Positioning Flashcards
What standard is positioning according to the AANA?
Standard 8: patient positioning collaborate with the surgical or procedure team to position, assess, and monitor proper body alignment. Use protective measures to maintain perfusion and protect pressure points and nerve plexus
What is the most common closed claim analysis?
ulnar and brachial plexus nerve
Goals of Positioning
patient safety optimize surgical exposure preserve patient dignity maintain hemodynamic stability maintain cardiorespiratory function no ischemia, injury or compression JC Patient Safety Goal #14- prevent healthcare associated pressure ulcers
How do volatile agents effect our cardiovascular system?
myocardial depressants
decrease CO and BP
How do NMB effect our cardiovascular system?
Decrease muscle tone and venous return
How do opioids effect our cardiovascular system?
decrease HR (CO and BP)
Cardiovascular concerns while positioning
redistribution of circulating blood volume
depressed CO
compression of extremities or great vessels
impaired autonomic NS function
anatomy cephalad to heart risks hypoperfusion/ischemia
Pulmonary Problems d/t Positioning
Barriers to thoracic excursion
Positive pressure ventilation
Gravity related effects
Mechanisms associated with nerve injury
compression
stretch
traction
transection
Risk factors of Integumertary Issues:
elderly diabetes PVD surgical time chronic hypotension increased Body temperature body habitus
Nerve Sheath Ischemia can be
direct and indirect
Pressure Points in Supine
heel, toes, thighs, sacrum, elbow, humerous, vertebrae, occiput
Describe the Supine position
arms secured, armboards padding w/ straps
Arms are laterally or abducted at less then 90degree angle and supinated
Legs are flat, uncrossed with heels padded
If the arms are proned in supine, which is erroneous, what will it cause?
ulnar nerve compression (at the cubital tunnel at elbow)
describe arms are tucked in supine position
palmar aspects of hands parallel to thighs/trunk elbows padded (ulnar nerve)
Cardiopulmonary Implications in Supine
BP stable ANS mechanisms to compensate Reduced TLC and FRC diagraphm shifted cephalad GA and NM enhance
Ventral Decubitus
Prone often intubated induction/intubation occurs on stretcher head and neck are neutral Arms <90 elbow, axilia body/trunk support
What type of cases are performed prone?
spine, buttocks, rectum, peri-rectal, ankle, intracranial
Cardiovascular and Pulmonary Implications for Prone
pooling of blood in (lower extremities/gut)
compression of IVC
epidural engorgement
Decreased compliance if chest not freely hanging
increased FRC
Post-Operative Vision Loss
prolonged surgical time spine surgeries central retinal artery occulsion central retinal vein occulsion ischemic optic neuropathy cortical blindness
What is the most common POVL?
ischemic optic neuropathy at 89%
associated with: extended surgical time and excessive blood loss
not associated with global pressure
obesity, male gender, wilson frame,
Prevention of POVL
surgical duration <6hrs
10-15 degrees head up (reduce orbital edema)
BP 20% of pre-operative baseline (MAP >70mmHg)
Maintain Hct >25
Ocular Perfusion Pressure
OPP= MAP-IOP
Central Retinal Artery Occlusion Clinical
eye stroke
sudden, profound vision loss
painless, monocular
Central Retinal Artery Occlusion Etiology
Embolism vasculitis vasospasm sickle cell trauma glaucoma
Central Retinal Artery Occlusion Diagnosis
retinal pallow
macular cherry red spot
+/- afferent pupillary defect
Central Retinal Artery Occlusion Treatment
consult Optho + neurology
case reports of intra-arterial TPA
limited evidence- digital massage, lowering IOP
Central Retinal Vein Occlusion Clinical
Eye DVT
variable- blurred vision to sudden vision loss
painless
monocular
Central Retinal Vein Occlusion Etiology
typical stroke risk factors
hyper coagulability states
glaucoma
compression of the vein in the thyroid or orbital tumors
Central Retinal Vein Occlusion Diagnosis
Optic disk edema
diffuse retinal hemorrhages (blood and thunder)
Central Retinal Vein Occlusion Treatment
optho + neuro consult
no specific treatment
Lithotomy Position
legs abducted, elevated
fingers free watch footboard
legs free watch peroneal nerve
Hip Flexion in lithotomy position
sciatic/ obturator stretch
femoral nerve palsy
Lithotomy facilitates access to
perineal structures
gynecological
urology
Cardiovascular and Respiratory Implications of Lithotomy
20% reduced FRC Reduced VC hypoventilation breathing spontaneously increased CVP auto-transfusion 250-300ml/leg when raised
Describe Lateral Positioning
head neutral and supported
pressure free eyes/ears/face
shoulders, hips, head, and legs aligned
chest and hips supports or bean baf
regularly assess perfusion of arms
dependent arm on padded arm board, less then 90 degrees and perpendicular to torso
axillary roll under dependent side of thorax (slightly caudad, not directly in axilla)
When is lateral positioning used?
kidney
shoulder
orthopedic (THA, Hip)
thorax
Cardiovascular and Respiratory Implications of Lateral Position
Euvolemic, minimal changes
V/Q mismatch possible
FRC: increased in nondependent lung (top)
decreased in dependent lung (buttom)
Dependent lung lower then left atrium, prone to: atelectasis and fluid accumulation
Sitting position is used for
cervical spine surgery
shoulder surgery
posterior fossa
breast reconstruction
When kidney rest is elevated in the lateral position, cardiovascular changes include
slowly, under iliac crest
great vessels compressed
decreased venous return
Describe the sitting position
HOB 30-90 degrees above horizontal plane
OR table flexed and backrest elevated
Head secured (2 fingerbreadths b/t neck and mandible)
endobronchial intubation
dislodge head w/ headrest w/ vigrous surgical manipulation
pad heels, legs flexed (prevent sciatic stretch)
arms secured (padded arm boards or patients lap with drawsheet
Potential Complications of Sitting
VAE d/t negative pressure gradient
pnemocephalus
quadriplegia
VAE
negative pressure gradient
RA and operative site veins
most common
Pnemocephalus
Neuro procedures, often benign
air enters open dura, CSF drainage, surgical decompression
Quadriplegia
spinal cord stretch when head flexed + loss of autoregulation with GA
ensure 2 fingerbreadths = limit strain at C5 verbetra
Sitting Cardiovascular and Respiratory Implications
reduced SV and CO (up to 20%) decreased MAP and CVP lower extremity venous pooling decreased cerebral perfusion increased FRC increased compliance
Trendelenburg
head down
degree T burg (dependent edem)
increased ICP, IOP, CVP)
shoulder braces- plexus stretch, plexus compression
Reverse T
bed flat, head up
increased pulmonary compliance, FRC
decreased IOP,ICP, CPP and BP
Brachial Plexus
supine- arms abducted >90, humeral head rotated
lateral decubits: stretch/traction/tension
chest- dependent compression
Avoid
excessive pressure at peripheral nerves, bony prominences, eye pressure, abrasions, irritants
extremity injury
strain/dislocation of joints and muscles
Ensure
adequate circulation, head and neck support, airway protection, antatomical alignment
access
