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SRNAProfessionalGuide II > Positioning > Flashcards

Positioning Flashcards

1
Q

Possible complications include

A

Peripheral nerve injuries
Hypotension
Ventilatory compromise
Optic neuropathy

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2
Q

Physical injuries associated with positioning: such as

A

skin damage, fractures and amputation.

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3
Q

Can contribute to post-op complications.

A 
Obesity
Diabetes
Arthritis
Peripheral vascular disease,
Alcohol abuse pre-existing neurological conditions
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4
Q

Most common surgical positions

A 
Supine
Trendelenburg
Prone
Lateral Decubitus
LITHOTOMY
Sitting
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5
Q

This position produces minimal circulatory effects

A

The supine (lying down)

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6
Q

FRC with supine

A

decreased by about 800 ml

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7
Q

The decrease in FRC with supine position reflect

A

Cephalad displacement of the diaphragm compressing the lung bases

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8
Q

What conditions can further decrease the FRC

A

This is further exacerbated by an enlarged abdomen such as with obesity, pregnancy, or ascites.

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9
Q

The hips and knees in supine position

A

are often flexed slightly with a pillow under the knees,

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10
Q

Hips and knees flexed in supine Facilitating

A

venous drainage from the lower extremities and decreasing anterior abdominal wall tension.

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11
Q

Heels and occiput should be

A

padded

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12
Q

For pregnant patient remember

A

put a wedge under the right hip of the pregnant patient in the supine position

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13
Q

What does the LEFT LATERAL DISPLACEMENT do

A

Keeps the gravid uterus from causing too much pressure on the inferior vena cava that decreases venous return to the heart further resulting to decrease in cardiac output.

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14
Q

If the arms can be abducted on a padded board it

must be no more than

A

90 degrees

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15
Q

Take care that there is no pressure on the

A

ulnar nerve at the elbow in the condylar groove.

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16
Q

The arms are often secured in a “papoose”
manner with a draw sheet. This effectively limits
the

A

anesthetist’s access to the arms.

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17
Q

Supine summary

A

Equalization of pressures throughout the arterial system;

increased right-sided filling and cardiac output
decreased heart rate and peripheral vascular resistance (PVR).

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18
Q

Gravity and lungs

A

Increases perfusion of dependent (posterior) lung segments; abdominal viscera displace diaphragm cephalad.

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19
Q

SV favors

A

dependent lung segments,

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20
Q

CV favors

A

independent (anterior) segments.

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21
Q

FRC decreases and may

A

fall below CV in older patients.

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22
Q

________the patient in supine position with a

head-down tilt

A

Trendelenburg

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23
Q

Trendelenburg abdominal viscera action ? can accentuate HyPOTENSION

A

The abdominal viscera push on the diaphragm, compressing lung bases and heart (↓SV). this can accentuate HYPOTENSION

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24
Q

Cardiac output also decreases in this position d/t

stimulation of baroreceptors

A

Trendelenburg

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25
Q

Cardiac output decreases in this position TRENDELEBURG

A

Stimulation of baroceptors

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26
Q

Trendelenburg ____ICP how?

A

In some patients, this position can increase intracranial

pressure by elevating venous pressure

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27
Q

_________can also be caused by decreased venous

return

A

Hypotension

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28
Q

NO longer use _____braces why?

A

Shoulder braces are no longer used routinely due
to possible brachial plexus injury caused by the
compression of the plexus against bony
structures of the shoulder

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29
Q

If shoulder braces are used they should be well

A

padded

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30
Q

If shoulder braces used positioned so they are over the not the ______or ______

A

acromion, the clavicle or base of the neck

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31
Q

CV of Trendelenburg

A

Activation of baroreceptors, generally causing

decreased cardiac output, peripheral vascular resistance, HR and BP.

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32
Q

Respiratory effects of Trendelenburg: lung capacities _______from ?

A

Marked decreases in lung capacities from shift of

abdominal viscera;

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33
Q

Respiratory effects of Trendelenburg: VQ

A

Increased V/Q mismatching and Respiratory atelectasis; increased likelihood of regurgitation.

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34
Q

Trendelenburg: NEURO

A

Increased ICP and decrease in CBF because of cerebral Neuro venous congestion

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35
Q

Trendelenburg: EYE

A

Increased IOP in patients with glaucoma.

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36
Q

Reverse Trendelenburg: Cardiac

Preload, CO, arterial pressure

A

preload, cardiac output and arterial pressure decrease.

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37
Q

Reverse Trendelenburg Baroreflexes i

A

Increase sympathetic tone, HR and PVR.

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38
Q

Reverse Trendelenburg: SV and FRC

A

SV requires less work; FRC increased.

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39
Q

Reverse Trendelenburg: NEURO

A

Decreased CPP and CBF

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40
Q

PRONE position do not

A

*DO NOT TUG, PULL, PUSH, HELP

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41
Q

Main Objective for PRONE Is

A

Maintain alignment of the head, neck and spinal cord with neck slightly flexed.

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42
Q

In prone The diaphragm is displaced _______there is

impediment of _______________

A

cephalad, downward descent of the diaphragm,

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43
Q

Prone Peak airway pressures______ and pulmonary

compliance_____

A

increase ; decreases

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44
Q

In prone, pressure on the-____and _______ lung bases

forced. This can be offset by________, which may further

A

inferior vena cava and aorta; cephalad

mechanical ventilation; compromise blood flow

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45
Q

Bolsters (“jelly rolls”)

A

can be placed under the patient from iliac crests to shoulders;

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46
Q

When using these techniques (frames) the arms can be placed ________or on_______ palongside the
patient’s head taking care to avoid pressure on the______

A

at the sides, ; added boards; ulnar nerves at the elbows

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47
Q

Be aware that prolonged time in the prone position and large fluid loads can cause_______. Evaluated______

A

cause swelling of the upper airway and tongue. Evaluate the face before you extubate.

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48
Q

Ischemic optic neuropathy, a rare but potentially

devastating complication can occur with the

A

prone position

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49
Q

What is Ischemic optic neuropathy?

A

An infarction of the optic nerve due to decreased

oxygen delivery by one or more small arterioles supplying the nerve

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50
Q

Potential causes of ION

A

Potential causes include: long operating times
(average 7 hours or more), large blood loss, relative
hypotension and anemia

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51
Q

Prone position and ION

A

The prone position may elevate CVP and retard the

drainage through opthalmic veins

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52
Q

Risk factors for ION

A

Patient risk factors include hypertension, diabetes, CAD,

and smoking

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53
Q

ION can be partial or cause complete blindness and is

A

not reversible

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54
Q

Summary PRONE CV

A

Pooling of blood in extremities and compression of abdominal muscles may decrease preload, cardiac output and BP.

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55
Q

SUMMARY Resp PRONE

A

Compression of abdomen and thorax decreases total lung

compliance and increases work of breathing.

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56
Q

Summary Neuro effects prone

A

Extreme head rotation may decrease cerebral venous drainage and CBF.

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57
Q

This position is most often used for hip, kidney, and

thoracic procedures

A

Lateral Decubitus

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58
Q

In lateral decubitus

A

The inferior vena cava can be compressed by the kidney
bar under the dependent iliac crest compromising blood
flow

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59
Q

During mechanical ventilation, the dependent lung is

relatively_______ due to compression by the

A

underventilated ; weight of the mediastinum and abdominal contents

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60
Q

IN lateral decubitus The nondependent lung is relatively______because its compliance is______

A

overventilated ;increased

61
Q

Gravity causes pulmonary bloodflow to favor the

A

dependent lung

62
Q

Should not pose problems with venous return

A

Lateral decubitus

63
Q

In lateral decubitus This mismatching of Ventilation and Perfusion (V/Q mismatch) can lead

A

to hypoxemia

64
Q

*****To avoid compression of the neurovascular bundle in the dependent axilla

A

*****axilla, an “axillary roll” is placed just caudad

to the axilla

65
Q

Axillary roll placement in the axilla may displace the ____________against __________ causing nerve injury from stretch and compression

A

head of the humerus; brachial plexus

66
Q

Placing the pulse oximeter on the ______ _______and periodically checking the _______of the dependent arm ensures there is

A

dependent hand; radial pulse; no neurovascular compromise

67
Q

The upper arm can rest on pillows or be placed in a padded support bar (Allen arm rest) taking care not

A

to stretch the brachial plexus

68
Q

Position the patient’s head on a pillow, preferably an

anesthesia___________ with or without extra blankets to keep the_________

A

“donut”, or shea headrest ; neck in normal

alignment

69
Q

A pillow is placed between the knees, and the lower
leg should be to________ pad bony
prominences and lessen stretch on nerves

A

flexed slightly

70
Q

Genitals must be free of

A

pressure

71
Q

Lateral Decubitus: CV

A

Cardiac output remains unchanged unless venous return
obstructed (e.g. kidney rest). Arterial BP may fall as a result
of decreased vascular resistance (right side > left side).

72
Q

Resp LATERAL DECUBITUS

A

Decreased volume of dependent lung; increased perfusion of dependent lung. Increased V of dependent lung in awake patients (no V/Q mismatch); decreased V of dependent lung in anesthetized patients (V/Q mismatch). Further decreases in dependent lung ventilation with paralysis and open chest.

73
Q

Sitting position Most often used for

A

shoulder surgeries and posterior fossa craniotomies

74
Q

Sitting May cause gravity _____

A

dependent hypotension

75
Q

Causes venous drainage from head and neck

A

Supine

76
Q

Decreases intrathoracic blood volume

A

Supine

77
Q

No pulmonary changes with this position

A

Supine

78
Q

Venous return from the lower extremities is enhanced by the use of

A

compression stockings and pumps

79
Q

↓ cerebral perfusion pressure and cardiac output

A

SItting

80
Q

What happens when the surgical site is higher than the heart, there is potential to entrain room air into open vessels and cause venous air embolism

A

When the surgical site is higher than the heart, there is
potential to entrain room air into open vessels and cause
venous air embolism
Air enters the right ventricle interfering with blood flow into the pulmonary artery
Pulmonary edema and reflex bronchconstriction can occur
Death can result from acute cardiovascular collapse and
arterial hypoxemia
Air may reach the cerebral and coronary circulation via a
patent foramen ovale (present in approximately 20% to 30% of the population)

81
Q

VAE is treated by

Telling the surgeon so he can

A

prevent the further entraining of air by irrigating and applying an occlusive dressing

82
Q

In sitting, Placing the patient in a head down position (to

A

trap the air in the right atrial apex preventing entrance to the pulmonary artery)
Withdrawing air through a previously placed right atrial
catheter
Cardiovascular collapse will need treatment with pressors

83
Q

_______is the most sensitive noninvasive indicator of VAE

A

Placement of a doppler ultrasound transducer at the
second or third intercostal space to the right of the
sternum (over the right atrium)

84
Q

Most definitive test VAE

A

Most definitive is still with the TEE

85
Q

Sudden decrease in end-tidal CO2 indicates

A

decreased perfusion to the lungs

86
Q

Sitting SUMMARY CV

A

• Pooling blood in lower body decreases central blood volume.
Cardiac output and arterial BP fall despite rise in HR and SVR.

87
Q

Sitting summary Respiratory

A

Lung volumes and FRC increase, work of breathing increases.

88
Q

SItting summary

A

CBF decreases

89
Q

places the supine patient’s legs in abduction with hips and knees flexed and supported in separate holding devices
referred to as “stirrups

A

Lithotomy position

90
Q

Used for gynecological and lower GI procedures

A

Lithotomy position

91
Q

In the lithotomy, circulation can be

A

Circulation can be disrupted by increased pressure on the inferior vena cava especially in the presence of obesity, an abdominal mass, or pregnancy

92
Q

The diaphragm is displaced

A

cephalad by the abdominal viscera, compressing lung bases

93
Q

Lithotomy May aggravate______

A

back problems.

94
Q

Lithotomy, the legs should be raised and lowered in unison to prevent

A

rotary stretch on the lumbar spine

95
Q

When the patient has been placed in the stirrups, the

bottom part of the table (foot) is

A

lowered to provide access to the patient

96
Q

IN lithotomy position; always be aware of

A

ALWAYS BE AWARE OF WHERE THE PATIENT’S
HANDS ARE WHEN RAISING AND LOWERING
THE END OF THE OR TABLE

97
Q

T/F Finger damage and even amputations have resulted from crush injuries with fingers caught between the sections of the OR table

A

True

98
Q

The biggest hazard of the lithotomy position

A

Injury to peripheral nerves (sciatic, common peroneal,

femoral, saphenous and obturator) i

99
Q

To prevent nerve injury in lithotomy

A

Proper padding between the patient’s legs and the

stirrups is essential

100
Q

A rare complication of lithotomy is_______ due to decreased perfusion and pressure on

A

compartment syndrome; the lower extremities

101
Q

This results in tissue necrosis and rhabdomyolysis

A

Compartment syndrome with lithotomy

102
Q

In lithotomy autotransfusion from leg vessels _____ Effect

A

increases circulating blood volume and preload;lowering legs has opposite effect.

103
Q

BP and CO in lithotomy position

A

BP and cardiac output depends on volume status.

104
Q

Decreases vital capacity; increases likelihood of aspiration

A

Lithotomy

105
Q

Causes of peripheral nerve injuries

Position related compression or stretching of nerves

A

Cubital tunnel entrapment
Type of surgery
Prolonged placement (usually more than 4 hours) in the
lithotomy position
Prolonged application of a tourniquet (usually more than 2
hours)
Hereditary neuropathy or congenital anomalies

106
Q

Pre-existing diseases for cause peripheral nerve injuries

A

(DM, Vit. Deficiency, Alcoholism, Ca, Cigarette Smoking, PVD, etc).

107
Q

*****The most common peripheral nerve injury

A

Ulnar nerve injury

108
Q

The two major sites of injury are

A

the elbow at the condylar groove AND

the cubital tunnel

109
Q

The condylar groove is formed by the medial epicondyle of the humerus and the olecranon process
of the ulna. The ulnar nerve is shallow at this points
pre-disposing to

A

compression injury, especially in males where there is less protective adipose tissue

110
Q

The cubital tunnel is formed by the________________ also

A

aponeurosis of the flexor capri ulnaris, designated the cubital tunnel retinaculum

111
Q

Injury to the ulnar nerve causes the inability to__________or _________

A

abduct or oppose the fifth finger,

112
Q

Injury to the ulnar nerve, there is diminished sensation over both surfaces of the

A

forth finger and 1/2 fifth finger, and eventually, atrophy of the intrinsic muscles of the handknown as “claw hand” or “Pope Sign”.

113
Q

The second most common postoperative nerve injury

A

Brachial Plexus injury

114
Q

An axillary roll placed too proximal can compress

A

the head of the humerus against the brachial plexus

115
Q

Shoulder braces can compress the

A

brachial plexus between the clavicle and the first rib

116
Q

Radial nerve injury manifested as a

A

Injury is manifested by wrist drop, inability to
extend the metacarpophalageal joints, & weakness
of abduction of the thumb.

117
Q

_____ not likely to be injured from positioning.

A

The median nerve

118
Q

Axillary: other injury

A

inability to abduct arm

119
Q

Musculocutaneous

A

inability to flex forearm

120
Q

Stretching is most likely to occur in___

A

lithotomy position

121
Q

To minimize sciatic nerve stretch, it is recommended patients in lithotomy position be positioned with ________external rotation, hips and knees should be______, and duration be limited ideally to

A

minimal ;flexed; less than 4 hours

122
Q

Injury can manifest as “foot drop” and may be

erroneously diagnosed as

A

peroneal nerve injury

123
Q

The most frequently damaged nerve in the lower

extremities

A

Common Peroneal Nerve

124
Q

______And _____can show the extent of the injury

A

Nerve conduction velocity and electromyography studies

125
Q

T/ F If the electromyogram is performed promptly, it can
show if there was neuropathy pre-op because signs of
denervation resulting from acute injury do not appear
until 18 to 21 days after the event and are limited to a
specific nerve distribution

A

True

126
Q

 Limit arm abduction to

A

90 degrees or less

127
Q

In lateral position, use a correctly placed

A

axillary roll

128
Q

Ulnar Nerve
Avoid ____________
 Limit flexion of the elbow to less than ____degrees

A

Avoid compression on the condylar groove

 Limit flexion of the elbow to less than 110 degrees

129
Q

Radial Nerve

 Avoid pressure against

A

posterior and lateral humerus

130
Q

Median Nerve

Avoid ______

A

 Avoid extreme wrist dorsiflexion

 Be aware of caustic infusions in the antecubital fossa

131
Q

A tourniquet is used on an arm or a leg to provide the

surgeon with a bloodless field, and is inflated to at least

A

50mmHg higher than the patient’s systolic BP

132
Q

3 are recorded on the anesthesia record

A

The time of inflation, deflation, and the tourniquet

pressure

133
Q

Typically the anesthetist notifies the surgeon at

A

one hour,

ninety minutes and two hours

134
Q

Ischemic nerve damage can occur after _______of
tourniquet time. Typically the surgeon will let the
tourniquet down for ______after two hours and reinflate if needed.

A

two hours ; 15 minutes

135
Q

External pressure on the eyes can cause thrombosis of

the

A

central retinal artery

136
Q
  1. Venous Air Embolism. Common in sitting, prone,
    and reverse T positions. Prevention:
    •**
    •
A

maintain venous pressure above 0 at the wound.

137
Q
  1. Backache: All positions.
A

Lumbar support, padding and slight hip flexion.

138
Q

Compartment syndrome: esp. Lithotomy. ***.

A

Maintain perfusion pressures and avoid external

compressions

139
Q
  1. Alopecia: Common in supine, lithotomy and T

positions. *

A

Normotension, padding and occasional head turning.

140
Q
  1. Corneal Abrasion. Esp. Prone. **
A
  • Taping and/or lubricating eye.
141
Q
  1. Digital Amputation: All positions. ***
A

Check for protruding digist before changing table

position/configuration

142
Q
  1. Nerve palsies

• a. Brachial plexus. All positions. **

A

Avoid stretching or direct compression of neck or axilla

143
Q

• c. Radial. All positions. ***

A

Avoid compression of lateral humorous.

144
Q

• d. Ulnar. All positions. ***

A

Padding at elbow, forearm supination.

145
Q
  1. Retinal ischemia. Prone and sitting. ***
A

Avoid pressure on the globe.

146
Q
  1. Skin necrosis. All positions.
A

Padding over bony prominences

147
Q

Common peroneal. Lithotomy & lateral

decubitus. *

A

Pad lateral aspect of upper fibula.

148
Q

“axillary roll” is placed

A

just caudad to the axilla

SRNAProfessionalGuide II (13 decks)

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