Positioning (Exam II) Flashcards
What is the most common surgical position?
Supine
Arm boards must be secure if in use.
What are the pathophysiological considerations for the supine position?
↑ Venous return, ↑ preload, ↑ SV, and ↑ CO
↓Tidal volume, ↓ FRC
Describe arm abduction
Arm out to the side, < 90 degrees
Padded arm boards secured to the table and patient at the axilla
The arms should be supine (palms up)
Elbows padded and arm is secured with a Velcro strap
Describe arm adduction
Arm tucked alongside the body
Arms held along the side of body via draw sheet under the body and over the arm
Hand and forearm are supine (palms up) or neutral position (palms toward body)
Elbows are padded
May tuck one arm if surgeon must stand on side of patient
What are the 5 complications of the supine position?
Backache
Pressure alopecia
Brachial plexus or axillary nerve injury if arms abducted > 90 degrees
Ulnar nerve injury if hand/arm is pronated (palm down)
Stretch injury when neck is extended and head turned away (brachial plexus)
What position is this patient in?
Trendelenburg (head down)
Describe the safety/general considerations for the Trendelenburg postion.
Use a non-sliding mattress/pad to prevent the patient from sliding cephalad
Avoid using bean bags or shoulder braces
Consider making a mark at the level of the patient’s head on the sheet or pad so you can determine easily if the patient has slid
Pathophysiological considerations with Trendelenburg positioning.
↑ CO, ↑ Venous Return from lower extremities
↑ ICP, ↑ IOP
Facial edema, conjunctiva, larynx, and tongue
↑ Intraabdominal Pressure
↓ FRC and ↓ Pulmonary Compliance
May need higher pressure in ventilated patients
Risk of endobronchial intubation as abdominal contents push the carina cephalad
What position is this patient in?
Reverse Trendelenburg
Describe safety/general considerations with Reverse Trendelenburg positioning.
Use a non-sliding mattress/pad to prevent the patient from sliding
Use a footrest or something under the feet to prevent the patient from sliding
In what position should bean bags and shoulder braces be avoided?
Trendelenburg
Can cause Brachial Plexus injury
Pathophysiological considerations with Reverse Trendelenburg positioning.
Risk of Hypotension (↓ Venous Return, Venous pooling)
Downward displacement of abdominal contents/ diaphragm (better ventilation)
↓ Perfusion to the brain
At what level will an ART line need to be leveled when in Reverse Trendelenburg or the Sitting position?
Tragus
Name the two following positions
Left Picture: Beach Chair Position
Right Picture: Full Sitting Position
When will the patient be in the Beach chair position?
Shoulder Cases
Beach chair position will have less severe hip flexion and slight leg flexion.
Describe the set-up of the full sitting position.
Head must be stabilized – taped to special headrest or rigid pins
Hips are flexed < 90 degrees and knees slightly flexed for balance to reduce stretching of the sciatic nerve
Feet are supported – prevent sliding
Compression stockings/wraps to maintain venous return
Keep at least two finger’s distance between the chin and sternum
What neurological risks are associated with the Sitting position?
Cerebral hypoperfusion and air embolism
Pneumocephalus
Quadriplegia and spinal cord infarction
Cerebral ischemia
Peripheral nerve injuries (Sciatic nerve injury)
Pathophysiological considerations of the Sitting position.
Risk of hypotension d/t ↓ venous return.
↓ MAP, ↓ Cardiac Index, and ↓ Cerebral Perfusion Pressure
What position is the patient in?
Prone
Describe the prone position.
Patient lying on stomach
Arms at side tucked or outstretched (< 90 degrees), with flexion at elbows
Head supported face down using a prone pillow, horseshoe headrest, or rigid fixation with pins in a neutral position without pressure on eyes, nose, mouth, and ears
Avoid compression of breasts, abdomen, and genitalia
Legs padded and slightly flexed at the knees and hips
Compression stockings for lower extremities to prevent pooling
Intubate the patient supine and then turn Prone
Place EKG leads on patient’s back
Why do you not turn a prone patient’s head to one side or the other?
Risk of jugular occlusion or carotid occlusion
What risks are associated with Prone positioning?
Facial and airway edema
Nerve injuries
Ulnar nerve injury if elbows are not padded
Brachial plexus injury if arms are abducted > 90 degrees
Post-op visual loss secondary to decreased perfusion/ischemia
Eye injuries r/t head position
ETT dislodgement
Loss of monitors and IV lines
Pathophysiological considerations for Prone positioning
Edema of face, conjunctiva, larynx, and tongue
↑ Abdominal pressure
↓ Venous return through compression of the inferior vena cava
↓ CO
Improved ventilation
Ventilation and perfusion in the lungs shift to the dependent areas
What position is the patient in?
Lithotomy
Describe the Lithotomy position.
Patient laying supine with legs up in padded or “candy cane” stirrups
Arms tucked or on arm boards
If using Trendelenburg or reverse Trendelenburg, need non-sliding mattress
Hips flexed 80 -100 degrees and legs abducted 30 - 45 degrees from midline, knees flexed
Lower extremities MUST be raised and lowered in synchrony together
Foot of the bed is lowered, must protect the hands and fingers from crush injury
Surgery > 2-3 hours, periodically lower the legs
What risks are associated with Lithotomy positioning?
Back pain
Brachial plexus
Ulnar nerve injury
Common peroneal injury
Lateral femoral cutaneous injury
Compartment syndrome
What position is the patient in?
Lateral Decubitus position
What is done to prevent Brachial Plexus compression for the Lateral Decubitus position?
Use of axillary rolls, along the nipple line
