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6900 > Patient Positioning > Flashcards

Patient Positioning Flashcards

1
Q

What do you document from patient positioning?

A
  • Pre-op patient limitations in movement strength, nerve abnormalities.
  • Numbness, tingling, loss of sensation to any extremity pre-op
  • Foot drop
  • Head movement limitations
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2
Q

Head-up, sitting, and lithotomy position effect on hemodynamic changes

A

Regions above the heart at risk for hypoperfusion and ischemia (esp if hypotensive), COP decreased 20%

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3
Q

Prone and lateral position effect on respiratory system

A

Redistribute ventilation and perfusion the most in these positions

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4
Q

Lateral decubitus position effect on respiratory system

A
  • Abdominal contents shift cephalad
  • Anesthetized patient: Dependent lung (down) underventilated but gravity favors blood flow there. Nondependent lung (up) is over ventilated
  • Awake patient: Dependent lung has increased ventilation and blood flow
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5
Q

Prone position effect on respiratory system

A

Decreased diaphragmatic excursion, abdomen hangs free

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6
Q

Lithotomy and Trendelenburg position effect on respiratory system

A
  • Abdominal viscera shifted cephalad

- TLC, VC, and FRC all decreased

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7
Q

Steep Trendelenburg position effect on respiratory system

A
  • ETT migrates to right mainstem bronchus (recheck breath sounds after position change)
  • Increased pulmonary venous pressure
  • Decreased pulmonary compliance, FRC (d/t increased central venous pressure from abdominal contents shifting cephalad against diaphragm)
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8
Q

How to prevent V/Q imbalance with positioning

A

Increase FIO2, TV, RR, maybe PEEP to improve oxygenation

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9
Q

Position that helps lung capacities

A

Sitting, some say prone

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10
Q

Nerve injuries caused by: (3 things, and common component of all causes)

A
  • Transection (trauma, surgical maneuvers)
  • Compression, kinking (against bony prominence, 2 immovable structures, or a hard surface)
  • Stretch (causes conduction changes, axonal disruption, or interruption of vascular supply) Common in sciatic or brachial plexus
  • Common component of all: Ischemia
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11
Q

Patient risk factors for peripheral nerve injuries

A
  • Male
  • Increased muscle decreased adipose
  • Body habitus (underweight, obese, bulky)
  • DM, HTN, PVD, neuropathy, ETOH
  • Smoking within 1 month of surgical procedure
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12
Q

Most common nerve injury in anesthetized patient

A

Ulnar Neuropathy

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13
Q

Ulnar nerve injured when:

A

Compressed between medial epicondyle and armboard or bed

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14
Q

Recommendations to avoid ulnar neuropathy

A
  • Tuck arms at the side of the body with palms facing inward
  • Place arms in supine position (palm up) and abduct <90 on arm board
  • Avoid over flexion of the elbow if secured across chest or in lateral position
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15
Q

Brachial Plexus Injury vulnerable in ___ position

A

Almost every surgical position (2nd most common peripheral nerve injury)

  • Turning head stretches and compresses the contralateral brachial plexus under the clavicle
  • Shoulder braces-place over acromion and distal clavicle (not mid clavicle or root of neck)
  • Lateral decubitus compresses lower shoulder/axilla - axillary roll caudal to dependent axilla relieves pressure
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16
Q

Common peroneal injury

cause, presentation, prevention

A

Most common injury in lithotomy position

  • Happens when lateral knee is compressed against stirrup
  • Presentation: Foot drop, loss of dorsal extension of toes, inability to evert foot
  • Prevention: Pad between leg and stirrup, flex knees with minimal rotation
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17
Q

Sciatic injury

cause, presentation, prevention

A
  • Cause: Excessive flexion of hips from overstretching in lithotomy or sitting with legs strait
  • Presentation: Weakness in all muscles below the knee, foot drop
  • Prevention: Pad under buttocks, avoid external rotation of hips, flex table at knees
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18
Q

Femoral nerve injury

Cause, Presentation

A
  • Cause: Trapped under inguinal ligament from extreme flexion/abduction of thighs or excessive traction during lower abdominal surgery
  • Presentation: Decreased knee jerk, loss of flexion of hip and extension of knee, reduced sensation over anterior thigh
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19
Q

Saphenous nerve injury

Cause, presentation, prevention

A
  • Cause: Medial tibial condyle compressed by leg support in lithotomy position
  • Presentation: Parasthesia along medial/anteriomedial calf
  • Prevention: Pad between leg and stirrup
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20
Q

Anterior tibial nerve injury

Cause, presentation

A
  • Cause: Feet plantar flexed for extended period of time (sitting, prone)
  • Presentation: Foot drop
21
Q

Obturator nerve injury

Cause, presentation, prevention

A
  • Cause: Excessive flexion of thigh to groin, excessive traction during lower abdominal surgery or forceps delivery
  • Presentation: Inability to adduct leg, diminished sensation along medial thigh
  • Prevention: Minimize hip flexion
22
Q

Postoperative visual loss treatment

A

Immediate ophthalmologist consult

23
Q

Ischemic optic neuropathy

A
  • 89% of POVL after prone spinal procedures

- Commonly caused by decreased ocular perfusion and increased intraocular pressure

24
Q

Postoperative visual loss prevention

A
  • Avoid hypotension, especially if pt has history of hypertension
  • Avoid direct pressure over eyes
25
Q

Corneal abrasion

A

Most common type of eye injury

  • Eyes should be protected and frequently checked during surgery
  • Usually resolves without sequelae in several days
26
Q

Facial nerve injury

Cause and branches of facial nerve

A
  • Cause: Face straps that are tight across face with prolonged use
  • Branches of facial nerve: Two zebras bit my cat
  • Temporal
  • Zygomatic
  • Bucal
  • Mandibular
  • Cervical
27
Q

Compartment Syndrome

A
  • Damage to neural and vascular structures from tissue swelling
  • Increased pressure and decreased perfusion in muscles with tight fascial borders
28
Q

Venous Air Embolism

Positions, cause, manifestation

A
  • Positions: Sitting position or any where negative pressure gradient exists between right atrium and veins at operative site (spinal surgery)
  • Manifestation: Small amounts of air-decreased SaO2, decreased EtCO2, hypotension, arrhythmias. Large volume-cardiac arrest
29
Q

Venous air embolism on monitors

A
  • Esophageal or precordial stethoscope: mill-wheel murmur

- Precordial Doppler: place over 3-6 intercostal space to right of sternum after in sitting position

30
Q

Venous Air Embolism treatment

A
  • Surgeon flood field with saline, apply bone wax to boney edges
  • Aspirate through CVP, give 100% O2
  • Head down, tilt to left
31
Q

ETT displacement with surgical positions

A

Right mainstem with steep Trendelenburg and neck flexion

32
Q

Airway edema with surgical positions

A
  • Edema in face or tongue says pharynx is edematous
  • Prone/Trendelenburg: increased hydrostatic pressure
  • Sitting position: WIth excessive neck flexion-venous drainage from head impaired
  • Equipment may limit lymphatic drainage (oral airway, ETT, esophageal stethoscope)
33
Q

Where to place pillow during lawn chair position

A

Under patients knees

  • Decreases back pain
  • Facilitates venous drainage from LE
  • Decreases anterior abdominal wall tension during closure
34
Q

Attention to ___ during lithotomy position

A

-Fingers when arms are at sides and the feet of OR table are lowered

35
Q

Moving the table during lithotomy position

Also HD effect of movement

A
  • Legs elevated and lowered simultaneously

- Leg elevation=increase in venous return-transient rise in CO/ICP

36
Q

Alterations in ____ most responsible for hemodynamic changes during anesthesia position changes

A

Pre-load

37
Q

Nerves at risk for injury in lithotomy position

A
  • Peroneal (most common) and Saphenous-leg compressed by leg support (manifestation=peroneal-foot drop, saphenous-paresthesia along medial/calf)
  • Obturator, femoral, sciatic-hip flexion >90 (manifestation=obturator-inability to adduct leg, decreased sensation along medial thigh, femoral-loss of hip flexion/knee extension, sciatic-weakness in all muscle below knee, foot drop)
38
Q

Compartment syndrome from lithotomy position

A

From leg holders-inadequate perfusion

  • Rare but can progress to rhabdo and/or reperfusion injury
  • Surgical time>2 hours increases risk
39
Q

Axillary roll in lateral decubitus position

A

Prevents compression injury to the brachial plexus on dependent side

40
Q

Monitor SaO2 in ___ arm in lateral decubitus position

A

Dependent arm (to assess compromised blood flow and bundle compression

41
Q

Flex point for lateral decubitus position

A

Should be under dependent iliac crest (not rib cage) to prevent compression of inferior vena cava

42
Q

___ space on neck for sitting position

A

At least 2 fingerbreadths between neck and mandible to prevent midcervical tetraplegia

43
Q

Sitting position effect on BP in brain

A

Every 1 inch change of cuff position there is a 2mmHg rise or drop in MAP (or 1.25cm-1mmHg)
-Measure vertical distance between external auditory meatus and BP cuff, brain MAP will be 8-24mmHg lower

44
Q

Turning the patient from supine to prone

A
  • Place on 100% FiO2
  • Disconnect from breathing circuit for turn
  • CRNA controls airway/head/neck
  • Check breath sounds after intubation and after positioning
45
Q

Head and neck position when prone

A

Neutral position, avoid hyperextension or lateral rotation of neck (may compromise spinal cord blood flow)

46
Q

Arm position when prone on arm boards

A

Alongside head on padded arm boards, flexed and slightly abducted (<90) with forearms/hands lower than shoulders
-Pad under shoulders (avoid stretching brachial plexus)

47
Q

Arm position when prone at sides

A

Natural position, palms facing thighs using plastic or metal arm sleds with sufficient padding

48
Q

Prone position head inspection

A

Head, eyes, face, airway must be checked every 15 minutes to ensure weight is on bony structures only and no pressure on eyes

6900 (12 decks)

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