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NURA 641 Intro to Nurse Anesthesia > 190624_Positioning > Flashcards

190624_Positioning Flashcards

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1
Q

PNIs

A

22% of claims, 2nd only to deaths

Mechanisms of injury: stretching, compression, and ischemia

Pt positioning is always suspected

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2
Q

The position for surgery is largely DICTATED and ACCEPTED or MODIFIED by

A

the surgion

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3
Q

Primary role for the CRNA/MDA:

A

protect the airway and vascular access

promote physiologic homeostasis

all while the pt is in the required position.

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4
Q

Ulner neuropathy

A

in part, unknown

anethesia stress….virus

immunosuppression

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5
Q

Most common PNIs

A

Spinal cord
Bracial Plexis
Ulner nerve

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6
Q

Purpose of Operative Positioning

A

 Surgical Exposure and/or Surgical Access
 Comfort
 Patient Safet #1

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7
Q

Bed max weight

A

only over central column

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8
Q

Most Common Operative Positions

A 
 Supine or Dorsal Decubitus Position 
– Trendelenburg 
– Reverse Trendelenburg 
 Lithotomy 
 Prone or Ventral Decubitus Position 
 Lateral Decubitus 
 Sitting
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9
Q

Supine Position

A

Dorsal decubitus

hemodynamic reserve is maintained

Feet
– heels not hanging over bed
– heels padded
– legs not crossed

Lumbar support
– slight flexion hips and knees
– pillow under knees (caution-DVTs)
– elastic compression stockings and SCD/ sequential compression devices- increase venous return/ decrease risk DVT

Safety strap***

Arms Abducted < 90 degrees, avoids stretch brachial plexus

  • Hands- supinated (palm up) NOT pronated or
  • Draw sheet under pt. hip or torso, NOT mattress; palm in
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10
Q

Supine Position-Complications

A 
 Brachial Plexus Injury:  
Avoid abduction >90 degrees 
Produces caudal pressure in the axilla from the head of the humerus 
Avoid direct compression at neck 
Shoulder pads should be avoided

 Ulnar:
hands and forearms supinated, or
kept in a neutral pos w/ palms toward body,
proper padding at elbow

 Pressure alopecia 
 Backache 
 PNIs 
 Aortacaval compression syndrome
 Sit to supine = temp ^BP &amp; CO
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11
Q

Variations of the Supine Position

A

Lawn chair position:
Good for MAC or General
Legs elevated takes pressure off the lower back
Commonly for pt awake procedures

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12
Q

Trendelenburg

A

 Reasons: HTN, Central Line

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13
Q

Trendelenberg: Cerebral Blood Flow

A

 Increases intracranial vascular congestion ~GRAVITY!!! —INCREASED INTRACRANIAL PRESSURE— which decreases cerebral blood flow
 Intraocular pressure increases.
 Who would NOT be a good candidate for this position?
- obesity, glocoma, ICP (ex. tumor), cards complications

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14
Q

Steep Trendelenburg

A 
 steep (30-45 degrees)
 we dont like, but we do a lot
 commonly used: robotic/gyn surgeries
 Once robotic instruments are connected, OR table should not be moved.
 Arms tucked!!!

Anesthetic Concerns:
 cephalad slide ~ PNI
 How do we prevent?
- anti-skid, padding
- padding
- flexion of knees

 Use EXTREME caution with shoulder braces! - if they must be used they should be well padded and placed laterally away from the root of the neck over the arcomioclaviular joint

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15
Q

Trendelenburg complications

A

 swelling of the face, tongue (macroglossia), and/or larynx
– extubation concerns?
 stomach above the glottis—airway?
 migration of ETT?

 CV and respiratory consequences: 
– venous return = increase = work load increase
- temp BP increase
– Fnctional Residual Capacity = decrease
- Vt = decrease
– pulmonary compliance = decrease?
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16
Q

Reverse Trendelenburg

A

 “Head up”
 often facilitates upper abd sx (shifts abd contents caudad)
 Variations of this position may be used for shoulder, neck, intracranial surgery.
 This is a variation of the sitting position in terms of physiologic changes.

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17
Q

Reverse Trendelenburg complications

A

Anesthetic Concerns
 caudal slipping
 venous return? decreased
 What happens when the supine (flat) position is resumed? Temp increase in BP & Work load
 In the reverse Trendelenburg position, what happens to cerebral perfusion pressure? Decreased

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18
Q

Lithotomy position

A

 Common: GYN, rectal, and urology
 Hips flexed 80—100 degrees
 Legs abducted 30-45 deg from midline
 Knees are flexed until lower legs are parallel with torso
 If herniated disc, positioning might need to be assumed prior to anesthesia.
 Pt is usually asked to ”move down” to the foot of the bed.
 Intubation difficulties? YES
 Raising and lowering legs require a COORDINATED effort = same time same direction
 Recommendation: legs should be periodically lowered if the sx extends beyond 2-3 hours!
 Risk factors
– low BMI
– smokers
– prolonged duration of sx

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19
Q

Lithotomy complications

A

 Improper positioning may lead to the following nerve injuries: femoral, sciatic, obturator, lateral femoral cutaneous, saphenous, common peroneal*.

Anesthetic Considerations
 Requires careful positioning! 
careful padding of extremities 
watch fingers and hands 
major CRUSH injuries 
 Recommended position = armboards 
 If arms MUST be tucked, personally visualize fingers/hands prior to raising leg section
 PNI 
– common peroneal n. 
• Compression of the n. between the lateral head of the fibula and the candy-cane bar 
– sciatic 
– obturator 
– lateral femoral cutaneous

 Compartment syndrome—think perfusion

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20
Q

Lithotomy Position: Candy Can Stirrups

A

 Usually more acute flexion of the knees and/or hips  Watch injury to common peroneal nerve, femoral, sciatic

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21
Q

Lithotomy Position: Knee-Crutch Style

A

 Watch popliteal nerve (tibial nerve and common peroneal nerve

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22
Q

Lithotomy CV & Resp complications

A 
CV consequences 
• legs elevated > increase venous return 
• increases transient inc in CO 
Respiratory consequences 
• cephalad displacement of abd contents 
• decreased lung compliance 
• decreased tidal volume 
• increased peak pressures
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23
Q

Lateral Decubitus Position

Study These Flashcards
A

 Common: thorax (thoracotomy) retroperitoneal (kidney) hip
 Careful positioning! (Miller, p. 1249)
• Requires cooperation of ENTIRE team
 Focused attention to:
– head (neutral pos)-additional pillows
– arms abducted <90deg
– dependent ear
– dependent eye
 Speaking of eyes, when do you tape?
- after prop and before masking
 NIBP differences? Dep Arm > Non-Dep Arm
 Padding of bony prominences – nondependent/dependent arms – Knees (downside knee is bent) – Padding of knees • Common peroneal & saphenous n – Restraining straps

24
Q

Lateral Decubitus Position - Axillary roll

Study These Flashcards
A

 Axillary roll (I do not agree w name) – b/t chest wall and the bed just caudal to the dependent axilla (never IN the axilla)
 Purpose: ensures weight of the thorax is borne by chest wall and to avoid compression on axillary neurovascular structures.
 ALWAYS check pulse in dep arm
 Indication(s) of vascular compression?
- 5Ps
- Pulse Ox = decreased wave form

25
Lateral Decubitus Position-Pulmonary consequences
– Mechanically ventilated, paralyzed pt The dep lung is compressed by the weight of the mediastinum and cephalad pressure of abd contents Therefore ventilation is better which lung? Non-dep lung Perfusion is better in which lung? Dep-lung ~ gravity - V/Q = 0.8 Unanesthetized Anesthetized V Q V Q Non-dep Lung down down up down Dep-Lung up up down up  Awake and spontaneous breathing – Dependent (lower) lung is both better perfused and better ventilated, but lung volumes (FRC, VC, TV decrease)  Anesthetized but spontaneous breathing – Nondependent lung better ventilated and dependent lung is better perfused (V/Q mismatch)  Anesthetized, mechanically ventilated patient – Nondependent lung is overventilated and dependent lung is overperfused (worse V/Q mismatch) READ NOTES!!!!! Slide 59
26
Lateral Position: Cerebral Blood Flow
 Minimal change unless there is extreme flexion of the head.
27
Prone Position
Ventral decubitus  Thoracic Outlet Syndrome~similar to bracial plexus injury - wave arms and extend behond hea, if pain, then hands need to be placed at side!  Common: posterior fossa, post spine, perirectum, and lower extremities  Intubation of the trachea, IV access, esophageal temp probe, oral airway, foley, etc OCCURS ON THE STRECHER!  Eye care—tape, lubricant, goggles  Secure ETT very WELL  Who is responsible for coordinating the move and repositioning the head? WE ARE!!!!  MAC or GA: Flex and pad the legs  Face: facedown or turned to side  Arms: tucked @ sides or pos above above head (“Superman”)  Remember, arms < 90deg, especially if head is turned—prevention of brachial plexus injury  Padding of the elbow prevents PNT  Usually compression hose to minimize venous pooling
28
Moving into Prone Position
 Move from stretcher to OR table is a coordinated event  Who is responsible for coordinating the move and repositioning the head? WE ARE!  Disconnection vs disconnection of lines? WTF do whats safe!  After the move, immediately reapply monitors  CHECK ETT position (how?)~listen  Check head (neutral or side lying)~PMH
29
Prone Position - Anesthetic Concerns
 Mirror systems?  Horseshoe adapter?  Mayfield rigid pins (cranial or cervical spine surgeries)  check and recheck face  visual loss  ischemic optic neuropathy – intraoperative hypotension – anemia – Inc. crystalloid use – large blood loss – long duration of surgery – Head down leading to inc IOP  check abd —avoid compression – Abd pressure impedes venous return by compressing IVC, thus decreasing CO – External pressure  elevates intraabd & intrathoracic pressures – Significance? INCREASED VENOUS PRESSURES = INCREAESED bleeding  Respiratory consequences – Ext pressure on abd  dec FRC, pulm compliance, and inc peak airway press  Use bilateral firm rolls or bolsters – Clavicle to iliac crests  Check breasts and male genitalia
30
Mayfield Head Tongs/ Pins
 Watch for bolt slippage  Want natural neck alignment  Eyes, nose, chin free of pressure/ metal components touching
31
Prone Position: Cardiovascular Changes
 IVC and Aortic Compression - hypotension  Venous pooling in lower extremities hypotension – Leads to decreased preload, C.O. and BP  Hypotension associated with the move to prone position must be anticipated, monitored and treated as necessary. – Prolonged hypotension in addition to pressure on the face/eyes may lead to blindness!!
32
Prone Position: Cerebral Blood Flow
 Turning head obstructs venous drainage leading to increased cerebral volume and ICP.  Excess flexion or turning obstruction of vertebral artery flow.  Spinal cord injury from stretch
33
Prone Position: dec abd compression
 Firm rolls or bolsters – Clavicle to iliac crest  Wilson frame  Jackson frame All serve to dec abd compression by the OR table and maintain normal pulm com'  Female breast: free of compression and positioned medial to gel bolsters  Male genitalia: free of pressure
34
Prone Position: Concerning populations
 morbidly obese  resp compromised  repositioning difficulty
35
Sitting position
 sx adv: post cerv spine and post fossa – excellent surgical exposure – dec blood in operative field – reduced perioperative blood loss  sx disadv: venous and paradoxical air embolism
36
Sitting Position-Anesthesia advantages
– superior access to airway – reduced facial swelling – improved ventilation
37
Sitting Position-Anesthetic Concerns
 head may be pinned or taped  arms need supporting to the point of slight elevation of the shoulders  knees slightly flexed to reduce stretching on sciatic nerve  feet supported and padded  Monitor BP in reference to the level of brain  Avoid and rapidly treat hypotension or bradycardia  Careful positioning of head to prevent occlusion of cerebral vessels  Monitoring of CPP, if available
38
Sitting Position-Anesthetic Concerns-HEMODYNAMIC EFFECTS
``` DRASTIC HEMODYNAMIC EFFECTS Pooling of blood = hypotension • incremental positioning • IVFs, vasopressors • adjustment of anesthetic depth • leg compression devices = maintain VR ```
39
Sitting Position-Anesthetic Concerns-Head and neck position
– Hyperextension = cervical cord injuries – Flexion = impedance of blood flow • hypoperfusion or venous congestion of brain • impedance of breathing / blockage of ETT • pressure on the tongue • midcervical tetraplegia  Rule of Thumb: maintain @ least 2 FBs distance b/t the mandible and the sternum
40
Beach Chair: Variation of Sitting Position
 Common: shoulder surgery  Surgical adv: superior access to shoulder when compared with lat dec. position  Better mobility/manipulation of joint
41
Beach Chair: Variation of Sitting Position-neuro & CV alterations
Significant neuro & CV alterations: Pooling  decreased venous return – Reduced CPP – Reduced preload, CO, BP! – Hypotension (deliberate or permissive) • loss of compensatory mech a/w anesthesia • Failure to compensate for height of head ****delta = 0.77mmHg/cm, 1mmHg/com, 2mmHg/2.5com ***CPP = 35 = flatline EEG, = 20 = irreverable damage
42
Sitting Position: Ventilatory Changes
 Lung volumes and capacities increase  Lung compliance increases  Work of breathing easier  Mechanical ventilation and spontaneous ventilation easier in this position
43
Sitting Position: Venous Air Embolism (VAE)
 Elevation of the surgical field above the heart and open dural sinus (creation of pressure gradient between the atmosphere and the veins) might cause VAE  VAE is a risk ANY TIME the surgical site is above the level of the heart !!!  Inability of venous sinuses to collapse  It is a potentially LETHAL complication!  Detection of entrained air with TEE or precordial Doppler ultrasound
44
Signs of VAE
change in heart tones (wind mill murmur) heard via doppler placed at the parasternal border (2nd-6th IC space), new murmur, dysrhythmias, hypotension, desaturation, DECREASED EtCO2, Nitrogen in exhaled gas, circulatory compromise, and cardiac arrest
45
Sitting Position: Venous Air Embolism (VAE) Treatment
– Flood surgical field with NS, apply wax to cut bony edges, close any open vessels – D/C nitrous oxide – Place on 100% O2, PEEP – T-berg position – Aspirate air from right atrium via a catheter
46
Brachial Plexus
 The Risk: The nerve travels a long superficial course through fixed points * cervical vertebrae * axillary fascia
47
Brachial Plexus Injury
 Positioning injury occurs with – neck extension, head turned to side, or sagging sideways – excessive abduction of arm > 90 degrees – arm/ arm board falls off table – depressed sagging shoulders (prone/sitting) – extending arms overhead (prone) – compression plexus against thorax (lateral) – shoulder braces – sternal retractors in cardiac surgery
48
Brachial Plexus: Deficit if injured
– limp or paralyzed arm – lack of muscle control in arm, hand, wrist – lack of sensation in arm or hand
49
Ulnar Nerve
 Nerve runs in groove between olecranon of ulna and medial epicondyle of humerus
50
Ulnar Nerve injury
 Injury with: – compression of nerve between the olecranon of ulna & medial epicondyle of humerus (entrapment with arm extension) – stretch with severe elbow flexion – dislocation over medial epicondyle with pronation hand causing stretching – compression against bed – misplaced BP cuff
51
Ulnar Nerve Deficit if injured
 Inability to abduct or oppose 5th finger  Loss of grip strength, esp. ulnar side of fist  Loss sensation palmar surface of hand, 4th or 5th fingers  Eventually, leads to atrophy of intrinsic muscle of hand (claw hand)
52
Common Peroneal Nerve Injury
 Most frequently damaged nerve of lower extremity  Branch of sciatic  Injury from – Compression of lateral aspect of knee against stirrup or lateral position  Symptoms – foot drop, inability to evert the foot, loss of dorsal extension of toes
53
Sciatic Nerve Injury
 Sciatic nerve injury – excessive external rotation hips; hyperextension of knee – pressure in sciatic notch from stretching  Symptoms – weakness or paralysis of muscles below knee; numbness of foot & lateral half of calf; foot drop
54
Femoral Nerve Injury
 Injured with compression at pelvic brim by retractor or excessive angulation of thigh/ abduction of thighs and external rotation of hips  Results in loss of flexion hip and loss of extension of knee; decreased sensation over superior aspect thigh
55
Saphenous Nerve Injury
 Occurs when medial aspect of lower leg compressed against support bar  Results in paresthesias medial and antermedial side of calf
56
Lower Extremity Compartment Syndrome
 Occurs when perfusion to an extremity is inadequate, resulting in ischemia, edema, and extensive rhabdomyolysis from increased tissue pressure  Occurs with long surgical procedures (> 2-3 hours)  Occurs with lithotomy and lateral decubitus positions  Treatment is fasciotomy
57
PNI Worksheet??????????????
= Test questions WTF is this work sheet??????

NURA 641 Intro to Nurse Anesthesia (8 decks)

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