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Perioperative Positioning Flashcards

(63 cards)

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1
Q

Standard 8

A

Patient positioning - collaborate with the surgical/procedure team to position, assess, and monitor proper body alignment

Use protective measures to maintain perfusion and protect pressure points/nerve plexus

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2
Q

What is the most common nerve injury

A

Ulnar and brachial plexus nerve

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3
Q

What are the seven positioning goals

A
  1. Safety
  2. Optimize surgical exposure
  3. Preserve patient dignity
  4. Maintain hemodynamics stability
  5. Maintain cardio respiratory function
  6. No ischemia, injury, or compression
  7. Prevent pressure ulcers
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4
Q

How do volatile agents effect CO/BP

A

Decrease

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5
Q

How do NMBs affect the cardiac system?

A

Decreased muscle tone = decreased venous return

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6
Q

What is the concern for anatomy cephalad to heart

A

Risk for hypoperfusion/ischemia

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7
Q

How does gravity effect the pulmonary system

A

Ventilation - non dependent = dead space
Perfusion - dependent = shunt
Loss of HPV?

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8
Q

What are the ways in which nerves can be injured

A

Compression, transaction, stretch, traction

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9
Q

Risk factors for pressure ulcers

A

Elderly, diabetes, PVD, surgical time, chronic hypotension, increased body temp (?), body habitus

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10
Q

Supine positioning mechanics

A

Lying on back
Arms - secured with arm boards, padding, straps, laterally or abducted (<90 degrees with supinated forearm)
Legs - flat, uncrossed, heel padding
Consider lumbar support

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11
Q

Supine arm positioning/nerve concerns

A

Avoid brachial plexus injury by keeping arms abducted <90
Avoid ulnar nerve compression by padding elbows and avoiding pronation

(Brachial nerve compression/stretch at shoulder/axial level and ulnar nerve compression at AC/elbow level)

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12
Q

How does the supine position effect the respiratory system

A

Reduced TLC and FRC
Diaphragm shifts cephalad
General anesthesia and NMBs enhance respiratory effects

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13
Q

Prone mechanics

A

Head/neck = neutral
Often intubated
Arms abducted but <90
Body/trunk support to keep abdomen from being compressed

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14
Q

How to facilitate proning in OR

A

Intubate and get lines and everything on the stretcher
Flip on anesthesia’s count - and anesthesia maintains airway
Before anything else - ensure that you still have your airway
Make sure you have enough help and that everyone is sharing the same “mental model”

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15
Q

What types of surgery would you use prone for

A

Spine, butt, rectum, ankle, intracranial, etc

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16
Q

CV considerations of prone positioning

A

Pooling of blood in dependent extremities
Compression of inferior vena cava
Epidural engorgement

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17
Q

Respiratory considerations of prone positioning

A

Decreased compliance if chest/abdomen not freely hanging
Increased FRC
-improved posterior lung ventilation may increase oxygenation

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18
Q

Post op vision loss causes

A 
Prolonged prone position
Central retinal artery occlusion
Central retinal vein occlusion
Ischemic optic neuropathy (89% cause)
Cortical blindness
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19
Q

Ways to prevent POVL

A 
Surgical duration <6h
10-15 degree head up (to reduce orbital edema)
Bp 20% of preop baseline and MAP > 70
Maintain Hct >25
Avoid prolonged targeted hypotension
Avoid head and neck flexion
Avoid direct pressure on the eye
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20
Q

Ischemic optic neuropathy

A

Most common type of POVL
Associated with extended surgical time and extensive blood loss
Not associated with globe pressure
RF = obseity, male, Wilson frame (blood pools in the face because it is dependent d/t frame)

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21
Q

Equation for ocular perfusion pressure

A

OPP = MAP-IOP

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22
Q

Central retinal artery occlusion clinical signs and symptoms

A

Sudden, profound vision loss
Painless
Monocular

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23
Q

Etiology of CRAO

A

“Eye stroke”

Embolism, vasculitis, vasospasm, sickle cell, trauma, glaucoma

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24
Q

Diagnosis of CRAO

A

Retinal pallor, macular cherry red spot, +/- afferent pupillary defect

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25
Treatment of CRAO
Consult optho and neuro Case reports of intra-arterial TPA Limited evidence for treatment - possibly digital massage and lowering IOP
26
Central retinal vein occlusion “eye dvt” signs and symptoms
Variable - blurred vision to sudden vision loss Painless Monocular
27
CRVO etiology/ risk factors
``` “Eye dvt” Typical stroke risk factors Hypercoagulable states Glaucoma Compression of vein in thyroid or orbital tumors ```
28
Diagnosis of CRVO
Optic disk edema | Diffuse retinal hemorrhages “blood and thunder”
29
Treatment of CRVO
Consult optho and neuro No specific treatment
30
Nerve Compression
Force nerve against bony prominence or some other hard surface (can be a surgical surface like the OR table or positioning tools)
31
Nerve Transection
Nerve is cut
32
Stretched nerve
Nerves are pulled tightly
33
Nerve traction
Nerve stretched over or under something that is immovable
34
Nerve sheath ischemia direct vs indirect
Direct - d/t something like compression of the nerve itself Indirect - compartment syndrome
35
Lithotomy mechanics
``` Legs abducted and elevated Keep fingers free of footboard Keep legs free to save peroneal nerve Hip flexed Facilitates access to perineum/gyn/urology ``` ***ensure adequate padding
36
Nerve considerations for lithotomy
Peroneal nerve injury d/t stirrups | Sciatic obturator stretch and femoral nerve palsy d/t hip flexion
37
Respiratory considerations of lithotomy
20% reduced FRC Reduced vital capacity Hypoventilation if breathing spontaneously
38
Cv considerations of lithotomy
Increased (shifted) central blood volume Auto Transfusion of 250-300ml/leg when raised
39
Mechanics of lateral positioning
Head and neck neutral and supported Shoulders, hips, head, legs aligned in same plane Eyes, ears, and face should be pressure free Chest and hip supports Dependent arm on padded arm board - perpendicular to torso <90 Non dependent arm should be supported - flexion at elbow, padded, secured Axillary roll should be in use under dependent side of thorax There should be knew flexion with pillows between knees REGULARLY assess perfusion
40
Jack-knife position
Lateral position with the use of a kidney rest
41
lateral positioning used for
Kidney, shoulder, orthopedic (THA/hip), thorax surgeries
42
CV considerations of the lateral position
Minimal changes (euvolemic) Kidney rest elevated may compress great vessels and decrease venous return
43
How to place kidney rest
Slowly under iliac crest
44
Resp considerations of lateral position
V/Q mismatch possible In anesthetized patients: - FRC is increased in non dependent lung and decreased in dependent lung because diaphragm relaxes and rises to compress dependent lung In awake patients: - you have enhanced VQ matching and you do not get the compression of diaphragm Dependent lung lower than left atrium so its prone to atelectasis and fluid accumulation
45
Sitting position used for
Cerivical spine surgery, shoulder surgery, posterior fossa, breast reconstruction
46
Sitting mechanics
``` HOB 30-90 degrees OR table flexed and backrest elevated Head secured Pad heels and flex legs Secure arms ``` Dislodge head from headrest with vigorous surgical manipulation is possible so be careful
47
How do you prevent sciatic stretch in the sitting position
Pad heels and flex legs
48
Potential complication of Sitting position
VAE Pneumocephalus Quadriplegia
49
Pneumocephalus and the sitting position
Associated with Neuro procedures, often benign | Air enters open dura, CSF drainage, surgical decompression
50
Quadriplegia and sitting position
Spinal cord stretch when head is flexed combined with loss of auto regulation associated with general anesthesia Ensure 2 fingerbreadths to limit strain at C5 vertebrae
51
Cv effects of sitting position
Reduced SV and CO (up to 20%) Decreased MAP and CVP Lower extremity venous pooling Decreased CPP
52
Respiratory considerations of sitting position
Increased FRC and compliance
53
Rise in cm to drop in MAP conversion
Every 1 cm rise = 0.75mmHg drop in MAP So A map of 65 degrees on an arm BP cuff at level of heart correlates to a MAP of 50 in the brain (if your head is 20cm away from the level of the cuff)
54
Trendelenburg
Patient is lying in one plane with the head down
55
Shoulder braces with trendelenburg can cause
Plexus nerve stretch and compression Stretch if placed to laterally Compression if placed too medically Avoid shoulder pads if possible
56
Pressure changes with trendelenburg
Patient will have increased ICP, IOP, and CVP
57
Hemodynamics and T-burg
Degree of T-burg = degree of dependent edema and therefore hemodynamic impact
58
Reverse t-burg
Body is in same plane, bed flat, head up
59
Physiologic considerations of reverse T-burg
Increased pulmonary compliance and FRC Decreased ICP, IOP, CPP, BP
60
Brachial plexus considerations in supine
Make sure arms are abducted less than 90 and make sure humeral head is not rotated
61
Signs of brachial plexus injury
Weakness in the arms, decreased reflexes and corresponding sensory deficits
62
Lateral decubitus considerations for brachial plexus injuries
Can cause stretch, traction, tension | And dependent compression via chest
63
Res Ipsa Loquitor
The thing speaks for itself Provider presumed negligent if cause of injury is under providers control and issue would not occur without negligence Stay vigilant

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