Operative Positioning Flashcards by Hailey Haas

Who is responsible for making sure no nerve or soft tissue injury and treating physiological changes in OR

Anesthetist

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What is primary concern

Patient safety and comfort

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Documentation:
Describe baseline \_\_ \_\_ \_\_
Describe \_\_ \_\_ 
Use of \_\_\_, \_\_, \_\_ position 
\_\_ done and \_\_\_

Range of motion
Infra operative position
Padding, frame, body
Checks, frequency

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OR table
Weight limit
Length

136 kg or 300 lbs

80.7 inches

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During transfer what is anesthesia responsible for

Head, neck, ivs, monitors

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Safety strap
What it doesn’t do
What it does do

Doesn’t hold pt on table

Reminds them if they wake up to stay on table or keeps extremities on table

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Most common positions 
Supine or \_\_ which can go to \_\_ or \_\_ \_\_
\_\_\_\_
Prone or \_\_\_ \_\_ position 
\_\_\_ \_\_\_ 
\_\_\_

Supine or dorsal decubitus: trendelenburg or reverse trendelenburg

Lithotomy

Ventral decubitis

Lateral decubitis

Sitting

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Supine 
\_\_ \_\_ operative position 
Position preferred by \_\_\_\_ 
Access to \_\_\_, \_\_ for \_\_ and \_\_
Less \_\_\_ changes than other positions

Most common
Anesthesia
Airway, arms for ivs and monitors
Physiologic

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Pillow under head in supine 
Allows proper \_\_\_ position 
Avoids \_\_\_ extension and \_\_ flexion of neck- avoids plexus stretch or vascular compromise 
Doughnut shaped pillow avoids \_\_\_\_ 
No pressure on \_\_\_

Sniffing
Dorsal, lateral
Alopecia
Eyes

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Arm boards in supine
Arms abducted __ __ degrees
Hands __ with palm __ not __

Less than 90 degrees

Supination, up, pronated

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Arms tucked in supine
__ __ under pt __ or __ not ___
___ padded with palm __

Draw sheet, hip or torso, mattress

Elbow, in

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Supine

Feet: heels not __ __ bed, heels __, legs not __

Hanging over
Padded
Crossed

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Supine lumbar support
Slight \_\_\_ of hips and knees 
Pillow under \_\_\_
\_\_/\_\_ shouldn't be crossed
\_\_ and \_\_ are highest points of spine when supine

Flexion
Knees
Legs/feet
C5 and L3

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Mechanisms of peripheral nerve injury

Stretching 
Compression 
Kinking 
Ischemia 
Transection

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Brachial plexus
Nerve travels a __ __ course through fixed points
The __ __ fascia
Runs through __, __, and __

Long superficial
Vertebral foramina
Clavicle, scapula, humerus

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Brachial plexus

Positioning injury occurs with __ extension, head ___ to __, or sagging ___

Excessive ___ of arm greater than __ degrees

__ or __ __ falls off of table

Neck, turned to side, sideways

Abduction, 90

Arm or arm board

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Brachial plexus injury

___ __ shoulders in __ or __ position

Extending arms overhead in __ position

Compression against __ in __ position

Depressed sagging, prone or sitting

Prone

Thorax, lateral

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Brachial plexus injury

___ braces

__ __ in cardiac surgery

Deficit if injured

__ or __ arm

Lack of muscle control in __, __, __
Lack of sensation in __ or ___

Shoulder

Sternal retractors

Limp or paralyzed

Arm, hand, wrist

Arm or hand

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Radial nerve injury

Due to __ __ of radial nerve on the __ aspect of the __ against: surgical __, __ screen, ___ arm board, repeat __ __

External compression
Lateral, humerus
Retractors, ether, mismatched, BP inflation

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Radial nerve deficit

Loss of __ of forearm
Weakness of __
Loss of __ of hand, __ drop, __ affected
Loss of sensation in __ arm, __ forearm, and part of __

Extension

Supination

Extension, wrist, fingers

Lateral, posterior, hand

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Most common post op peripheral nerve injury

Ulnar nerve

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Ulnar nerve runs in groove between __ of ulna and __ __ of humerus

Olecranon, medial epi condyle

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Ulnar nerve

Injury with compression of nerve between the olecranon of __ and medial epicondyle of __ (___ with arm __)

__ with severe elbow ___

Ulna, humerus
Entrapment, extension

Stretch, flexion

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Ulnar nerve injury

__ over medial epicondyle with __ of hand causing stretching

Compression against ___

Misplaced __ __

Dislocation, pronation

Bed

BP cuff

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Ulnar nerve injury Inability to __ or __ 5th finger Loss of __ strength, esp ulnar side Loss of sensation of __ surface of hand, __ or __ fingers Eventually leads to atrophy of __ muscle of hand: __ hand

Abduct or oppose Grip Palmar, 4th or 5th Intrinsic, claw

Supine CV changes Minimal effect on __ and __ Initially have increased __ __. Increased __, __ ___, __, and __. This activates baroreceptors which __ sympathetic outflow and increases __ impulses. Leads to decrease of __ and __ if not blunted by ___

Circulation and perfusion Venous return. Preload, stroke volume, CO, BP Decreases, PNS HR and PVR, anesthetics

Supine CV changes Have reduced __ __ due to venous pooling in lower extremities Decreases __ and __ Increases __

Venous return CO and BP HR

Supine CV changes -__ compression by masses, pregnancy, obese abdomen, or ascites __ decrease ___ __ to the __ __ and decrease __ __ even more

``` IVC May Venous return Right heart Cardiac output ```

Supine ventilatory changes | __ __ __ decreases +/- ___ ml due to cephalad displacement of the __ and compression of lung bases

Functional residual capacity, 800 | Diaphragm

Supine vent changes Lung volumes reduced by __ __ -loss of chest wall muscle tone with muscle relaxants reduces __ to inherent elastic recoil -overcome with __ __ __

Muscle relaxants Opposition PPV

Supine cerebral blood flow - __ change due to __ __ - there for ICP ___

Minimal, tight auto regulation | Unchanged

Trendelenberg - used to treat __ by increasing __ __ - improves __ __ during abdominal and laparoscopic cases - helps prevent __ __ - facilitates __ during CVL placement

Hypotension, venous return Surgical exposure Air embolism Cannulation

Trendelenburg Extreme caution with __ __ Place __ from root of neck over the __ __

Shoulder braces | Laterally, acromioclavicular joint

Trendelenberg CV changes - counteracts hypotension __ __ - increases venous return up to __ __ into central circulation - increases __ workload

Short term 1 L Heart

Trendelenberg CV changes - causes ___ blood flow to lower extremities - may cause compression of __ by abdomen pushing __ - __ __ congestion - ___ activated which leads to: peripheral __ and __, decreases __ __ and may make __ __ worse in the long run

``` Reduced Heart, cephalad Pulmonary vascular Baroreceptors, vasodilation, bradycardia, cardiac output Shock syndrome ```

Trendelenberg vent changes | -decreased __ __ and ___, increased __ and __ __ __

Lung compliance, FRC | PIP and pulmonary vascular congestion

Trendelenburg vent changes - with spontaneous vent work of breathing is __ - VQ mismatch with __ exceeding __ in apex of lung - what can happen to ETT - risk of __ - what can lead to airway obstruction

``` Increased Perfusion, ventilation Dislodged into right bronchus Aspiration Face and airway edema ```

Trendelenburg CBF How ICP affects CBF What other pressure changes due to this position

Increased ICP decreases CBF | Intraocular pressure increases

Reverse trendelenburg Used for surgical exposure of what, 1 specific ex Variations may be used for 3 other surgeries Variation of which position in terms of physiologic changes

Upper abdomen Lap cholecystectomy Shoulder, neck, intracranial surgery Sitting position

Reverse trendelenburg Caution with what Excessive __ __ of feet can cause __ __ nerve injury which results in what

Plantar flexion Anterior tibial Foot drop

Reverse trendelenburg cv changes - ___ venous return leads to __ preload, __ co (__-__%), and __ BP - compensatory __ SNS tone, __, and __ by +/- __% which may be blunted by __

Decreased, decreased, decreased, 20-40, decreased Increased, SVR, HR, 30, anesthetics

Reverse trendelenburg vent changes - abdomen __ __ impede diaphragmatic excursion, FRC __ - Ventilation is __

Does not Increases Easier

Reverse trendelenburg CBF - CBF __ proportional to the degree of the __ __ (can be up to __%) - __ decreases

Decreases, head tilt up, 20 ICP

Lithotomy position - hips flexed __-__ degrees - legs abducted __-__ degrees from midline - Lower legs __ to torso - watch __, __, and __ __ nerves

80-100 30-45 Parallel, femoral, sciatic, lower leg

Lithotomy candy cane stirrups - __ __ flexion of the knees and or hips - common injury to __ __ nerve most, then __ and __

More acute Common peroneal, sciatic, femoral

Lithotomy knee crutch Watch __ nerve 1st Then also __ nerve and __ __ nerve

Popliteal Tibial and common peroneal

Lithotomy Used for __, __, and __ procedures Both legs positioned together to prevent __ of __ spine and hip flexion beyond __ degrees Improper positioning can lead to nerve injuries in 6

Gyn, gu, rectal Torsion, lumbar, 110 Femoral, sciatic, obturator, lateral femoral cutaneous, saphenous, common peroneal

Most common damaged nerve of lower extremity

Common peroneal nerve

Common peroneal nerve injury Branch of __ Injury from __ of lateral aspect of knee in __ or __ position Symptoms: __ __ and inability to __ foot, loss of ability to __ __ toes

Sciatic Compression, stirrup, lateral Foot drop, evert, dorsally extend

Sciatic nerve injury From excessive __ __ of __ Pressure in __ notch from __ Weakness or paralysis of muscles __ knee, __ foot, and __ half of calf.foot __

External rotation, hip Sciatic, stretching Below, numbness, lateral Foot

Femoral nerve injury From __ at __ brim by __ Or excessive __ of thigh or __ of thighs and __ __ of hips

Compression, pelvic, retractor Angulation, abduction, external rotation

Femoral nerve injury Results in loss of __ of hip and loss of __ of knee Decreased sensation over __ aspect of __

Flexion, extension Superior, thigh

Saphenous nerve injury Occurs when __ aspect of lower leg is __ against support bar Results in __ in __ and __ side of calf

Medial, compressed Parenthesis, medial, antermedial

Lower extremity compartment syndrome - occurs when __ to an extremity is inadequate, resulting in __, __, and extensive __ from increased __ pressure - occurs with long surgical cases >__-__ hours - occurs with __ and __ __ positions

Perfusion, ischemia, edema, rhabdomyolysis Tissue 2-3 Lithotomy and lateral decubitus

Lithotomy CV changes | -__ venous return, __ preload to heart with __ increase in __ and increase in __

Increased, increased, transient, CO, BP

Lithotomy CV changes - perfusion to __ __ reduced - perfusion pressure changes __ mmHg for each __ cm that a given point varies in vertical height above or below __

Lower extremities | 2, 2.5, heart

Lithotomy vent changes Depending on degree of __ __ abdominal contents may push on diaphragm and impede __ with a decrease of lung __ and decrease __ and __ __

Hip flexion, excursion | Compliance, TV, vital capacity

___ risk increases in lithotomy

Aspiration

Lithotomy cerebral changes | __ __ in cerebral venous blood flow and increase in __ __ with legs elevated

Transient increase, ICP

__ head tongs Watch for bolt __ Want natural __ alignment __, __, and __ free from pressure or metal parts touching

Mayfield Slippage Neck Eyes, nose, chin

Prone position Do what first Check __ and __ working __ and __ supported to allow for free __ __ movement and increased __ __

Check lung sounds IV, a line Chest and hips, abdomen diaphragmatic Neck alignment

Head prone position Head can be turned to side if adequate ___ Caution of obstruction of __ __ drainage and __ __ flow __, __, and __ free of pressure

Mobility Jugular venous, vertebral artery Eyes, nose, ears

Prone position eye injury Direct __, __ eye, __ Treatment is __ __ and eye patch

Trauma, dry, swelling | Antibiotic ointment

Prone position Blindness caused by __ __ __ via __ __ or __ obstruction By sustained direct pressure on eye/__ Leads to visual __, __ or __ blindness

Ischemic optic neuropathy, central vein or artery Retina Changes, partial, complete

Risk factors for ischemic optic neuropathy: __ position, operative __, large operative __ __, large __ use Pt specific risk factors: 6 Inc risk in __ and __ surgery

Prone, hypotension, blood loss, crystalloid Anemia, smoker, diabetes, male, vascular pathology Spinal and cardiac

Prone position extremities Where arms are, abducted how many degrees, extra padding where, prevent shoulders from what

On boards by head, less than 90, at elbow, sagging

Prone position extremities Watch for __ __ syndrome. If present do what to arms Legs: __ __ and wear what

Thoracic outlet, arms tucked at sides Slightly flexed, SCDs or TED hose

Prone position CV changes __ and __ compression lead to __ __ __ in lower legs leads to ___ In effect these decrease 3

IVC and aortic, hypotension Venous pooling, hypotension Preload, CO, BP

Prone position vent changes - posterior ventilation __ perfusion - anterior perfusion __ ventilation - lung compliance __. __ __ pressures increase. __ of __ increases - use of what frees chest excursion, and __ __ __ overcomes compression

- greater than - greater than - decreases. Peak airway. Work of breathing. - Rolls or bolsters, positive pressure ventilation

Prone position and CBF -turning head obstructs __ __ leading to __ __ volume and __ Excess flexion or turning obstructs __ __ flow __ __ injury from stretch

Venous drainage, increased cerebral, ICP Vertebral artery Spinal cord

Lateral decubitis position Used for 4 surgeries __ support to prevent brachial plexus injury Limit pressure on dependent __ and __ __ roll placed __ to and __ of __ axillary

Shoulder, hip, kidney, thoracotomy Head Eye and ear Axillary, caudad, outside of lower

Lateral position Arms: dependent vs non dependent Legs: padding between legs and flexed __ leg to prevent which nerve injury. Padding on bed to prevent which nerve injury

Dependent arm on padded arm board perpendicular to torso Non dependent arm supported over folded bedding or suspended w arm rest Dependent, saphenous nerve. Common peroneal.

Lateral position __/__ support __ __ or __ posts Safety strap between __ of __ and __ __

Anterior posterior Bean bag or hip Head of femur and iliac crest

Lateral position cv changes ___ change __ change in CO unless venous return obstructed by __ resting on vena cava NIBP __ in __ arm

Minimal No, kidney Higher in dependent

Lateral position vent changes | Awake and spontaneous breathing: lower lung is __ perfused and __ ventilated, but __, __, and __ increase/decrease

Better, better, FRC/Vc/tv decrease

Lateral position vent changes Anesthetized but spontaneous breathing -__ lung better ventilated and __ long is better perfumed Anesthetized and ventilated -non dependent lung is __ and dependent lung is __ (__ VQ mismatch)

Non dependent, dependent Over ventilated, over perfused, worse

Lateral position CBF | __ change unless there is extreme __ of head

Minimal, flexion

Sitting position Used for 3 types of surgery Facilitates __ drainage

Cranial, shoulder, numeral Venous

Sitting position Head fixed in __ or __ Avoid excessive __ __ which obstructs venous outflow causing __ -or __ __ of brain, stretches __ nerve roots, can obstruct __, and can cause pressure on __

Pins or tape Flexion, hypo perfusion, venous congestion, cervical ETT, tongue

Sitting position Want at least __ __ between mandible and sternum Avoid rigid __ __ which can lead to __ ischemia

2 finger breadths Bite block, tongue

Sitting position Arms: prevent pressure on __ and __ them to prevent pulling on shoulder Buttocks: positioned in __ of table __ knees and hips to decrease stretch of __ nerve

Frame, support Crease Flex, sciatic

Sitting position CV changes -pooling of blood decreases __, __, and __ ____** -__ and __ increase to compensate but blunted by anesthetics -treatment 5

Co, BP, preload Hypotension HR and SVR Ivf, pressers, adjust anesthetic depth, stockings, active leg compression

Sitting position vent changes Lung __ and __ increase ______ easier

Volume and capacity WOB

Sitting CBF CBF __ ICP __ Positioning can impede flow and cause __ or __ __ of brain

Decreased Decreased Hypo perfusion or congestion

Sitting venous air embolism - risk __ __ during procedure when the __ __ is above the level of heart - inability of __ sinuses to __

Venous air embolism, surgical site Venous, collapse

Sitting air embolism Signs: change in __ tones (__ __ murmur) heard via __ placed at ___ border which is __-__ IC space, __ murmur, __, __, __, decreased __, ___ in exhaled gas, circulatory compromise, __ __

Heart, wind mill, Doppler Parasternal, 2-6th, new, dysrhythmias, hypotension, desat, etco2 Nitrogen, cardiac arrest

Sitting air embolism detected with __ or __ __ ultrasound

TEE or precordial Doppler

``` Venous air embolism treatment ___ surgical field with __ Apply __ to cut bony edges Discontinue __ __ Close any open __ Place on __ o2, ___ ___ position Aspirate air from __ __ via a __ ```

``` Flood, NS, Wax Nitrous oxide Vessels 100%, peep Trendelenburg Right atrium, central catheter ```