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N928 Basic Principles of Anesthesia > Positioning > Flashcards

Positioning Flashcards

1
Q

What AANA standard addresses positioning?

A

Standard 8

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2
Q

What are the most common nerve positioning injuries?

A

ulnar nerve and brachial plexus

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3
Q

Goals for positioning include:

A 
patient safety
optimize surgical exposure
preserve patient dignity
maintain hemodynamic stability
maintain cardiorespiratory function
No ischemia, injury, or compression
prevent pressure injuries
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4
Q

Cardiovascular concerns related to positioning include:

A

redistribution of circulating blood volume
depressed cardiac output
reduced preload and SV- blood pooling (dependent)
compression of extremities or great vessels
impaired autonomic nervous system function
anatomy cephalad to heart risk hypoperfusion/ischemia

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5
Q

Volatile agents cause (CV effects)

A

decreased CO & BP

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6
Q

NMBs cause (CV effects)

A

decreased muscle return/venous return

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7
Q

Opioids cause (CV effects)

A

decreased HR (CO/BP)

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8
Q

To avoid dramatic effects on the CV system, it is important to

A

avoid quick positioning changes

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9
Q

Barriers to thoracic excursion include

A

supine, lateral and prone positioning= cephalad displacement

Prone= reduced capacity for chest expansion

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10
Q

Gravity related effects include

A

ventilation- nondependent (dead space)
perfusion- dependent (shunt)
loss of hypoxic pulmonary vasoconstriction

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11
Q

Mechanisms associated with nerve injury include

A

compression, transection, stretch, traction

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12
Q

Nerve sheath ischemia can be

A

direct or

indirect

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13
Q

Compression of a nerve occurs when

A

we force a nerve against a bony prominence or other hard surface

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14
Q

Transection occurs when

A

the nerve is cut

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15
Q

Stretch injury occurs when

A

the nerve is extended or pulled tightly

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16
Q

Traction injury occurs when

A

is pulled over or under some immovable structure which is a bone

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17
Q

Patients are more likely to experience a nerve injury if

A

they have extremes of body habitus (obese or thin)

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18
Q

Comorbidities associated with nerve injuries include

A

smoking, alcoholism, diabetes

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19
Q

Risk factors for skin issues include

A

elderly, diabetes, PVD, surgical time, chronic hypotension, increased body temperature, body habitus
smokers are prone to developing vasoconstriction of cutaneous vessels

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20
Q

The goal for integumentary issues is

A

prevent development of pressure ulcers, assess and reassess patients for pressure-ulcer risk, address identified risks.

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21
Q

The preoperative anesthesia interview allows us to

A

identify patients at risk for positioning injuries
perioperative nerve injury and comorbidities
mobility concerns?
take precautionary measures

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22
Q

Surgical positions include

A

supine, prone, lithotomy, high lithotomy, low lithotomy, jack knife, lateral, sitting (beach chair), trendelenburg, and reverse T-burg

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23
Q

Arm positioning for supine includes:

A

arms secured
armboards, padding, arm straps
arms laterally or abducted- <90 degrees, supinated forearm, avoid brachial plexus injury (stretch), pronation of the arms causes ulnar nerve compression at the cubital tunnel at elbow
tucking arms- elbow padded (ulnar nerve)
palmar aspects hands parallel to thighs/trunk

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24
Q

Lower limb positioning for supine includes:

A

legs flat, uncrossed
heel padding
small lumbar support

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25
Q

Cardiovascular considerations when supine

A 
BP stability
compensatory mechanisms (worse compensatory mechanisms in anesthesia
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26
Q

Respiratory considerations when supine include

A

reduced TLC & FRC
diaphragm shifted cephalad
general anesthesia and NMBs enhanced

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27
Q

Prone is also known as

A

ventral decubitus

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28
Q

Considerations for prone patients include

A

often intubated, induction/intubation on the stretcher, head/neck neutral, on anesthesia provider’s count, arms <90 degrees, elbow/axilla support, body/trunk support

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29
Q

What type of cases use the prone positioning?

A

spine, buttocks, rectum or peri-rectal, ankle, intracranial

30
Q

Cardiovascular concerns for patients who are prone include

A

potential for compression of inferior vena cava, epidural engorgement, and pooling of blood (lower extremities/abdomen)

31
Q

Respiratory concerns for prone patients include

A 
decreased compliance if chest not hanging freely
increased FRC (improved posterior lung ventilation may increase oxygenation)
32
Q

When patients are prone we take special care with the

A

genitalia (penis), breasts, lower legs, face, eyes, & nose

33
Q

Prevention of postoperative vision loss includes

A

surgical duration < 6 hours, 10-15 degree head up (reduce orbital edema), maintain Hct >25, & BP 20% of preoperative baseline (MAP >70 mmHg)

34
Q

Postoperative vision loss can occur due to

A

prolonged surgical time spine surgeries (prone), cortical blindness, central retinal artery occlusion, central retinal vein occlusion, ischemic optic neuropathy (89% of the time)

35
Q

Ischemic optic neuropathy is associated with

A

extended surgical time & extensive blood loss, obesity, male gender, Wilson frame, & decreased ocular perfusion pressure
not associated with globe pressure

36
Q

It is our goal to ensure (to prevent positioning injuires)

A

adequate circulation, head and neck support, airway protection, anatomical alignment, and access

37
Q

The goal to preventing positioning injuries is to avoid

A

excessive pressure (peripheral nerves, bony prominences), extremity injury, strain/dislocation of joints and muscles, eye pressure, abrasions, irritants

38
Q

When moving a patient, at a minimum the

A

pulse oximeter should be left on

39
Q

____is responsible for calling turns/repositioning

A

the CRNA

40
Q

The primary causes of injury include

A

positioning negligence & lack of vigilance

41
Q

Brachial plexus injury can occur from

A

supine: arms abducted >90 degrees, humeral head rotated

lateral decubitus: stretch/traction/tension, chest- dependent compression

42
Q

Pulmonary changes with reverse trendelenburg include

A

increased pulmonary compliance & FRC

43
Q

Reverse trendelenburg is when

A

the bed is flat & the head is up

44
Q

Reverse trendelenburg causes a decrease in

A

ICP, IOP, BP, and CPP

45
Q

Trendelenburg positioning is when

A

the head is down

46
Q

Trendelenburg causes an increase in

A

ICP, IOP, and CVP

47
Q

The degree of Trendelenburg has an effect on

A

dependent edema & physiologic/hemodynamic impact

48
Q

For every 1 cm head rise, there is a

A

0.75 mmHg drop in MAP

49
Q

The sitting positioning (respiratory impacts)

A

causes increased FRC & increased compliance

50
Q

The sitting positioning causes (CV impacts)

A

reduced SV & CO (up to 20%), decreased MAP & CVP, lower extremity venous pooling, & decreased cerebral perfusion (CPP= MAP-ICP)

51
Q

Potential complications with the sitting position include

A

quadriplegia, pneumocephalus, & venous air embolism

52
Q

Quadriplegia due to the sitting position is caused by

A

spinal cord stretch when head is flexed+ loss of regulation with general anesthesia
ensure 2 fingerbreadths= limit strain at C5 vertebra

53
Q

Pneumocephalus results from the sitting position because of

A

neuro procedures, often benign

air enters open dura, CSF drainage, surgical decompression

54
Q

What is the gold standard to treat a venous air embolism?

A

the Durant position which is trendelenburg with left lateral decubitus and that allows the air embolism to rise to the top of the right atrium and then a central line should be inserted and the air should be aspirated

55
Q

Sitting is used for

A

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

56
Q

The sitting position is when

A

HOB 30-90 degrees above horizontal plane
OR table flexed and backrest elevated
head secured (2 fingerbreadths between neck and mandible)
arms secured (padded arm boards or patient’s lap with drawsheet)
Endobronchial intubation
pad legs, heels flexed (prevent sciatic stretch)
dislodge head from headrest with vigorous surgical manipulation

57
Q

A cranial retinal artery occlusion can be caused by

A

embolism, vasculitis, vasospasm, sickle cell, trauma, glaucoma

58
Q

A cranial retinal artery occlusion clinical signs include

A

sudden profound vision loss, painless, monocular

59
Q

Diagnosis of a cranial retinal artery occlusion includes

A

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

60
Q

Treatment for cranial retinal artery occlusion includes

A

consult ophto+ neurology, possible digital massage or lower intraocular pressure

61
Q

Risk factors for cranial retinal vein occlusion includes

A

typical stroke risk factors, hypercoagulable states, glaucoma, compression of the vein in the thyroid or orbital tumors

62
Q

Clinical symptoms of cranial retinal vein occlusion includes

A

blurred vision to sudden vision loss, painless, monocular

63
Q

Diagnosis of cranial retinal vein occlusion includes

A

optic disk edema & diffuse retinal hemorrhages

64
Q

Treatment for cranial retinal vein occlusion includes

A

consult ophtho+ neurology

65
Q

The lithotomy position is where

A

the legs are abducted, elevated
fingers free–> footboard
legs free–> peroneal nerve
Hip flexion for preventing sciatic/obturator stretch & femoral nerve palsy

66
Q

The lithotomy position facilitates access to

A

perineal structures, gynecological, & urology

67
Q

Respiratory considerations with the lithotomy position include

A

20% reduced FRC, reduced VC, & hypoventilation when breathing spontaneously

68
Q

Cardiovascular considerations with the lithotomy position include

A

Increased (shifted) central blood volume

autotransfusion 250-300 mL/leg when raised

69
Q

The lateral position includes

A

head neutral, supported
pressure free of the eyes/ears/face
shoulders, hips, head, & legs aligned
chest and hip supports or bean bag
regularly assess perfusion
dependent arm on padded arm board, perpendicular to torso <90 degrees
axillary roll under dependent side of thorax

70
Q

The lateral position is used for

A

kidney, shoulder, thorax, and orthopedic surgeries (THA, hip)

71
Q

The CV considerations with the lateral position include

A

Euvolemic minimal changes

w/ kidney rest elevated: slowly under iliac crest, great vessels compressed, decreased venous return

72
Q

The respiratory considerations with the lateral position include

A

V/Q mismatch is possible, FRC is increased in the nondependent lung (top) & decreased in the dependent lung (bottom), the dependent lung lower than the left atrium is prone to atelectasis and fluid accumulation

N928 Basic Principles of Anesthesia (16 decks)

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