Operative positioning Flashcards
1) What should your documentation be composed of?
2) How can you avoid liability?
1) Documentation- describe baseline range of motion, describe intra-operative position, use of padding, frame, body position, checks done and frequency, etc.
2) Liability- avoided by responsible, vigilant care; documentation
What is the purpose of operative positioning?
●Comfort
●Patient Safety
●Surgical Exposure and/or Surgical Access
What is the weight and length limit of the OR table?
136 kg (300 lbs) and 80.7 inches (205 cm or 6.7 ft)
Why is the supine position most common operative position and the Position preferred by anesthesia providers?
1) access to airway
2) access to arms for IV’s/monitors
3) less physiologic changes than in other positions
Why would you want to put a pillow under the head when a patient is in the supine position?
–Allows proper sniffing position
–Avoids dorsal extension and lateral flexion of neck
–Doughnut shape pillow - avoids alopecia
–No pressure on eyes
What should you do with the arms when a patient is in the supine position?
1) Tuck arm: Draw sheet under pt. hip or torso, NOT mattress; elbow padded; palm in.
2) Arm boards •Properly secured to OR table •Abducted < 90 degrees, avoids stretch brachial plexus •Padded •Safety straps •Hands- supinated (palm up) NOT pronated
What should you do with the feet when a patient is on the supine position?
1) Heels not hanging over bed
2) Heels padded
How can you provide a lumbar support when a patient is on the supine position?
1) Slight flexion hips and knees
2) Pillow under knees (caution)
3) Legs/feet should not be crossed
4) Elastic compression stockings and SCD/ sequential compression devices- increase venous return/ decrease risk DVT
●Safety strap
What are the mechanisms of nerve injury?
1) Stretching
2) Compression
3) Kinking
4) Ischemia
5) Transection
How can injury to the brachial plexus occurs in the supine position?
1) neck extension,or head turned to side
2) excessive abduction of arm > 90 degrees
3) arm/ arm board falls off table: Mostly stretching injuries
What are the deficit seen when the brachial plexus is injured in supine position?
1) electric shocks or burning sensation shooting down arm,
2) numbness or weak arm function
How can radial nerve injuries occur in a supine position?
Injury due to external compression of the radial nerve on the lateral aspect of the humerus against –Surgical retractors –Ether screen –Mismatched arm board (“step off”) –Repeat BP inflation
What is the results of a radial nerve injury in a supine position?
Injury results in wrist drop/ weakness in abduction of the thumb/ numbness 1, 2, ring fingers, inability to extend elbow
What is the most common postoperative peripheral nerve injury in supine position?
Ulnar Nerve
Where and how does injury to the ulnar nerve occur when a patient is in the supine position?
1) In cubital tunnel @elbow groove – compression of nerve between the olecranon of ulna & medial epicondyle of humerus (entrapment with arm extension)
2) Also, injured by stretch with severe elbow flexion, dislocation with pronation hand, nerve dislocation over medial epicondyle w/ stretching, compression against bed
What is the result of ulnar nerve injury in supine position?
1) Inability to abduct or oppose 5th finger
2) Weak grip ulnar side of fist
3) Loss sensation palmar surface 4th or 5th fingers
4) Eventually, leads to atrophy of intrinsic muscle of hand (claw hand)
How can you reduce the risk of ulnar injury in a supine position?
1) Pad arm boards
2) Avoid downward compression by strap
3) Assure surgical personnel do not compress patient’s arm
4) Place BP cuff proximally so that it does not impose on ulnar groove or cubital tunnel
6) Avoid prolonged FLEXION of elbow
What are some Cardiovascular changes seen in a supine position?
MINIMAL effects on circulation and perfusion.
1) Initially, have increased venous return to heart
–Increased preload, stroke volume, CO, BP
–This activates baroreceptors which decrease sympathetic outflow and increases parasympathetic impulses
–Compensatory decreases HR, PVR
2) Reduced venous drainage from lower extremities – uncross legs, pad heels, pillow beneath knees, flexed hips and knees = all improve venous return
3) IVC compression by masses, pregnancy, obese abdomen or ascites may decrease venous return to the right heart and decrease cardiac output.
What are some ventilatory changes seen in the supine position?
1) FRC decreases +/- 800 ml, r/t cephalad displacement of the diaphragm and compression of lung bases
2) Lung volumes further reduced by muscle relaxants
–Loss of chest wall muscle tone with muscle relaxants – reduces opposition to inherent elastic recoil of pulmonary tissues.
–Overcome with positive pressure ventilation.
What are some cerebral blood flow changes seen in supine position?
Minimal change r/t “tight” autoregulation
Why would want to put a patient in a tredelenberg position?
1) Used to treat hypotension by increasing venous return
2) Improves surgical exposure during abdominal and laparoscopic surgery
3) Helps prevent air embolism
4) Facilitates cannulation during central line placement
What are some precautions you be thinking when a patient is on tredelenberg position?
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
What are some cardiovascular changes seen in patients on tredelenberg position?
1) Used to counteract hypotension - controversial (short term only)
–Increases venous return to the heart - up to 1L into central circulation
2) Causes reduced blood flow to the lower extremities
3) May cause compression of heart by abdominal contents pushing cephalad
4) Baroreceptors activated – peripheral vasodilation and bradycardia- may make “shock syndromes” worse in the long run
●What happens when the supine position is resumed?
What are some ventilatory changes seen in tredelenberg position?
1) Contents of the abdomen displaced cephalad impeding diaphragmatic excursion, compresses lung bases, decreases lung compliance, decreases FRC, PIP increases.
2) With spontaneous ventilation, work of breathing is increased.
3) V:Q mismatch with perfusion exceeding ventilation in the apex of the lung.
3) ETT is easily shifted into right mainstem bronchus as abdominal/thoracic contents shift cephalad.
4) Risk of aspiration
5) Face and airway edema can lead to airway obstruction
What are some cerebral blood flow seen in tredelenberg?
1) Increases intracranial vascular congestion- GRAVITY!!!
2) INCREASED INTRACRANIAL PRESSURE–
3) Intraocular pressure increases.
4) Who would NOT be a good candidate for this position? CNS disease and glaucoma.
When would you want to use the reverse trendelenberg position?
1) Utilized to enhance surgical exposure of the upper abdomen by shifting the abdominal contents caudad.
– ex. laparoscopic cholecystectomy
2) Variations of this position may be used for shoulder, neck, intracranial surgery.
2) This is a variation of the sitting position in terms of physiologic changes.
What are some precautionary measure with using the reverse trendelenberg position?
Caution with foot board
Excessive plantar flexion of the feet for extended periods of time
–Anterior tibial nerve injury
–Results in foot drop
