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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
Cardiovascular considerations when supine
``` BP stability compensatory mechanisms (worse compensatory mechanisms in anesthesia ```
26
Respiratory considerations when supine include
reduced TLC & FRC diaphragm shifted cephalad general anesthesia and NMBs enhanced
27
Prone is also known as
ventral decubitus
28
Considerations for prone patients include
often intubated, induction/intubation on the stretcher, head/neck neutral, on anesthesia provider's count, arms <90 degrees, elbow/axilla support, body/trunk support
29
What type of cases use the prone positioning?
spine, buttocks, rectum or peri-rectal, ankle, intracranial
30
Cardiovascular concerns for patients who are prone include
potential for compression of inferior vena cava, epidural engorgement, and pooling of blood (lower extremities/abdomen)
31
Respiratory concerns for prone patients include
``` decreased compliance if chest not hanging freely increased FRC (improved posterior lung ventilation may increase oxygenation) ```
32
When patients are prone we take special care with the
genitalia (penis), breasts, lower legs, face, eyes, & nose
33
Prevention of postoperative vision loss includes
surgical duration < 6 hours, 10-15 degree head up (reduce orbital edema), maintain Hct >25, & BP 20% of preoperative baseline (MAP >70 mmHg)
34
Postoperative vision loss can occur due to
prolonged surgical time spine surgeries (prone), cortical blindness, central retinal artery occlusion, central retinal vein occlusion, ischemic optic neuropathy (89% of the time)
35
Ischemic optic neuropathy is associated with
extended surgical time & extensive blood loss, obesity, male gender, Wilson frame, & decreased ocular perfusion pressure not associated with globe pressure
36
It is our goal to ensure (to prevent positioning injuires)
adequate circulation, head and neck support, airway protection, anatomical alignment, and access
37
The goal to preventing positioning injuries is to avoid
excessive pressure (peripheral nerves, bony prominences), extremity injury, strain/dislocation of joints and muscles, eye pressure, abrasions, irritants
38
When moving a patient, at a minimum the
pulse oximeter should be left on
39
____is responsible for calling turns/repositioning
the CRNA
40
The primary causes of injury include
positioning negligence & lack of vigilance
41
Brachial plexus injury can occur from
supine: arms abducted >90 degrees, humeral head rotated | lateral decubitus: stretch/traction/tension, chest- dependent compression
42
Pulmonary changes with reverse trendelenburg include
increased pulmonary compliance & FRC
43
Reverse trendelenburg is when
the bed is flat & the head is up
44
Reverse trendelenburg causes a decrease in
ICP, IOP, BP, and CPP
45
Trendelenburg positioning is when
the head is down
46
Trendelenburg causes an increase in
ICP, IOP, and CVP
47
The degree of Trendelenburg has an effect on
dependent edema & physiologic/hemodynamic impact
48
For every 1 cm head rise, there is a
0.75 mmHg drop in MAP
49
The sitting positioning (respiratory impacts)
causes increased FRC & increased compliance
50
The sitting positioning causes (CV impacts)
reduced SV & CO (up to 20%), decreased MAP & CVP, lower extremity venous pooling, & decreased cerebral perfusion (CPP= MAP-ICP)
51
Potential complications with the sitting position include
quadriplegia, pneumocephalus, & venous air embolism
52
Quadriplegia due to the sitting position is caused by
spinal cord stretch when head is flexed+ loss of regulation with general anesthesia ensure 2 fingerbreadths= limit strain at C5 vertebra
53
Pneumocephalus results from the sitting position because of
neuro procedures, often benign | air enters open dura, CSF drainage, surgical decompression
54
What is the gold standard to treat a venous air embolism?
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
Sitting is used for
cervical spine surgery, shoulder surgery, posterior fossa, breast reconstruction
56
The sitting position is when
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
A cranial retinal artery occlusion can be caused by
embolism, vasculitis, vasospasm, sickle cell, trauma, glaucoma
58
A cranial retinal artery occlusion clinical signs include
sudden profound vision loss, painless, monocular
59
Diagnosis of a cranial retinal artery occlusion includes
retinal pallor, macular cherry red spot, +/- afferent pupillary defect
60
Treatment for cranial retinal artery occlusion includes
consult ophto+ neurology, possible digital massage or lower intraocular pressure
61
Risk factors for cranial retinal vein occlusion includes
typical stroke risk factors, hypercoagulable states, glaucoma, compression of the vein in the thyroid or orbital tumors
62
Clinical symptoms of cranial retinal vein occlusion includes
blurred vision to sudden vision loss, painless, monocular
63
Diagnosis of cranial retinal vein occlusion includes
optic disk edema & diffuse retinal hemorrhages
64
Treatment for cranial retinal vein occlusion includes
consult ophtho+ neurology
65
The lithotomy position is where
the legs are abducted, elevated fingers free--> footboard legs free--> peroneal nerve Hip flexion for preventing sciatic/obturator stretch & femoral nerve palsy
66
The lithotomy position facilitates access to
perineal structures, gynecological, & urology
67
Respiratory considerations with the lithotomy position include
20% reduced FRC, reduced VC, & hypoventilation when breathing spontaneously
68
Cardiovascular considerations with the lithotomy position include
Increased (shifted) central blood volume | autotransfusion 250-300 mL/leg when raised
69
The lateral position includes
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
The lateral position is used for
kidney, shoulder, thorax, and orthopedic surgeries (THA, hip)
71
The CV considerations with the lateral position include
Euvolemic minimal changes | w/ kidney rest elevated: slowly under iliac crest, great vessels compressed, decreased venous return
72
The respiratory considerations with the lateral position include
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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