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N928 - Basics of Anesthesia > Positioning > Flashcards

Positioning Flashcards

1
Q

Standard 8

A

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

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2
Q

Claims analysis for positioning injuries

A
  • liability and nerve injury
  • ulnar nerve and brachial plexus most common
  • ulnar nerve injury and GA
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3
Q

goals for positioning

A
  • patient safety
  • optimize surgical exposure
  • preserve patient dignity
  • maintain hemodynamic stability
  • maintain cardiorespiratory function
  • no ischemia, injury, or compression
  • 2015 joint commission patient safety goal #14 to prevent healthcare associated pressure ulcers
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4
Q

volatile anesthetic effect on CV system

A
  • decreased CO

- decreased BP

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5
Q

NMBDs effect on CV system

A
  • decreased muscle tone

- decreased VR

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6
Q

opioids effect on CV system

A

-decreased HR –> decreased CO and BP

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7
Q

CV concerns with positioning

A
  • redistribution of circulating blood volume
  • depressed CO
  • reduced preload and thus SV
  • blood pooling in dependent areas
  • compression of extremities or great vessels
  • impaired ANS function
  • anatomy cephalad to heart risk hypoperfusion and/or ischemia
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8
Q

pulmonary concerns with positioning

A
  • barriers to thoracic excursion/expansion (supine/lateral/prone = chephalad displacement; prone = reduced capacity for chest expansion)
  • positive pressure ventilation
  • gravity related effects (ventilation - nondependent; perfusion - dependent)
  • loss of HPV with anesthesia
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9
Q

mechanisms associated with nerve injury

A
  • compression (force nerve against bony prominence or other hard surface)
  • transection (nerve cut)
  • stretch (nerve pulled tightly)
  • traction (nerve pulled over or under immovable structure like a bone)
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10
Q

nerve sheath ischemia

A
  • direct (r/t compression)

- indirect (like compartment syndrome)

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11
Q

risk factors for nerve injury

A
  • DM
  • HTN
  • PVD
  • alcohol abuse
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12
Q

joint commission patient safety goal for skin

A

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

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13
Q

risk factors for pressure injuries

A
  • age (elderly - thin skin, decreased circulating time, poor mobility)
  • DM
  • PVD
  • surgical time
  • chronic hypotension
  • increased body temperature
  • body habitus
  • smoking
  • infant (large head, occiput a risk)
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14
Q

supine

A
  • arms secured (armboards, padding, arm straps)
  • arms laterally or abducted
  • arms <90 degrees
  • supinated forearm and pad elbow
  • legs flat, uncrossed
  • heel padding
  • equipment/monitors padded
  • consider small lumbar support
  • palmar aspects hands parallel to thighs/trunk
  • pillow under knees
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15
Q

why do we keep arms <90 degrees?

A

to avoid a stretch brachail plexus injury

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16
Q

why do we supinate the forearms in supine position?

A
  • avoid ulnar nerve compression

- pronation could cause ulnar nerve compression at cubital tunnel of elbow

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17
Q

why do we put a pillow under the knees?

A

avoid sciatic nerve stretch

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18
Q

supine CV implications

A
  • BP stability

- compensatory mechanism of ANS reduced (i.e., decreased SNS response)

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19
Q

supine respiratory implications

A
  • reduced TLC and FRC
  • diaphragm shifts cephalad
  • general anesthesia and NMBDs enhance effects
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20
Q

prone (ventral decubitus)

A
  • often intubated, so do induction/intubation on stretcher
  • head/neck neutral
  • arms < 90 derees
  • elbow flexed free of pressure
  • body/trunk support with foam/pillows
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21
Q

what is the number 1 priority after any movement change?

A

reassess the airway placement

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22
Q

what types of surgical cases would we use the prone position?

A
  • spine
  • buttocks
  • rectum or peri-rectal
  • ankle
  • intracranial
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23
Q

prone CV implications

A
  • pooling of blood in lower extremities and dependent areas of gut/abdomen
  • compression of inferior vena cava
  • epidural engorgement
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24
Q

prone respiratory implications

A
  • decreased compliance if chest not freely hanging

- increased FRC - improved posterior lung ventilation may increase oxygenation

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25
Q

prone… be cautious with

A
  • genitalia (penis)
  • breasts
  • lower legs
  • face
  • eyes
  • nose
  • boney prominences
26
Q

POVL

A

postoperative vision loss

27
Q

POVL causes

A
  • most often occurs in the prone position
  • prolonged surgical time spine surgeries (prone)
  • most common cause –> ischemic optic neuropathy (ION)
  • central retinal artery occlusion (CRAO)
  • central retinal vein occlusion (CRVO)
  • cortical blindness
28
Q

ION

A

ischemic optic neuropathy

89% of POVL –> most common cause!!!

29
Q

POVL prevention

A
  • surgical duration < 6 hours
  • 10-15 degree head up (reduces orbital edema and thus compression of nerve)
  • BP 20% of preoperative baseline (MAP > 70 mmHg, anything less than this have potential for adverse effects)
  • maintain Hct > 25; if not there is a reduction in O2 carrying capacity
30
Q

ischemic optic neuropathy risk factors

A

-extended surgical time
-extensive blood loss
-obesity
-gender –> male
-wilson frame
-decreased OPP (ocular perfusion pressure)
NOTE –> not associated with globe pressure

31
Q

OPP

A

ocular perfusion pressure

OPP = MAP - IOP

32
Q

CRAO

A
  • central retinal artery occlusion
  • eye stroke
  • presentation - sudden, profound vision loss; painless
  • etiology - embolism, vasculitis, vasospasm, sickle cell, trauma, glaucoma
  • dx - retinal pallor; macular cherry red spot
  • consult optho + neuro
33
Q

CRVO

A
  • central retinal vein occlusion
  • eye dvt
  • presentation - variable from blurred vision to sudden vision loss; painless
  • risk factors - typical stroke risk factors, hypercoagulable states, glaucoma, compression of vein in thyroid or orbital tumors
  • dx - optic disc edema; diffuse retinal hemorrhages
  • no specific treatment, consult optho + neuro
34
Q

lithotomy

A
  • legs elevated and abducted
  • fingers free of footboard (IMPT bc dont want compression)
  • less free –> peroneal nerve!!!
  • hip flexion - prevent sciatic/obturator nerve stretch; femoral nerve palsy
35
Q

lithotomy procedures

A
  • perineal structures
  • gynecological
  • urology
36
Q

lithotomy CV implications

A
  • 20% reduced FRC
  • reduced VC
  • hypoventilation breathing spontaneously
  • increased intra-abdominal pressure
37
Q

lithotomy respiratory implications

A
  • increased (shifted) central blood volume

- autotransfusion 250-300 mL/leg when raised

38
Q

lateral

A
  • head neutral, supported
  • pressure off eyes, ears, and face
  • shoulders, hips, head and legs aligned
  • chest and hip supports or bean bag
  • regularly assess perfusion
  • dependent arm (down arm) on padded arm board, perpendicular to torso <90 degrees
  • nondependent arm (up arm) axillary roll under dependent side of thorax, slightly caudad, not directly in axilla
39
Q

lateral surgical procedures

A
  • kidney
  • shoulder
  • orthopedic (THA, hip)
  • thorax
40
Q

lateral CV implications

A
  • optimize volume status (euvolemic), minimal changes

- kidney rest elevated –> slowly under iliac crest, great vessels compressed, decrease venous return

41
Q

lateral respiratory implications

A
  • VQ mismatch possible
  • FRC - increased in nondependent lung (top) and decreased in the dependent lung (bottom)
  • dependent lung lower than LA, prone to atelectasis and fluid accumulation
42
Q

sitting surgical procedures

A
  • cervical spine surgery
  • shoulder surgery
  • posterior fossa
  • breast reconstruction
43
Q

sitting

A
  • HOB 30-90 degrees above horizontal plane
  • OR table flexed and backrest elevated
  • head secured (ensure 2 fingerbreadths between neck and mandible)
  • endobronchial intubation (careful because if head flexion occurs ETT can advance in up to 1.9 cm)
  • dislodge head from headrest with vigorous surgical manipulation
  • pad heels, legs flexed (prevent sciatic stretch)
  • arms secured (padded arm boards or patient’s lap with drawsheet)
44
Q

sitting complications

A
  • VAE
  • pneumocephalus
  • quadriplegia
45
Q

VAE

A
  • venous air embolism
  • most commonly occurs in the sitting position
  • RA and operative site veins incidence ~1-74%
  • fatal amount of air = 0.5-1 mL/kg
46
Q

S/S VAE

A
  • sudden decreased ETCO2
  • decreased BP
  • decreased SpO2
  • increased CVP
  • air visualized on TEE
  • if patient awake –> dyspnea, respiratory distress, meal-wheel murmur, pulmonary HTN
47
Q

what to do if have a VAE?

A
  • get the code cart and call for help!!
  • durant position - trendelenbery with L lateral decubitis – allows air emboli to rise to top of RA and NOT go to lungs
  • if have a CVC, aspirate air from RA
48
Q

pneumocephalus

A
  • the presence of air in the epidural, subdural, or subarachnoid space, within the brain parenchyma or ventricular cavities
  • can occur in neuro procedures, often benign
49
Q

Quadriplegia

A
  • spinal cord stretched when head is flexed + loss of autoregulation with general anesthesia
  • ensure 2 fingerbreadths of space between neck and mandible … limits strain at C5
50
Q

sitting CV implications

A
  • reduced SV and CO (up to 20% reduced)
  • decreased MAP and CVP
  • lower extremity venous pooling
  • decreased cerebral perfusion, CPP = MAP - ICP
51
Q

sitting respiratory implications

A
  • increased FRC

- increased compliance

52
Q

trendelenburg

A
  • head down
  • degree of trendelenberg will determine the amount of dependent edema and the physiologic/hemodynamic impact
  • increased –> ICP, IOP, CVP, and BP in dependent extremities
  • shoulder braces
  • normal or steep
53
Q

shoulder braces too wide

A

brachial plexus stretch

54
Q

shoulder braces too narrow

A

brachial plexus compression

55
Q

reverse trendelenburg

A
  • bed flat, head up
  • increased pulmonary compliance and FRC
  • decreased ICP, IOP, CPP, BP
  • common in laparoscopic procedures
56
Q

brachial plexus injury

A
  • can occur in supine or lateral decubitus position
  • in supine, arms abducted >90 degrees or humoral head rotated
  • in lateral decubitus there can be stretch, traction, or tension of brachial plexus; also chest can cause compression of dependent arm (down arm)
57
Q

S/S brachial plexus injury

A
  • weakness in arm
  • diminished reflexes
  • sensory deficits
58
Q

CRNA role positioning

A
  • calls turns/repositioning
  • ensure patient stability
  • EVERYONE is responsible
59
Q

when positioning avoid

A
  • excessive pressure on peripheral nerves and bony prominences
  • eye pressure, abrasions, irritants
  • extremitiy injury
  • strain/dislocation of joints/muscles
60
Q

when positioning ensure

A
  • adequate circulation
  • head and neck support
  • airway protection
  • anatomical alignment
  • access

N928 - Basics of Anesthesia (17 decks)

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