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2-General Principles Exam 3 > Positioning Overview > Flashcards

Positioning Overview Flashcards

1
Q

What is the goal of positioning?

A

allow optimal surgical access while minimizing potential risk to the patient

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2
Q

What is the risk of positioning for surgery?

A

Risk: pt is unable to make necessary changes in positioning as needed

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3
Q

The preoperative interview should include specific questions that will determine the patient’s ability to _____________

A

tolerate the planned procedure

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4
Q

What is the components of patient’s interview?

A
  • General level of awareness
  • Age
  • Weight and height
  • Skin condition
  • Nutritional status
  • Current medications
  • Normal range of motion and limitations on range of motion
  • Physical abnormalities or limitations, such as back problems or deformities
  • Preexisting medical conditions (e.g., vascular, respiratory, circulatory, or neurological problems, immune compromise)
  • Previous surgeries and surgical complications
  • Implants, such as total joint prostheses
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5
Q

Who determines the right position?

A

Positioning is a compromise between what an anesthetized patient can tolerate

  • Structurally and physiologically vs. Surgical team access
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6
Q

Positioning-related complication often lead to ________

A

medicolegal scenarios

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7
Q

Why is position related to medicolegal?

A

Notations absent or uninformative

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8
Q

What is the documentation of patient positioning?

A
  • Descriptive notation about position
  • Note frequent checks as the body will shift during surgery, protective measures (eyes, pressure points, etc.), and complications in positioning
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9
Q

What is the cause of damage of neural tissue?

A

Hypoperfusion

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10
Q

What are the different types of neural tissue damage? (3)

A

stretch, compression, disruption

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11
Q

What can stretching of neural tissues cause?

A

peripheral & central neuropathies

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12
Q

When can tissue ischemia occur?

A
  • > 5% than normal resting length = ISCHEMIA (reducing both arteriole & venule blood flow)
  • Kinking of arterioles/venules associated w/ neural stretch = ISCHEMIA
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13
Q

What happens if ischemia is prolonged?

A

may result in permanent neural damage!

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14
Q

What can direcet compression of neural and soft tissue?

A

ischemia & tissue damage

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15
Q

What nerves are more susceptible to ischemia?

A

Peripheral nerves

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16
Q

Not always recognized ____________ after surgery and may manifest/be recognized weeks later

A

Immediately

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17
Q

What can happen to pressure points on soft tissue?

A

reduce local blood flow = ISCHEMIA

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18
Q

What is the prevention for damage to pressure points?

A

Padding (gels, foams, etc.)

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19
Q

What change in BP with change in height between the heart and body region?

A

MAP increases or decreases ~2mmHg/inch

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20
Q

When is MAP alterations a concern?

A

cerebral perfusion at the Circle of Willis

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21
Q

What positions are at risk for hypoperfusion and ischemia?

A

Head up, sitting and lithotomy

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22
Q

What happens to cardiac output in the full sitting position?

A

Cardiac output decreases 20% in full sitting position (90 degrees) secondary to venous pooling

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23
Q

Review the anatomy of the circle of willis.

A
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24
Q

What are the cardiovascular changes in the prone position?

A
  • CVP increased
  • BP and LV volume decreased
    • Decreased venous return and increased intrathoracic pressure
  • CI decreased or unchanged
  • Increased venous pressure to the head
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25
Q

What are the cardiovascular changes in the lateral decubitus position?

A
  • BP decreased if flexed
  • Elevated kidney rest
    • Legs dependent
    • Venous return decreased by extreme flexion
    • Vessel compression (vena cava)
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26
Q

What are the cardiovascular changes in the lithotomy position?

A
  • BP appears normal or elevated
  • Gravity dependent redistribution of blood (autotransfusion)
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27
Q

What are the cardiovascular changes in the sitting position?

A
  • BP, CI, CVP and PCWP decrease
  • SVR increases
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28
Q

What are the cardiovascular changes in the Trendelenburg position?

A
  • Venous return (CVP), mean PAP, PCWP and MAP increased - problematic in CV disease
    • Leads to vasodilation and decreased HR from stimulation of baroreceptor reflexes
  • Increased venous pressure to the head
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29
Q

What are the respiratory changes in the prone position?

A
  • Improved V/Q matching
  • May depend on excursion of abdomen
    • Improved FRC if abdomen excursion good
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30
Q

What are the respiratory changes in the lateral decubitus position for awake patient?

A

Ventilation favors dependent lung with awake, spontaneous ventilation

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31
Q

What are the respiratory changes in the lateral decubitus position for ventilated patient?

A
  • With anesthesia, PEEP, paralysis, nondependent lung easier to ventilate
  • Decreased ventilation and compliance in dependent lung
  • Increased ventilation and compliance in nondependent lung
  • V/Q mismatch can worsen: as perfusion directed to dependent lung- normally HPV compensates but inhibited by inhaled anesthetics
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32
Q

What are the respiratory changes in the Lithotomy position?

A
  • Minimal resp effect in normal situations
  • Extreme flexion and/or obesity
    • Compliance and TV decreased
    • Airway pressures and dead space / tidal volume ratios increased
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33
Q

What are the respiratory changes in the sitting position?

A
  • Forced vital capacity and FRC normal
  • Most favorable for ventilation
  • If hips flexed may decrease FRC and closing volumes by shifting abdominal contents cephalad
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34
Q

What are the respiratory changes in the Trendelenburg position?

A
  • Decreased FRC
  • Potential for ETT to migrate right mainstem, especially if pneumoperitoneum achieved
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35
Q

What are the respiratory changes in the supine position?

A

FRC and total lung capacity decreased

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36
Q

What are the components of the brachial plexus?

A
  • 5 roots (merge, split and converge)
  • 3 trunks
  • 6 divisions
  • 3 cords
  • 5 Terminal branches
37
Q

What is true about positioning of the brachial plexus?

A

]The brachial plexus is vulnerable to injury in almost every position

38
Q

Where is the brachial plexus?

A

is formed by the anterior primary rami of C5 through T1 and provides sensory and motor innervation of the upper extremity

39
Q

What is the supraclavicular portion?

A

Roots, trunks, divisions - emerging through the posterior triangle of the neck between the anterior and middle scalene muscles

40
Q

What is the infraclavicular?

A

Cords, terminal branches - lies within the axilla (cords named to their relation to the axillary artery)

41
Q

What forms the trunks of the brachial plexus?

A

formed from anterior rami of C5—C8 and T1 (Roots)

42
Q

Where do the trunks merge?

A

C5-C6 merge to form superior trunk, C5 to medial trunk, C8-T1 to inferior trunk

43
Q

Where are the divisions?

A

Divisions converge under pectoralis minor to form cords (axilla)

44
Q

What are the terminal branches?

A

Divisions become the terminal branches (immediately after the pectoralis minor)

  • Ulnar n.
  • Radial n.
  • Median n.
  • Axillary n.
  • Musculocutaneous n.
45
Q

Review brachial plexus.

A
46
Q

Define Radial n.

A

(C5-8; T1) (upper and middle trunks; post divisions, cords)

47
Q

Define musculocutaneous n.

A

(C5-7) (upper, middle trunks, ant. Divisions, lateral cord

48
Q

Define median nerve.

A

(C6-T1) (all trunks, lateral and medial cords)

49
Q

Define axillary n.

A

(C5-6): Motor to deltoid, teres minor, sensory to deltoid

50
Q

Define ulnar nerve

A

(C8-T1) (Lower trunk, anterior divisions, medial cord)

51
Q

Review distribution of the terminal nerves of the brachial plexus.

A
52
Q

What are the two types of brachial plexus palsies?

A
  • UBP injury-Erb’s Palsy
  • LBP injury- Klumpke’s pLSY
53
Q

Define ERB’s palsy.

A

Upper brachial plexus injury

  • Increase in angle between neck & shoulder
  • Traction (Strethcing or avulsion) of upper ventral rami (C5, C6)
54
Q

Define Klumke’s Palsy.

A
  • Excessive upward pull of limb
  • Traction (Strethcing or avlusion) of lower ventral rami (C8, T1)
55
Q

Review the classic sign of the Erb’s and klumpke palsy.

A
56
Q

What is another perherial nerve that can be damaged?

A
  • Ulnar nerve damage
57
Q

Define ulnar nerve damage.

A

Results from damage to medial cord of brachial plexus

58
Q

How does ulnar nerve damage occur?

A

Compression at the cubital tunnel (groove of medial epicondyle of humerus and olecranon)

59
Q

What is the characteristics of ulnar nerve damage?

A
  • Results in inability to oppose 5th finger and diminished sensation to 4th and 5th finger
  • Clawlike contracture
60
Q

Who is at high risk for ulnar nerve damage?

A

Male gender, presence of preexisting asymptomatic neuropathy, prolonged hospital stay, extremes of body habitus

61
Q

What is the hallmark characteristics of ulnar nerve damage?

A

Claw hand

  • Inability to extend fingers at interphalangeal joints, result in permananet flexion= claw
62
Q

What is the hallmark characteristics of median nerve damage?

A

Ape hand

  • inability to oppose thumb
63
Q

What is the hallmark characteristics of radial nerve damage?

A

Wrist drop

  • inability to extend the hand, inability to fully extend forearm
64
Q

What effect can happen to the eye after surgery?

A

Postoperative visual loss

65
Q

Where can vision loss occur?

A

May occur in one or both eyes

66
Q

What are the components of vision loss?

A

Range of defects from loss of visual acuity to total blindness

67
Q

Incidence of POVL is approximately ________ of all general anesthetics

A

1/60,000 to 1/125,000

68
Q

What are the five primary causes of vision loss?

A
  1. Ischemic optic neuropathy (ION)*
  2. Central retinal artery occlusion (CRAO)*
  3. Central retinal vein occlusion
  4. Cortical blindness
  5. Glycine toxicity
69
Q

What are the two primary causes of vision loss?

A
  1. Ischemic optic neuropathy (ION)*
  2. Central retinal artery occlusion (CRAO)*
70
Q

Ischemic optic neuropathy (ION)* ______ of all cases of POVL

A

89%

71
Q

What position does Ischemic optic neuropathy (ION)* occur?

A

Most common and associated with prone and adult patients (and CABG)

72
Q

Where does Ischemic optic neuropathy (ION)* occur?

A

Ischemia in a portion of the optic nerve (suspectible to hypoperfusion)

73
Q

What are the two types ofIschemic optic neuropathy (ION)*?

A

Two types based on position of the injury relative to the lamina cribrosa:

  • Anterior ION (AION)
  • Posterior ION (PION)
74
Q

What are the risk factors Ischemic optic neuropathy (ION)*?

A

male, obese, Wilson frame, long operative time, increased blood loss and lower colloid to crystalloid ratio in nonblood fluid administration

75
Q

What are the characteristics of Ischemic optic neuropathy (ION)*?

A

Sudden onset painless vision loss and a visual field defect

76
Q

What is the prevention for Ischemic optic neuropathy (ION)*?

A
  • Avoid decreasing MAP
  • Avoid venous congestion leading to increased intraocular pressure
    • Not having the head below the heart
77
Q

What is the cause of CRAO (Central retinal artery occlusion)?

A

Caused by decreased blood supply to entire retina

78
Q

What is the most common cause of CRAO (Central retinal artery occlusion)?

A

Most common cause related to incorrect positioning with external pressure on the eye (central retinal artery comes off internal carotid artery)

79
Q

What are the risk factors of CRAO (Central retinal artery occlusion)?

A

Prone spine cases, CPB, head and neck procedures with injections around nose and eyes, hypertension, CVD, increased BMI, open angle glaucoma, sickle cell anemia, steep Trendelenburg position

80
Q

How does CRAO (Central retinal artery occlusion) present?

A

Often presents as severe unilateral vision loss immediately following surgery

81
Q

What Factors are Associated with Position Related Injuries?

A
  • Positioning Devices
  • Length of Procedure
  • Body Habitus
  • Pre-existing Pathophysiology
  • Anesthetic Technique
82
Q

What are components of positioning devices that can be caues of injuries?

A

–Table straps

–Leg holders and stirrups

–Axillary roll

–Bolsters

–Fracture table post

–Shoulder braces

–Positioning frames

–Headrests

–Ether screen

83
Q

What are components of length of procedure that can be caues of injuries?

A

Longer than 4-5 hours

84
Q

What are components of body habitus that can be caues of injuries?

A

–Obesity

–Malnutrition

–Bulky musculature

85
Q

What are components of pre-existing pathophysiology that can be caues of injuries?

A

–Anemia

–Diabetes mellitus

–Peripheral vascular disease

–Liver disease

–Peripheral neuropathies

–Alcoholism

–Limited joint mobility

–Smoking

86
Q

What are components of anesthetic technique that can be caues of injuries?

A

–General anesthesia

–Hypotensive techniques

–Neuromuscular blockade

87
Q

What needs to be done to the operating room table?

A

Always inspect to ensure working properly and correct attachments (head rests, armboards, leg holders, etc.)

88
Q

What should the SRNA/CRNA know about the operating table?

A

Know how to operate (lock properly, hand controls working, plugged in/has a plug)

89
Q

What are other components of operating room table?

A
  • Ensure correct bed (fluoro or xrays needed?)
  • Have appropriate persons to help with positioning including surgeon

2-General Principles Exam 3 (11 decks)

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