Positioning (Exam II) Andy's Cards 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
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)
Safety/general considerations with Trendelenburg position.
- 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 position.
- ↑ CO, ↑ Venous Return from lower extremities
- ↑ ICP, ↑ IOP, Facial Edema
- ↑ Intraabdominal Presure
- ↓ 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 (head up)
Safety/general considerations with Reverse Trendelenburg position.
- 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
Pathophysiological considerations with Reverse Trendelenburg position.
- Risk of Hypotension (↓ Venous Return, Venous pooling)
- Downward displacement of abdominal contents/ diaphragm (better ventilation)
- ↓ Perfusion to the brain
Name the 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
Describe the set-up of the full sitting position
- Head must be stabilized – taped to special headrest or rigid pins
- Keep at least two finger’s distance between the chin and sternum
- Hips are flexed < 90 degrees and knees slightly flexed for balance to reduce stretching of the sciatic nerve
- Compression stockings/wraps to maintain venous return
- Feet are supported – prevent sliding
What risks are associated with sitting position?
- Cerebral hypoperfusion and air embolism
- Pneumocephalus
- Quadriplegia and spinal cord infarction
- Cerebral ischemia
- Peripheral nerve injuries (Sciatic nerve injury)
Pathophysiological consideration of the sitting position?
- Risk of hypotension d/t ↓ venous return.
- ↓ MAP, ↓ Cardiac Index, and ↓ 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
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 and Brachial plexus injury if arms are abducted > 90 degrees
- Post-op visual loss secondary to decreased perfusion/ischemia and Eye injuries r/t head position
- ETT dislodgement and Loss of monitors and IV lines
Pathophysiological considerations for prone patients
- 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 position?
- Back pain
- Compartment syndrome
Nerve injuries (4)
* Brachial plexus
* Ulnar nerve injury
* Common peroneal injury
* Lateral femoral cutaneous injury
What position is the patient in?
- Lateral Decubitus Position
What is done to prevent brachial plexus compression for lateral decubitus positioning?
Axillary rolls
