

CV changes in lateral D

A

minimal, no changes in CO unless obstruction in venous return (kidney resting against vena cava)
Higher BP in dependent

46
Q

Vent changes in lateral D

A
  • awake and spent breathing
  • dependent lung gets better perfusion and vent
  • decreased FRC, VC, TV
  • anesthetized but spont breathing
  • nondependent lung better vent
  • dependent lung better perfusion
  • Anesthetized mech breathing
  • same as above but OVER vent OVER perf
  • -Worse V/Q mismatch
47
Q

Cerebral blood flow changes in lateral D

A

minimal unless extreme flexion of head

48
Q

Sitting head, arms, butt, feet

A

used for cranial, shoulder & humeral surg (good exposure/access)
-facilitates venous drainage
HEAD: fixed in pins, or taped in place
-avoid excess Cervical flexion:
–obstructs venous outflow–causing hypoperfusing or venous congestion of brain
–stretch cervical nerve roots
–obstruct ETT
–can place pressure on tongue..must have 2 finger breaths btwn mandible and sternum
ARMS: avoid pressure on frame, traction pulling down on arms (brachial)
BUTTOCKS- postion in break of table
-flex knees and hip to decreased stretch in sciatic
FEET- support, padded SCD

49
Q

CV changes in Sitting

A

-pooling of blood in lower extremities
-Decreased CO, BP, preload
*hypotension
-HR, SVR increased as a compensatory measure (can be blunted by anesthetics)
TX: IVF, vasopressors, adjustment of anesthetic depth, SCD

50
Q

Vent changes in sitting

A

good
-increased: lung volumes, capacities, compliance
-WOB easier
everything easier (spont, mech)

51
Q

Cerebral blood flow changes in Sitting

A

Gravity

  • decreased CBF
  • decreased ICP
  • watch positioning-can lead to impediment of arterial and venous blood flow, causing hypoperfusion or venous congestion of brain.
52
Q

Venous air embolism VAE

A

risk anytime the surgical site is above the heart
-inability of venous sinus to collapse
**can be Lethal
S/S: changes in heart tones–windmill murmur
heard via doppler placed @parasternal border (2-6IC space)
-dysrhythmias, hypotension, desat **decreased ETCO2, nitrogen is exhalled
circulatory compromise and cardiac arrest

53
Q

VAE detection and Tx

A

-detection of entrained air with TEE or precordial doppler ultrasound
Tx: flood surgical field with NS
-apply wax to cut bony edges, close any open vessels
-D/C nitrous (bc it expands air pockets)
-place on 100% O2 PEEP
-T-berg position
-aspirate air from R atrium via catheter

HA (5 decks)

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