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
For the Lithotomy Position, the_______ nerve is particularly prone to injury as it lies between the fibular head and compression from the leg support.
- Peroneal
For the Lithotomy Position, branches of the ____________nerves often pass directly through the inguinal ligaments and can be impinged and become ischemic within the stretched ligament.
- Lateral femoral cutaneous
Pathophysiological considerations for the lithotomy position.
- ↑ Venous return, CO, and ICP
- ↑ Intraabdominal pressure
- Displaces diaphragm cephalad
- ↓ Lung compliance and tidal volume
What position is the patient in?
- Lateral Decubitus Position
Describe the Lateral Decubitus position.
- Patient lying on non-operative (dependent) side and requires anterior and posterior support w/ rolls or bean bags
- Adequate head support… no pressure on eyes or ears
- Neutral position
- Dependent ear should be regularly checked
- Dependent leg is slightly flexed
- Arms are in front of the patient and both must be supported and abducted < 90 degrees
- Axillary roll placed between chest wall and bed, caudal to axilla to prevent brachial plexus compression
- Must place padding between the knees
For right Lateral Decubitus, what side of the patient will be down?
- RIGHT lateral decubitus = RIGHT side down
Safety/general considerations for the lateral decubitus position
- If bed flexed or kidney rest used, needs to be placed under iliac crest
- Inferior vena cava compression can occur
- Ulnar nerve injury if elbows are not padded
- Brachial plexus injury if arms are abducted > 90 degrees
- ETT dislodgement; caution with use of LMA
Pathophysiological considers for the Lateral Decubitus position
- Venous pooling in lower extremities
- Use compression stockings/devices
- V/Q mismatch due to inadequate ventilation to dependent lung and decreased blood flow to the nondependent lung
Peripheral nerve injury can be caused by what factors?
- Stretch
- Pressure
- Ischemia
Peripheral nerve injury can occur in as a little as 30 minutes.
Can nerve injury occur even when optimal positioning is performed?
- Yes
Overall, cases of nerve injuries have decreased, but are still a major legal cause to professional liability claims and can still occur even when optimal positioning is performed.
What type of injury can occur with the arms abducted greater than 90°?
Brachial Plexus injury
What injury can occur if elbows are not properly padded?
Ulnar nerve injury
With what type of positioning is it common to see facial and airway edema?
Prone
What are the consequences of increased abdominal pressure from prone positioning?
- ↓ venous return (via vena cava compression)
- ↓ CO
In what position does improved ventilation occur?
Prone
What side is down when the patient is placed in right lateral decubitus position?
Right side down
If the arms are abducted, it must always be less than ______.
90°
What is done to prevent brachial plexus compression for lateral decubitus positioning?
Axillary rolls
What is the most commonly used surgical position?
Supine
Which of the following experience a decrease with supine positioning?
Venous return
preload
FRC
VT
SV
CO
VT and FRC
What position should the hands have when adducted in supine position?
Palms up or neutral (towards body)
Pressure alopecia and backache can occur with what positioning?
Supine
A patient’s arms have been abducted > 90°. What nerve injury is more possible now?
Brachial plexus or axillary nerve injury
What hand positioning would cause ulnar nerve injury?
Pronated hand/arm (palm down)
FRC and pulmonary compliance will decrease with this positioning.
Trendelenburg (probably supine to a lesser degree as well)
Which positioning may need higher pressures in ventilated patients for adequate ventilation?
Trendelenburg
What distance must be kept between the chin and the sternum in sitting positions?
2 fingers
What technique is used to prevent stretching of the sciatic nerve in sitting position?
Hips flexed < 90° and knees slightly flexed
Cerebral hypoperfusion, air embolus, pneumocephalus, quadriplegia, spinal cord infarction, sciatic nerve injury, and cerebral ischemia are all possible complications what type of positioning?
Sitting
MAP, CI, and cerebral perfusion pressure will all ______ in sitting position.
decrease
In which position are compression stockings necessary to prevent venous pooling?
Prone
In what position is possible ETT dislodgement a concern?
Prone
What nerve injuries are possible in Prone positioning?
- Ulnar nerve if not padded
- Brachial plexus if arms are abducted > 90°
Abdominal pressure is ______ in prone positioning.
What is the result of this.
Increased abdominal pressure results in ↓ CO & ↓ venous return
What is improved in prone positioning?
Ventilation
In Lithotomy position, it is important to lower one leg at a time. T/F?
False. Lower extremities must be raised and lowered in synchrony.
If surgery occurs longer than ______ hours in lithotomy position the legs must be periodically lowered.
2-3
In which position is compartment syndrome a risk?
Lithotomy
In which position can inferior vena cava compression occur?
Lateral Decubitus
In which positioning is V/Q mismatch due to imbalanced lung ventilation a concern?
Lateral Decubitus
