Patient Positioning Flashcards by Jackson Jones

Etiology of positioning injuries

Microvascular neuropathies-predisposition
• Blood transfusions- systemic inflammation
• Viruses
• Immunosuppression

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Stretching a nerve greater than 5% will cause what? best way to prevent?

Ischemia

Have patient position themselves

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What does peripheral nerve injury cause?

Disruption of nerve impulse leading to muscle weakness and impaired function

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What are the mechanisms of nerve injury

Mechanical distortion of nerve membrane or myelin sheath via:

Ischemia
Stretch
Compression
Traction
Kinking

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Neuropraxia

Demyelination

6 wks-3 months recovery

Good prognosis

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Axonotmesis

Axonal damage

9-12 months recovery

Fair prognosis

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Neurotmesis

Complete axonal transection

No regenertion or incomplete

Irreversible

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What are the most favorable types of nerve injury?

Reversible…

Neuropraxia

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Best thing we can do in pre-op for nerve injuries

Document pre-existing nerve injuries

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How do we protect patients from nerve injuries?

Proper alignment and understanding their baseline ROM

Foam/gel/cotton/bolsters/axillary rolls

Padding all bony prominences

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Supine (dorsal decubitus) considerations

Support occiput

Arms next to body or <90 degrees

No skin-metal contact

No hard plastic on skin

Bend knees for lumbar support

Bony contact points!

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Aortocaval syndrome

(Supine hypotensive syndrome)

When fetus or abdominal mass rests on aorta/vena cava compromising circulation

Use wedge to displace mass-this recommendation is becoming less common

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Problems with Lithotomy

Hip flexion >90degrees =stretch inguinal ligaments

Compartment syndromes

Finger amputation!!

Lateral femoral cutaneous nerves

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Lithotomy considerations

Protect arms! Use arm boards

Hips and knees at 90 degrees or less =legs parallel to floor

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Anatomy of radial nerve compression

Lateral epicondyle of humerus

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Median nerve injury etiology

Unclear

Possibly ischemia from AC IV

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Ulnar nerve impairment (causes)

Pressure against elbow

Flexion-nerve is pulled over the median epicondyle/epicondylar groove

Most common nerve injured!!

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Risk factors for ulnar nerve impairment

Male (70-90%)
High BMI
Hx cancer and prolonged bed rest

May have asymptomatic ulnar neuropathy at baseline

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Problems with supine positioning

Arm boards- too tight or lack padding

Elbow flexion

Backache- loss of lumbar curvature=neuropathy/pain

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Compartment syndrome causes :

Can happen in any extremity

-hypotension/loss of perfusion

-vascular obstruction by retractors, excessive knee/hip flexion

-compression of elevated extremity/straps

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Innervation of hand diagram

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Second most injured nerve

Brachial plexus

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Brachial plexus neuropathy causes

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Shoulder braces (steep head down)

Lateral head displacement (stretch)

Sternal retraction

Axillary trauma from humeral head (>90 degrees)

Main considerations from lateral

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Dependent leg flexed to stabilize

Axillary roll to prevent venous congestion

Head neutral

Minimize pressure on bony prominences!!!

Semi-supine/prone most important thing!

Check pulses!!!

Flexed lateral position

Lateral jackknife- iliac crest is over the hinge -opens intercostal spaces

Lateral position complications

Neck- neutral!! Endless nerve ischemia complications? Check body for extra leads/tape that could cause pressure

Prone position considerations

Neutral spine Genitalia/breasts free from pressure Eyes free from pressure Abdomen free

POVL 5 most common risk factors

Obesity Male Prone (Wilson frame) Length >6 hrs Blood loss Compression of globe, anemia, vasopressor use, hypotension

3 independent risk factors form ischemic optic neuropathy after spinal fusion surgery

Increased estimated blood loss Male gender Lower percentage colloid administration

Complications from prone positioning

Head below heart- congestion and edema Brachial plexus- stretch and compression Breast injuries- tissue necrosis Abdominal compression- impaired ventilation and impedes venous return Stoma/genitals

Complications of head elevation

Postural hypotension- no sympathetic response Midcervical tetraplegia- hyperflexion causing paralysis below c5 Venous air embolism- highest chance with operation above the heart

Pressure difference between circle of Willis and arm

15 mmhg

Sequence of events with venous air embolism

ETCO2 drops Hypotension Tachycardia Hypoxemia

What to do in Venous air embolism

Cover surgical field with saline/saline soaked dressings 100% oxygen Vasopressors Turn left lateral to sequester air in RV

Sciatic nerve injury cause

Over stretching in Lithotomy

Common peroneal nerve injury

Lithotomy- nerve compressed between head of fibulae and metal brace

Anterior tibial nerve injury

Plantar flexion for extended periods-sitting or prone

Femoral nerve injury

Excessive angulation during Lithotomy or compression at pelvic rim by retractors

Saphenous nerve injury

Compression against medial tibial condyle -Lithotomy

Obturator nerve injury

Excessive flexion of thigh to groin or difficult forceps delivery

Buccal branch of facial nerve injury cause

Excessive force with face mask ventilation or use of straps

Supraorbital branch injury cause

Upward force on tube after nasal intubation

Nerve injuries from Lithotomy

Sciatic Peroneal Femoral Saphenous

External abdominal pressure problems (vasculature)

Impedes venous return Increases venous pressure Impairs ventilation Pressure is transmitted to vena cava and communicated to the lumbar epidural veins causing congestion

Airway problem with neck flexion

Right mainstem

Shoulder braces

Don’t use when arms are extended (on boards) Should be placed over acromioclavicular joint If too medial or lateral will cause brachial plexus injury DONT USE

Pathophys of compartment syndrome

Increased pressure and decreased perfusion causes neural and vascular damage in muscles with tight, fascial borders

Another term for compartment syndrome

Called reperfusion injuries because injury happens when blood flow returns after a period of ischemia

Mitigating compartment syndrome in Lithotomy

Legs should be periodically lowered if procedure lasts more than 2-3 hours

Palm position on armboards

Supinated(palm up) Down can increase pressure over ulnar nerve

Problem with neuromuscular blocking drugs and patient positioning

Increases mobility of joints causing stretch injuries- this is why we have patients position themselves and assess function beforehand

Perineurium

Tough connective tissue that binds the fascicles into identifiable structures

Endoneurium

Loose connective tissue covering the neurolemma (Schwann cells that sheath axons)

Cross section of peripheral nerve trunk

Big lateral consideration

Minimize pressure on bony prominences

Nerve injured from arm abduction >90 degrees

Brachial plexus

Patient Positioning Flashcards

(57 cards)