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
prone... be cautious with
- genitalia (penis) - breasts - lower legs - face - eyes - nose - boney prominences
26
POVL
postoperative vision loss
27
POVL causes
- 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
ION
ischemic optic neuropathy | 89% of POVL --> most common cause!!!
29
POVL prevention
- 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
ischemic optic neuropathy risk factors
-extended surgical time -extensive blood loss -obesity -gender --> male -wilson frame -decreased OPP (ocular perfusion pressure) NOTE --> not associated with globe pressure
31
OPP
ocular perfusion pressure | OPP = MAP - IOP
32
CRAO
- 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
CRVO
- 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
lithotomy
- 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
lithotomy procedures
- perineal structures - gynecological - urology
36
lithotomy CV implications
- 20% reduced FRC - reduced VC - hypoventilation breathing spontaneously - increased intra-abdominal pressure
37
lithotomy respiratory implications
- increased (shifted) central blood volume | - autotransfusion 250-300 mL/leg when raised
38
lateral
- 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
lateral surgical procedures
- kidney - shoulder - orthopedic (THA, hip) - thorax
40
lateral CV implications
- optimize volume status (euvolemic), minimal changes | - kidney rest elevated --> slowly under iliac crest, great vessels compressed, decrease venous return
41
lateral respiratory implications
- 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
sitting surgical procedures
- cervical spine surgery - shoulder surgery - posterior fossa - breast reconstruction
43
sitting
- 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
sitting complications
- VAE - pneumocephalus - quadriplegia
45
VAE
- 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
S/S VAE
- 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
what to do if have a VAE?
- 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
pneumocephalus
- 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
Quadriplegia
- 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
sitting CV implications
- reduced SV and CO (up to 20% reduced) - decreased MAP and CVP - lower extremity venous pooling - decreased cerebral perfusion, CPP = MAP - ICP
51
sitting respiratory implications
- increased FRC | - increased compliance
52
trendelenburg
- 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
shoulder braces too wide
brachial plexus stretch
54
shoulder braces too narrow
brachial plexus compression
55
reverse trendelenburg
- bed flat, head up - increased pulmonary compliance and FRC - decreased ICP, IOP, CPP, BP - common in laparoscopic procedures
56
brachial plexus injury
- 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
S/S brachial plexus injury
- weakness in arm - diminished reflexes - sensory deficits
58
CRNA role positioning
- calls turns/repositioning - ensure patient stability - EVERYONE is responsible
59
when positioning avoid
- excessive pressure on peripheral nerves and bony prominences - eye pressure, abrasions, irritants - extremitiy injury - strain/dislocation of joints/muscles
60
when positioning ensure
- adequate circulation - head and neck support - airway protection - anatomical alignment - access