Positioning And Nerve Injuries

Question 1

What is the most common peripheral nerve injuries?

Answer 1

• ulnar 21%

- brachial plexus 20%

Question 2

Advantages of supine position

Answer 2

• easy access of airway/IV’s

- preservation of HD stability

Question 3

Describe proper placement of arms in supine position:

Answer 3

• arms abducted <90 degrees
• elbows padded
• arm supinated
• safety strap

Question 4

Describe proper positioning for arms that are tucked in:

Answer 4

-tucked in with palms facing patient, thumbs facing up. “Pencil” style

Question 5

How to avoid brachial plexus injury:

Answer 5

• avoid abducting arms greater than 90 degrees

- avoid direct compression on shoulders (no shoulder pads—if you must use them-place on acromion process)

Question 6

How can you avoid ulnar injury?

Answer 6

• supinate arms and hands

- pad elbows

Question 7

Trendelenburg

Answer 7

-feet up head down

Question 8

Describe the HD effects of trendelenburg.

Answer 8

• increase VR, CVP, C.O
• cerebral vascular congestion
• ocular vascular congestion
• risk of poor cerebral perfusion pressure
• facial edema and orbital, laryngeal, angioedema
• *not good for patients with head injuries or glaucoma

Question 9

Describe respiratory effects during Trendelenburg:

Answer 9

-abdominal contents move cephalad lowering FRC, increasing atelectasis, shunting blood, and inducing hypoxemia

Question 10

Describe Trendelenburg peripheral nerve injuries:

Answer 10

• brachial plexus - shoulder pad; poor arm abduction

- ulnar - supinate hands and padded elbows

Question 11

What are ways to reduce risk of complications in Trendelenburg:

Answer 11

• anti skid pads, egg crates
• conservation of IVF
• change positions slowly
• OGT
• low insufflation of abdomen

Question 12

Reverse Trendelenburg

Answer 12

-head up feet down

Question 13

Describe the HD effects of reverse Trendelenburg

Answer 13

• decreased venous return, decreased CVP, venous pooling and stasis

Question 14

Describe respiratory effects during Trendelenburg:

Answer 14

• abdominal contents move cauded and allow for greater lung expansion and higher FRC
• ** venous air embolism

Question 15

PNI for Reverse Trendelenburg

Answer 15

• brachial plexus

- ulnar

Question 16

Lithotomy

Answer 16

• hips flexed 90 degrees
• legs 30-45 degrees
• lower legs parallel to abdomen

Question 17

Describe the HD effects of Lithotomy

Answer 17

• increase venous return, increase CVP, increase C.O

Question 18

Describe the respiratory effects of Lithotomy

Answer 18

-abdominal contents move cephalad, pushing abdominal contents upward, reducing FRC, increased atelectasis, shunting blood, and creating hypoxemia

Question 19

PNI for Lithotomy

Answer 19

• common perineal
• sciatic
• obturator
• femoral

Question 20

What are ways to reduce complications in Lithotomy Position

Answer 20

• pay attention to fingers that they are not crushed in the knee gatch
• raising the legs should be done in synchrony
• try to use boots that distribute pressure evenly

Question 21

Compartment Syndrome

Answer 21

• perfusion reduced, ischemia, edema, rhabdo

- occurs most frequently 2-3 into case

Question 22

Lateral Decubitus Position

Answer 22

-side for “lung” surgery

Question 23

Describe the respiratory effects of the Lateral Decubitus

Answer 23

-V/Q mismatch

Question 24

What are ways to reduce complications in Lateral Decubitus?

Answer 24

• head neck neutral position
• dependent eye, ear
• “axilla” bean bag caudate to axilla under chest
• concern for vascular compression: NIBP, pulse on dependent arm
• compartment syndrome on dependent leg from upper leg and inguinal ischemia