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Principles of Anesthesia > Positioning (Exam II) Andy's Cards > Flashcards

Positioning (Exam II) Andy's Cards Flashcards

1
Q

What is the most common surgical position?

A
  • Supine

Arm boards must be secure if in use.

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2
Q

What are the pathophysiological considerations for the supine position?

A
  • ↑ Venous return, ↑ preload, ↑ SV, and ↑ CO
  • ↓Tidal volume, ↓ FRC
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3
Q

Describe arm abduction

A
  • Arm out to the side, < 90 degrees
  • Padded arm boards secured to the table and patient at the axilla
  • The arms should be supine (palms up)
  • Elbows padded and arm is secured with a Velcro strap
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4
Q

Describe arm adduction

A
  • Arm tucked alongside the body
  • Arms held along the side of body via draw sheet under the body and over the arm
  • Hand and forearm are supine (palms up) or neutral position (palms toward body)
  • Elbows are padded
  • May tuck one arm if surgeon must stand on side of patient
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5
Q

Complications of the supine position

A
  • Backache
  • Pressure alopecia
  • Brachial plexus or axillary nerve injury if arms abducted > 90 degrees
  • Ulnar nerve injury if hand/arm is pronated (palm down)
  • Stretch injury when neck is extended and head turned away (brachial plexus)
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6
Q

What position is this patient in?

A
  • Trendelenburg (head down)
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7
Q

Safety/general considerations with Trendelenburg position.

A
  • Use a non-sliding mattress/pad to prevent the patient from sliding cephalad
  • Avoid using bean bags or shoulder braces
  • Consider making a mark at the level of the patient’s head on the sheet or pad so you can determine easily if the patient has slid
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8
Q

Pathophysiological considerations with Trendelenburg position.

A
  • ↑ CO, ↑ Venous Return from lower extremities
  • ↑ ICP, ↑ IOP, Facial Edema
  • ↑ Intraabdominal Presure
  • ↓ FRC and ↓ Pulmonary Compliance
  • May need higher pressure in ventilated patients
  • Risk of endobronchial intubation as abdominal contents push the carina cephalad
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9
Q

What position is this patient in?

A
  • Reverse Trendelenburg (head up)
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10
Q

Safety/general considerations with Reverse Trendelenburg position.

A
  • Use a non-sliding mattress/pad to prevent the patient from sliding
  • Use a footrest or something under the feet to prevent the patient from sliding
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11
Q

In what position should bean bags and shoulder braces be avoided?

A

Trendelenburg

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12
Q

Pathophysiological considerations with Reverse Trendelenburg position.

A
  • Risk of Hypotension (↓ Venous Return, Venous pooling)
  • Downward displacement of abdominal contents/ diaphragm (better ventilation)
  • ↓ Perfusion to the brain
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13
Q

Name the positions

A
  • Left Picture: Beach Chair Position
  • Right Picture: Full Sitting Position
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14
Q

When will the patient be in the Beach chair position?

A
  • Shoulder Cases

Beach chair position will have less severe hip flexion and slight leg flexion.

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15
Q

Describe the set-up of the full sitting position

A
  • Head must be stabilized – taped to special headrest or rigid pins
  • Hips are flexed < 90 degrees and knees slightly flexed for balance to reduce stretching of the sciatic nerve
  • Feet are supported – prevent sliding
  • Compression stockings/wraps to maintain venous return
  • Keep at least two finger’s distance between the chin and sternum
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16
Q

Describe the set-up of the full sitting position

A
  • Head must be stabilized – taped to special headrest or rigid pins
  • Hips are flexed < 90 degrees and knees slightly flexed for balance to reduce stretching of the sciatic nerve
  • Feet are supported – prevent sliding
  • Compression stockings/wraps to maintain venous return
  • Keep at least two finger’s distance between the chin and sternum
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17
Q

What risks are associated with sitting position?

A
  • Cerebral hypoperfusion and air embolism
  • Pneumocephalus
  • Quadriplegia and spinal cord infarction
  • Cerebral ischemia
  • Peripheral nerve injuries (Sciatic nerve injury)
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18
Q

Pathophysiological consideration of the sitting position?

A
  • Risk of hypotension d/t ↓ venous return.
  • ↓ MAP, ↓ Cardiac Index, and ↓ Perfusion Pressure
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19
Q

What position is the patient in?

A
  • Prone
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20
Q

Describe the prone position.

A
  • Patient lying on stomach
  • Arms at side tucked or outstretched (< 90 degrees), with flexion at elbows
  • Head supported face down using a prone pillow, horseshoe headrest, or rigid fixation with pins in a neutral position without pressure on eyes, nose, mouth, and ears
  • Avoid compression of breasts, abdomen, and genitalia
  • Legs padded and slightly flexed at the knees and hips
  • Compression stockings for lower extremities to prevent pooling
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21
Q

Why do you not turn a prone patient’s head to one side or the other?

A
  • Risk of jugular occlusion or carotid occlusion
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22
Q

What risks are associated with prone positioning?

A
  • Facial and airway edema
  • Nerve injuries
  • Ulnar nerve injury if elbows are not padded
  • Brachial plexus injury if arms are abducted > 90 degrees
  • Post-op visual loss secondary to decreased perfusion/ischemia
  • Eye injuries r/t head position
  • ETT dislodgement
  • Loss of monitors and IV lines
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23
Q

Pathophysiological considerations for prone patients

A
  • Edema of face, conjunctiva, larynx, and tongue
  • ↑ Abdominal pressure
  • ↓ Venous return through compression of the inferior vena cava
  • ↓ CO
  • Improved ventilation
  • Ventilation and perfusion in the lungs shift to the dependent areas
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24
Q

What position is the patient in?

A
  • Lithotomy
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25
Q

Describe the Lithotomy position

A
  • Patient laying supine with legs up in padded or “candy cane” stirrups
  • Arms tucked or on arm boards
  • If using Trendelenburg or reverse Trendelenburg, need non-sliding mattress
  • Hips flexed 80 -100 degrees and legs abducted 30 - 45 degrees from midline, knees flexed
  • Lower extremities MUST be raised and lowered in synchrony together
  • Foot of the bed is lowered, must protect the hands and fingers from crush injury
  • Surgery > 2-3 hours, periodically lower the legs
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26
Q

What risks are associated with Lithotomy position?

A
  • Back pain
  • Nerve injuries
  • Brachial plexus
  • Ulnar nerve injury
  • Common peroneal injury
  • Lateral femoral cutaneous injury
  • Compartment syndrome
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27
Q

For the Lithotomy Position, the_______ nerve is particularly prone to injury as it lies between the fibular head and compression from the leg support.

A
  • Peroneal
28
Q

For the Lithotomy Position, branches of the ____________nerves often pass directly through the inguinal ligaments and can be impinged and become ischemic within the stretched ligament.

A
  • Lateral femoral cutaneous
29
Q

Pathophysiological considerations for the lithotomy consideration.

A
  • ↑ Venous return, CO, and ICP
  • ↑ Intraabdominal pressure
  • Displaces diaphragm cephalad
  • ↓ Lung compliance and tidal volume
30
Q

What position is the patient in?

A
  • Lateral Decubitus Position
31
Q

Describe the Lateral Decubitus position.

A
  • Patient lying on non-operative (dependent) side and requires anterior and posterior support w/ rolls or bean bags
  • Adequate head support… no pressure on eyes or ears
  • Neutral position
  • Dependent ear should be regularly checked
  • Dependent leg is slightly flexed
  • Arms are in front of the patient and both must be supported and abducted < 90 degrees
  • Axillary roll placed between chest wall and bed, caudal to axilla to prevent brachial plexus compression
  • Must place padding between the knees
32
Q

For right Lateral Decubitus, what side of the patient will be down?

A
  • RIGHT lateral decubitus = RIGHT side down
33
Q

Safety/general considerations for the lateral decubitus position

A
  • If bed flexed or kidney rest used, needs to be placed under iliac crest
  • Inferior vena cava compression can occur
  • Allowing best possible expansion of the dependent lung
  • Ulnar nerve injury if elbows are not padded
  • Brachial plexus injury if arms are abducted > 90 degrees
  • ETT dislodgement; caution with use of LMA
34
Q

Pathophysiological considers for the Lateral Decubitus position

A
  • Venous pooling in lower extremities
  • Use compression stockings/devices
  • V/Q mismatch due to inadequate ventilation to dependent lung and decreased blood flow to the nondependent lung
35
Q

Peripheral nerve injury can be caused by what factors?

A
  • Stretch
  • Pressure
  • Ischemia

Peripheral nerve injury can occur in as a little as 30 minutes.

36
Q

Can nerve injury occur even when optimal positioning is performed?

A
  • Yes

Overall, cases of nerve injuries have decreased, but are still a major legal cause to professional liability claims and can still occur even when optimal positioning is performed.

37
Q

What type of injury can occur with the arms abducted greater than 90°?

A

Brachial Plexus injury

38
Q

What injury can occur if elbows are not properly padded?

A

Ulnar nerve injury

39
Q

With what type of positioning is it common to see facial and airway edema?

A

Prone

40
Q

What are the consequences of increased abdominal pressure from prone positioning?

A
  • ↓ venous return (via vena cava compression)
  • ↓ CO
41
Q

In what position does improved ventilation occur?

A

Prone

42
Q

What side is down when the patient is placed in right lateral decubitus position?

A

Right side down

43
Q

If the arms are abducted, it must always be less than ______.

A

90°

44
Q

What is done to prevent brachial plexus compression for lateral decubitus positioning?

A

Axillary rolls

45
Q

What is the most commonly used surgical position?

A

Supine

46
Q

Which of the following experience a decrease with supine positioning?

Venous return
preload
FRC
VT
SV
CO

A

VT and FRC

47
Q

What position should the hands have when adducted in supine position?

A

Palms up or neutral (towards body)

48
Q

Pressure alopecia and backache can occur with what positioning?

A

Supine

49
Q

A patient’s arms have been abducted > 90°. What nerve injury is more possible now?

A

Brachial plexus or axillary nerve injury

50
Q

What hand positioning would cause ulnar nerve injury?

A

Pronated hand/arm (palm down)

51
Q

FRC and pulmonary compliance will decrease with this positioning.

A

Trendelenburg (probably supine to a lesser degree as well)

52
Q

Which positioning may need higher pressures in ventilated patients for adequate ventilation?

A

Trendelenburg

53
Q

What distance must be kept between the chin and the sternum in sitting positions?

A

2 fingers

54
Q

What technique is used to prevent stretching of the sciatic nerve in sitting position?

A

Hips flexed < 90° and knees slightly flexed

55
Q

Cerebral hypoperfusion, air embolus, pneumocephalus, quadriplegia, spinal cord infarction, sciatic nerve injury, and cerebral ischemia are all possible complications what type of positioning?

A

Sitting

56
Q

MAP, CI, and cerebral perfusion pressure will all ______ in sitting position.

A

decrease

57
Q

In which position are compression stockings necessary to prevent venous pooling?

A

Prone

58
Q

In what position is possible ETT dislodgement a concern?

A

Prone

59
Q

What nerve injuries are possible in Prone positioning?

A
  • Ulnar nerve if not padded
  • Brachial plexus if arms are abducted > 90°
60
Q

Abdominal pressure is ______ in prone positioning.
What is the result of this.

A

Increased abdominal pressure results in ↓ CO & ↓ venous return

61
Q

What is improved in prone positioning?

A

Ventilation

62
Q

In Lithotomy position, it is important to lower one leg at a time. T/F?

A

False. Lower extremities must be raised and lowered in synchrony.

63
Q

If surgery occurs longer than ______ hours in lithotomy position the legs must be periodically lowered.

A

2-3

64
Q

In which position is compartment syndrome a risk?

A

Lithotomy

65
Q

In which position can inferior vena cava compression occur?

A

Lateral Decubitus

66
Q

In which positioning is V/Q mismatch due to imbalanced lung ventilation a concern?

A

Lateral Decubitus

Principles of Anesthesia (24 decks)

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