Positioning

Question 1

supine

Answer 1

Legs uncrossed, pillow for support
▪ Hand positioning:
▪ If tucked, hands neutral
▪ If secured to arm boards, hands supinated

Question 2

Trendelenburg

Answer 2

Trendelenburg = head down
▪ Increases venous return
▪ Used to improve surgical exposure and robotic cases
▪ Physiological changes depend on the degree of tilt
▪ Potential complication

Question 3

Reverse Trendelenburg

Answer 3

▪ Decreases venous return
▪ Decreased perfusion to the brain
▪ laparoscopic surgeries
▪ Injury from securing straps

Question 4

lithotomy

Answer 4

Procedures requiring perineal exposure

▪ Legs are in flexion and abduction

Question 5

complications of lithotomy

Answer 5

▪ Crushing injury to fingers
▪ Peroneal injury

Question 6

Lateral decubitus

Answer 6

Used for surgeries for the thorax, kidneys, and
orthopedics

Question 7

complication of lateral decubitus

Answer 7

rhabdomyolysis

Question 8

what is sitting position Beach Chair used for?

Answer 8

neuro and shoulder surgeyr

Question 9

serious complicarions of beach chair

Answer 9

air embolism
pneumocephalis
quadripeldgia
nerve injury
extreme hypotension

Question 10

Prone positioning uses

Answer 10

orthopedic
spine
rectal
intracranial

Question 11

avoid pressure where during prone?

Answer 11

abdomen and eyes

Question 12

5 types of Postoperative visual loss (POVL)

Answer 12

1 Ischemic optic neuropathy (ION)
2 Central retinal artery occlusion (CRAO)
▪ Central retinal vein occlusion
▪ Cortical blindness
▪ Glycine toxicity

Question 13

Compartment
syndrome

Answer 13

increased pressure and decreased perfusion

venous obstruction in the inguinal region

Question 14

common surgery positions that cause compartment syndrome

Answer 14

lithotomy
trendelenberg

Question 15

treatment of compartment syndrome

Answer 15

stop the occlusion
fasciotomy

Question 16

crossing your legs will injure what nerve in the dependent leg

Answer 16

sup. peroneal n.

Question 17

crossing your leg in surgery will injure what nerve in the superior leg?

Answer 17

sural n.

Question 18

what should you check before extubating a patient that was in t berg?

Answer 18

airway edema

leak test
awake extubation sometimes

Question 19

reverse t berg effect on CO and CPP

Answer 19

decreases

Question 20

nerves that can be injured in stirrups

Answer 20

peroneal
sciatic
obturator

also crushing injury

Question 21

compartment syndrome in these positions

Answer 21

lithotomy
t berg
+

old
anemic
hypotensive
vasoconstrictors
overweight
long surgery

Question 22

lateral decub effect on dependent lung

Answer 22

better VQ ratio

Question 23

lateral decub effect on top lung

Answer 23

VQ mismatch because less perfusion

Question 24

major complication of lateral decub

Answer 24

rhabdo

Question 25

beach chair serious complications

Answer 25

hypotension bradycardia VAE peripheral nerve injury

Question 26

VAE treatment

Answer 26

Stop further air entrainment—ask surgeon to stop operating, flood field with NSS, or apply bone wax Administer 100% oxygen IVF and vasoactive agents If possible, place patient left side down and in Trendelenburg position (moves airlock in the R ventricular outflow track) Place central line in RA to aspirate entrained air

Question 27

ulnar nerve injury hand disfigurement

Answer 27

claw 4th and 5th finger

Question 28

common brachial plexus injury

Answer 28

The nerves are vulnerable to compression as they pass between the clavicle and the first rib Avoid shoulder compression and turning head away from abducted arm

Question 29

Ischemic neuropathy cause

Answer 29

improper positioning usually prone during spine fusion and cardiac surgery

Question 30

risk factor for Ischemic optic neuropathy (ION)

Answer 30

Your patient is fat, blind, overweight, hypertensive, has sickle cell, and CV disease. This patient was the OR for a long time and got a lot of crystalloid and lost a lot of blood HTN CV disease High BMI Open angle glaucoma Sickle cell disease Long OR times Large blood loss Lower colloid to crystalloid ratio

Question 31

preventing Ischemic optic neuropathy (ION)

Answer 31

Use a foam headrest or prone view pillow with a mirror Check eyes at least q20 minutes by palpation or visualization

Question 32

wrist drop

Answer 32

radial n. injury, cant abduct thumb

Question 33

How to Attenuate Hemodynamic Changes

Answer 33

Incremental position changes Nitrous narcotic technique <0.5 mac Gradually deepen anesthetic Consider IVF

Question 34

Prone Positioning Caviats

Answer 34

Support shoulders so they do not “sag” Chest rolls Bilateral bite blocks Do not extend arms over head >90 degrees Avoid pressure on abdomen Increase in CVP Decreased venous return Increased intrathoracic pressure CI = decreased or unchanged Document ETT cuff leak at end of the case

Question 35

MAP and positing changes

Answer 35

MAP increases or decreases 2 mm Hg per 1 inch for each change in height between the heart and a body region

Question 36

Ensure there are at least two fingerbreadths of space between the neck and mandible to prevent

Answer 36

Spinal Cord injury

Question 37

trendelenburg changes to ventilation

Answer 37

May have to change ETT, increase MV, change i:e ratio from 1:2 to 1:1.5

Question 38

legs should be lowered and raised simultaneously to prevent what?

Answer 38

spinal torsion: "twisted spine" or "spinal rotation", occurs when the spinal cord and surrounding muscles are pushed and twisted beyond their normal healthy range

Question 39

What position puts the patient at the most risk for POVL

Answer 39

prone causes direct pressure on the globe causing central retinal artery occlusion that can cause Ischemic Optic Neuropathy