test 2 GP Flashcards

Question

TID

Answer 1

Three times per day

Answer 2

Four times per day

Answer 3

Q6h- Every six hours Q8h- Every eight hours

Answer 4

Subarachnoid block (this is a spinal)

Answer 5

LMA- Laryngeal mask airway

Answer 6

OET- Oral endotracheal tube

Answer 7

NET- Nasal endotracheal tube

Answer 8

GETA- General endotracheal anesthetic

Answer 9

TIVA- Total Intravenous Anesthetic

Answer 10

MAC- Monitored anesthesia care (not to be confused with minimum alveolar concentration)

Answer 11

LOC- Level of consciousness

Answer 12

MAP- Mean arterial pressure

Answer 13

CSF- Cerebral spinal fluid

Answer 14

PAW- peak airway pressure

Answer 15

CPAP- Continuous positive pressure ventilation

Answer 16

EBL- Estimated blood loss

Answer 17

IVGA- Intravenous general anesthesia

Answer 18

PEEP- Positive end expiratory pressure

Answer 19

Intrathecal- inside the dura

Answer 20

Epidural- outside of the dura, In the epidural space (which is a potential space)

Answer 21

Oxygen slang

Answer 22

Gas- commonly the way an anesthesia provider refers to volatile anesthetic agents

Answer 23

GCS- Glasgcow coma scale

Answer 24

HOB- Head of bed

Answer 25

CVA- cerebral vascular accident (stroke)

Answer 26

MVA- Motor vehicle accident

Answer 27

GSW- Gun shot wound

Answer 28

OB- refers to obstetrics (usually the unit itself)

Answer 29

ED/ER- refers to the emergency department/ emergency room (depending upon your age)

Answer 30

PACU- Post anesthesia care unit

Answer 31

Pre-op- Preoperative area

Answer 32

Vt- Tidal volume

Answer 33

BBSE- Bilateral breath sounds equal (a fast way to chart lung sounds that are clear

Answer 34

IOP- Intraocular pressure

Answer 35

ICP- intracranial pressure

Answer 36

CABG- Coronary artery bypass graft (this patient has had CABG- pronounced cabbage)

Answer 37

CBF- Cerebral blood flow

Answer 38

CMR- Cerebral metabolic rate

Answer 39

MDA- Slang term for anesthesiologists, depending on the Doctor they may find this offensive. No other clinical specialty is defined this way and what if they are a D.O.? Will you refer to them as a DOA?? (please don’t) So understand to whom someone is referring but call them anesthesiologist. If you cannot say that word you are in the wrong field.

Answer 40

Can reduce cost of surgery Can reduce cancellation rates Increase resource utilization in the OR (Why do we care?)

Answer 41

Review of the medical record History and physical (pertinent to the surgery) Appropriate diagnostic tests Appropriate pre-op consultations Determine whether the patient’s condition can be improved prior to surgery Answer all questions Obtain informed consent

Answer 42

Pt having outpatient same day Fast turn over Limited time to get to know pt Limited time to create relationship Limited time to engender trust Limited time to answer questions

Answer 43

Forms are Rated using 3 Categories: Informational Content Ease of Use Ease of Reading

Answer 44

EMERGENCY- Life, Limb or Organ Saving; surgery \<6hours- examples: ruptured aortic aneurysm; major trauma to thorax or abdomen; acute increase in ICP URGENT- Conditions threaten life, limb or organ; surgery within 6-12 hours- examples: perforated bowel; compound fracture; eye injury TIME SENSITIVE- Stable but requires intervention; surgery within days-weeks- examples: tendon; nerve injuries; cancer ELECTIVE- Procedure planned at patient or surgeon convenience; surgery within 1 year- examples: all other procedures that can be planned in advance

Answer 45

Urgency of surgery must be weighed against the optimization of the patient Consider the implications of urgency (i.e. Bowel obstruction- Increased risk of aspiration = RSI) Planned procedures: (Carotid) may require neuro exam & cardiac workup/clearance Positioning & Necessity of blood products: Can surgery be delayed for optimization or will delay increase morbidity?

Answer 46

Dx & Procedure: Anesthetic/surgical Hx; MH/Adverse Rxn; Airway difficulties Airway: Known difficulty airway; Sleep Apnea; Teeth; Mallampati; Mouth opening; Chin length; Neck size & Mobility CNS: Seizures; CVA; Syncope; ICP; Mental status; H/A; Weakness; Spinal cord injury; Psych disorder Infectious: COVID; HIV; VRE; Flu; TB; Foreign travel Age/Gender/Height/Weight: Allergies; reactions; Medications (over the counter/herbals and illicit drugs) CV: Congenital disease; HTN; CAD; CHF; Cardiomyopathy; Valvular disorders; Syncope; Arrythmia; Pacer; PVD; Angina; Dyspnea; Orthopnea; Exercise tolerance GI/Hepatic: Liver disease; Hepatitis; N&V; GERD; Bowel obstruction; EtOH use Renal: Insufficiency; Failure; Dialysis Hematology: Anemia; Coagulopathy; Sickle cell; Chemo; Transfusion Hx Vital Signs: NPO status; IV access; Invasive monitoring; Advanced directives Pulmonary: URI/Bronchitis; Pneumonia; Smoking; Asthma; COPD; Cough; dyspnea; Sleep apnea; O2/Inhaler/Steroid use; Pneumothorax; Vent settings; Tube size/depth Endocrine/Metabolic: DM; Thyroid disease; rheumatoid arthritis; steroid use Other: Pregnancy; Weeks of gestation; Trauma Hx

Answer 47

Positive Risk Factors: Female; Hx of PONV or motion sickness; non-smoker; age\<50yrs; General vs Regional; Volatile agents; Nitrous Oxide; Post-operative opioids; Duration of anesthesia; Type of surgery (chole; laparoscopic; Gyn) Conflicting Data: ASA; Menstrual cycle; Anesthesia provider experience; Muscle relaxant reversal Apfel Risk Score: No risk factors= 10% chance of PONV; 1 risk factor= 20%; 2 risk factors= 40%; 3 risk factors= 60%; 4 risk factors= 80%

Answer 48

Ephedra: (wt. loss) Tachycardia; HTN; increased sympathomimetic effects with others (arrythmia with digoxin and HTN with oxytocin) Feverfew: (migraines) PLT inhibitor; Increased breathing risk; rebound H/A with cessation GBL; BD; & GHB (body building/ wt. loss) Illegal; death; seizures; severe bradycardia; unconsciousness Garlic: (antioxidant/lowers cholesterol) decreased PLT aggregation Ginger: (anti-nausea) Potent inhibitor of thromboxane synthetase; Increased bleeding time Gingko: (blood thinner) Increased bleeding in pts on anti-coags Ginseng: (energy/ antioxidant) Inhibits PLT aggregation Goldenseal: (laxative/diuretic) Oxytocic= worsens edema & HTN Kavakava: (Anxiolytic) potentiates sedatives & hepatotoxicity Licorice: (Tx of gastric ulcers) HTN; Hypokalemia & edema St John’s Wort (depression/anxiety) prolongs anesthetic effects Valerian: (anxiolytic/sedative) potentiates sedative effects of anesthesia Vitamin E: (slows aging) Increases bleeding in conjunction with anti-coagulants & anti-thrombin meds

Answer 49

1 MET: Daily self-care; eat; dress; walk indoors; walk a block or 2 on ground level 2-3mph 4METs: Climb a flight of stairs or walk up a hill; walk on ground level 4mph; run a short distance; heavy work around the house; participate in moderate activities (golf, bowling, dancing, doubles tennis) \>10METs: Participate in strenuous sports like swimming; singles tennis; football; basketball or skiing Exercise tolerance remains one of the MOST important predictors of Peri-op risk for non-cardiac surgery; also helps define the need for further testing

Answer 50

Excellent **exercise tolerance** (even in patients with stable angina) suggests that the myocardium can be stressed without failing

Answer 51

Based on an algorithm that integrates clinical hx; surgery specific risk & exercise tolerance Evaluate the urgency of surgery & appropriateness of formal pre-evaluation Determine if the pt. has undergone a recent revascularization or CV work up

Answer 52

AIRWAY- Evaluate the oral cavity Evaluate dentition Thyromental Distance Assess neck size, tracheal deviation or masses Ability of the patient to flex and extend the neck and head Evaluation of trauma patients, patients with severe rheumatoid arthritis or Down’s syndrome requires thorough C-spine eval. The presence of symptoms of cord compression may require X-ray exam Modified Mallampati Airway Classification: 1- Full view of soft palate, uvula, tonsillar pillars 2- Soft palate and upper portion of uvula 3- Soft palate 4- Hard palate only

Answer 53

LUNGS- History of tobacco use Dyspnea Exercise tolerance Recent upper respiratory infection Stridor Snoring Sleep Apnea Physical exam: Respiratory rate; chest excursion; use of accessory muscles; nail color; decreased breath sounds; wheezing; stridor; crackles History of asthma Last time use of a rescue inhaler Last asthma attack

Answer 54

Look for s/sx of uncontrolled hypertension and unstable cardiac disease (MI, CHF, Valvular disease; arrhythmia) Dyspnea Chest pain Syncope Racing rhythms Irregular beats Palpitations SOB Trouble going up and down a flight of stairs Presence of unstable angina = High perioperative risk of MI Periop period= catecholamine surges; hypercoagulable state therefore exacerbates underlying issues such as angina leading to MI Take BP Listen to the heart for murmur radiating to the carotids= aortic stenosis Abnormal rhythm or gallop= heart failure Presence of Bruits over the carotid= needs further work up for stroke risk M.A.C.E- Major adverse cardiac events Low risk procedure= \<1% risk of MACE High risk procedure= \>1% risk of MACE Advanced age = increased risk of MACE and ischemic stroke Hx of CV disease; DM; Cerebrovascular disease= Elevated risk of MACE The goal is to identify clinical risk and need of pre-op cardiac testing The Revised Cardiac Risk Index (RCRI)- assigns peri-op risk using clinical variables The Revised Cardiac Risk Index (RCRI)- High-risk type of surgery History of Ischemic Heart Disease History of Congestive Heart Failure History of Cerebrovascular Disease Pre-operative treatment with Insulin Pre-operative Serum Creatinine (\>2mg/dL) \*Cardiac complications increase with increased risk factors\* Clinical evidence of heart failure: Dyspnea Limited exercise tolerance Orthopnea JVD Crackles Third heart sound Peripheral edema Diabetes associated with CV disease: Diabetes accelerates atherosclerotic disease Diabetics have a higher incidence of silent MI and myocardial ischemia Diabetes requiring insulin for treatment is a risk factor in the RCRI The pre-op ECG should be evaluated for presence of Q-waves Hypertensive disease: Hypertension is associated with increased incidence of silent MI Aggressive treatment of BP is associated with reduction in long-term MI risk Treat SBP \> 150mmHg Treat DBP \> 90mmHg (in pts 60yrs old or \>) \* Elective surgery should be delayed for DBP \>110mmHg\*

Answer 55

Peripheral procedures are associated with extremely low incidence of morbidity and mortality Major open vascular procedures are associated with the highest incidence of complications High risk procedures: major vascular; abdominal; thoracic and orthopedic surgeries

Answer 56

One of the most important predictors of perioperative risk for non-cardiac surgery (helps define the need for further testing and invasive monitoring) Patients with good exercise tolerance that have stable angina suggests that the myocardium can be stressed without failing Patients with dyspnea associated with chest pain during minimal exertion= extensive CAD and greater perioperative risk

Answer 57

Early surgery after stent placement = adverse cardiac events (incidence of periop death and hemorrhage) Delay of non-cardiac surgery for 14 days after balloon angioplasty Delay of non-cardiac surgery for 30 days after bare metal stent placement Delay of non-cardiac surgery after drug eluding stents = 12 months

Answer 58

These devices can be impaired by electromagnetic interference (Bovie) during surgery Review the guidelines for AICDs, pacers and arrhythmia monitors

Answer 59

MI within 3 months or less = 30% incidence MI within 3-6 months = 15% incidence MI greater than 6 months = 6% incidence \*IF re-infarction occurs, the mortality rate is 50%!\*

Answer 60

Post-operative pulmonary complications occur more frequently than cardiac in patients having non-cardiac surgery! Complications include: Atelectasis; pneumonia; exacerbation of COPD; pulmonary edema and respiratory failure requiring post-op ventilation \*POST-OP RESPIRATORY FAILURE = MAJOR CAUSE OF M&M\*

Answer 61

Pulmonary functions testing (PFT) and chest X-rays (CXR)- proven to have limited benefit in predicting peri-operative respiratory failure and complications Decreased serum Albumin levels & Increased BUN = increased risk of peri-operative pulmonary morbidity Predictors- Open aortic, thoracic and upper abdominal procedures are associated with the HIGHEST RISK of peri-operative pulmonary morbidity Cranial, vascular and neck surgeries are associated with a HIGH RISK of peri-operative pulmonary morbidity \*These surgeries lead to decreased vital capacity; decreased FRC; and diaphragmatic dysfunction= hypoxemia and atelectasis\*

Answer 62

Tobacco- Increased carboxyhemoglobin levels Decreased ciliary function Increased sputum production Cardiovascular stimulation from Nicotine \* 4-8 weeks of smoking cessation is needed in order to decrease the incidence of post-operative complications\* (Airways are very Reactive!!)

Answer 63

Find out the patient’s severity! current status; frequency of bronchodilator use; frequency of hospitalization (r/t asthma) and steroid use Consider a “stress dose” if patient takes regular corticosteroids d/t adrenal insufficiency

Answer 64

defined as periodic obstruction of upper airway during sleep Leads to chronic sleep deprivation Chronic pulmonary hypertension Right heart failure \* These patients are susceptible to respiratory depressants! Use judiciously!\* OSA Characteristics: Obesity; Large neck; large tonsils; nasal obstruction; upper airway abnormalities Questions- Do you snore? Do you wake yourself up at night from snoring? Are you tired in the daytime? Do you have a hard time breathing?

Answer 65

The majority of diabetics develop secondary disease in one or more organ systems Increased risk for CAD; HTN; CHF & Peri-op MI Higher incidence of cerebral vascular, peripheral vascular and renal vascular disease DM is the leading cause of renal failure requiring dialysis! Increased peripheral neuropathies= careful positioning Gastroparesis= theoretical increased aspiration risk Stiff joints d/t glycosylation of proteins (could affect airway) Thorough H & P Draw blood glucose on arrival, hgbA1c; Lytes; creatinine and ECG Type 1 Diabetics= hgbA1c \<7.5% Type 2 Diabetics= hgbA1c \<7% - or abnormal lytes or ketonuria = DELAY ELECTIVE SURGERY!! \*optimize these patients then bring them back\* Perioperative sugar management- The periop experience comes with increased serum glucose d/t stress (cortisol and catecholamine release) Glycemic control decreases morbidity, infection rate, stroke incident and improves wound healing Goals- Cardiac surgery= maintain sugar 80-100 mg/dL Goals- non-cardiac surgery= maintain sugar \<200mg/dL Hold oral hypoglycemic meds the day of surgery Continue insulin (consider half dose)

Answer 66

Screen for s/sx of hyper/hypothyroidism- Hypo= hypothermia; hypoglycemia; hypoventilation; hyponatremia & heart failure Hyper= THYROID STORM- tachycardia; A-fib; CHF; tremor; muscle weakness & anemia \*enlarged thyroid may create airway difficulty\* Hyperparathyroidism= hypercalcemia (draw Ca++) s/sx= weakness; lethargy; headache; insomnia; apathy; bone pain & epigastric pain

Answer 67

Be suspicious of those on long term steroid use (Cushing’s- moon face; skin striation; truncal obesity & HTN) Make sure that they get a stress dose if steroids were taken for one month or greater within the last 6-12 months (if more than a minor procedure) Max dosing= 100mg hydrocortisone IVP before surgery then q8h x 1 day then 50mgIVP--- highly debated\*

Answer 68

Assess electrolytes Make patient euvolemic prior to induction (likely dry if hemodialysis recently) Be mindful of meds metabolized by kidneys

Answer 69

Coagulopathy (know levels before regional) Decreased plasma proteins- affects drug binding Consider labs if increased ETOH history

Answer 70

CBC- extremes of age; liver or kidney disease; anticoagulant use; bleeding; hematologic disorders; malignancy; type & invasiveness of surgery

Answer 71

COAGS- liver or kidney disease; bleeding disorder; anticoagulant use; chemotherapy

Answer 72

SERUM CHEMISTRY (glucose, lytes, renal & liver function)- liver or kidney disease; DM; CNS disease; Endocrine disorder; Elderly; Malnutrition; type & invasiveness of surgery

Answer 73

CXR- pulmonary disease or clinical findings (r/o pneumonia or pulmonary edema); unstable cardiovascular disease; type & invasiveness of surgery

Answer 74

ECG- CV disease or clinical findings; pulmonary disease; type & invasiveness of surgery

Answer 75

PREGNANCY TEST- possible pregnancy (child bearing years) everyone

Answer 76

Are risk factors modifiable? Will delaying the procedure add to peri-op risk or morbidity? What can we do in the peri-op period to decrease this patient’s risk? Do we have enough information to make an informed decision?

Answer 77

Emergency surgery Inadequate (light) anesthesia Abdominal pathology Obestity Opiates Neuro deficits Lithotomy Difficult intubation Reflux Hiatal Hernia

Answer 78

Clear liquids= 2 hour minimum Breast milk= 4 hour minimum Infant formula= 6 hour minimum Non-human milk= 6 hour minimum Light meal= 6 hour minimum

Answer 79

Bicitra: Increases gastric pH in 100% of the cases it is used – Highly effective antacid Famotidine: Increases gastric pH Reglan: Increases gastric emptying (obese; pregnant; diabetics; trauma & emergency surgery)

Answer 80

Diagnosis/Procedure Anesthetic/surgical Hx MH/Adverse rxn Airway difficulty Airway Difficult? Sleep Apnea Exam: teeth; mallampati; mouth opening; chin length; neck size and mobility CNS Stroke; mini-stroke; seizures; numbness; tingling; weakness Altered mental status; headaches; neuromuscular disease; spinal cord injury Psych disorders: anxiety, depression.. Etc.. Infectious If/When did you have COVID-19; HIV; MRSA; VRE; influenza; TB; foreign travel- Any Sequalae Age/ Gender/ Height/ Weight Allergies- adverse med reactions Medications Over the counter meds (herbals, illicit drugs) Cardiovascular Congenital heart disease; hypertension; coronary artery disease; heart failure; cardiomyopathy; valvular disease; syncope; arrhythmia; pacer; ICD; vascular disease Chest pain, SOB; racing rhythms; irregular beats; palpitations; able to go up and down stairs without SOB GI/ Hepatic Liver disease; reflux (GERD, Hiatal hernia) Bowel obstruction Alcohol use Renal Insufficiency; failure; dialysis Hematology Anemia; coagulopathy; sickle cell; chemo; transfusions (do this in lay terms) Vital Signs NPO status; IV access; invasive monitors; advanced directives Pulmonary URI; bronchitis; pneumonia; recent cough or cold; asthma - When’s the last time you used a rescue inhaler? Have you ever been hospitalized for your breathing? Endocrine/Metabolic Diabetes; thyroid; rheumatoid arthritis; steroid use

Answer 81

Problems arising from positioning such as peripheral neuropathies injuries fall under the doctrine “Res ispa loquitur” “the thing speaks for itself” This implies the injury sustained is so evident that it would not have occurred without negligence from someone else Patient only has to prove that there was an injury . . . This is why documenting pre-existing issues is so important

Answer 82

•The goal of the Anesthesia Closed Claims Project is to identify major safety concerns, patterns of injury and strategies for prevention to improve patient safety by anesthesiologists working in pain management, operating rooms, labor floor, remote locations and critical care.

Answer 83

Perioperative neuropathy or soft tissue injury when sleeping naturally Wakes us up Hip starts to hurt so we wake up and shift to the other side We can adjust ourselves when something gets uncomfortable Both consciously or unconsciously move and reduce the tissue stretch and compression forces that caused the symptoms

Answer 84

**\*\*Tissue stretch and compression**\*\* are most commonly associated with positioning-related problems in anesthetized or sedated patients Stretch (especially \> 5% of resting length): Kinks or decreases lumens feeding arterioles and draining venules Direct Ischemia from reduced arteriole blood flow Indirect ischemia from venous congestion Compression: (neuropraxia or axonotmesis) Direct pressure reduces local blood flow and disrupts cellular integrity Results in tissue edema, ischemia and possibly necrosis Padding

Answer 85

Don’t really know for sure Perioperative Inflammatory Responses Inflammatory neuropathy Microvascular neuropathies Autoimmune disease/Viruses/immunosuppression Radiation-induced Systemic inflammation from drugs

Answer 86

Gives the surgical team a clear view of the surgical site Provides the best access to the surgical site for the surgeon Gives anesthesia the best position for the optimal administration of drugs Can reduce bleeding before/during/after the surgery Decreases the risk of pressure and nerve related injuries Can prevent or reduce risk of respiratory problems (especially when anesthesia is involved) Prevents/reduces risks associated with circulatory issues

Answer 87

Surgeon - Optimal procedural exposure Anesthesia - Physiologic requirements (ABC’s) -Ongoing assessment -Ensure patient safety Nursing -Safe transfer -Use of adequate padding and positioning aids - Ongoing assessment

Answer 88

A through assessment of risk factors for complications related to positioning should be an interral part of the preoperative evaluation A history of surgeries related to positioning. Knee back hip of neck surgery may need special positioning considerations

Answer 89

Shared responsibility Must document every change and how you protected patient If head, neck or whole body moves must recheck and document breath sounds Hypotension biggest physiologic consequence of position changing Patients are unconscious and relaxed – can often be put in positions not tolerated.

Answer 90

\*\*Ulnar Neuropathies\*\* most common Brachial Plexopathies Median Neuropathies Radial Neuropathies Lower Extremity Neuropathies

Answer 91

Most COMMON perioperative neuropathy Key factors associated with ulnar neuropathy: Direct extrinsic nerve compression (often medial aspect of elbow) Intrinsic nerve compression (associated with prolonged elbow flexion) Inflammation Male, high BMI, older, prolonged postop bed rest

Answer 92

Most develop during postoperative period Studies suggest that those patients that develop ulnar neuropathy experience their first symptoms at least **_24-48_** hours postoperatively Medical patients can also develop ulnar neuropathies during hospitalization

Answer 93

Ulnar nerve passes behind medial epicondyle and under the aponeurosis that holds the two muscle bodies of the flexor carpi ulnaris together Proximal edge of aponeurosis (cubital tunnel retinaculum) is thick, especially in men The retinaculum stretches from the medial epicondyle to the olecranon Flexion of the elbow stretches the retinaculum and puts a lot of stress on the nerve as it passes underneath

Answer 94

**_Ulnar nerve is the only major peripheral nerve in the body that always passes on the extensor side of a joint…….. the elbow!_** All other major peripheral nerves primarily pass on the flexion side Peripheral nerves start to lose function and can develop ischemia when stretched \>5% of their resting length \>90 (110) degree elbow flexion stretches the ulnar nerve

Answer 95

Abduct less than 90 degrees Supinate the arm Use padding

Answer 96

About 40% of sensory-only ulnar neuropathies resolve within 5 days About 80% resolve within 6 months Only a few combined sensory and motor ulnar neuropathies resolve within 5 days About 20% resolve within 6 months and most result in permanent motor dysfunction and pain Compression or stretch injury

Answer 97

Compression at nerve between table and medial epicondyle Prevent by supination, avoid hypotension and hypoperfusion Pad arms properly Manifested by \***inability to abduct the 5th finger** Weakness/ atrophy of hand muscles **\*“claw-hand”\*** Numbness, tingling or pain in the lateral aspect of the hand on the side of the ulnar nerve injury

Answer 98

Patient characteristics prolonged bedrest and high body mass index Men: 1.5 times larger tubercle of the coronoid process, less adipose tissue, thicker cubital tunnel retinaculum Abnormal ulnar nerves before surgery (Contralateral neuropathy) Poorly formed fibrotendinous roof of the cubital tunnel External compression in the absence of stretch

Answer 99

Most common is patients undergoing sternotomy (especially those with internal mammary artery mobilization) Patients in prone and lateral have a higher risk than supine Things to think about: Brachial plexus entrapment Prone positioning Anatomy of shoulder abduction

Answer 100

Prone and lateral position patients Brachial plexus can become entrapped between compressed clavicles and rib cage Prone position Better if arms can be tucked Some patients can have somatosensory-evoked potential changes when their arms are abducted (surrender position)

Answer 101

Shoulder braces may compress nerve roots and stretch the plexus Turing the head (unconscious patient) may stretch the brachial plexus Spreading the sternal retractor causes the clavicle and rib to pinch the plexus. Unilateral retraction may cause stretching of the nerves.

Answer 102

Abduction \> 90 degrees places the distal plexus on the extensor side of the joint and possibility of stretching the plexus Goal is to avoid abduction \>90

Answer 103

Excessive external rotation or abduction of arm Avoid \> 90 degree abduction Avoid arm falling off of table! Watch lateral head rotation If prone watch flexion and abduction of arms overhead Lateral position requires an axillary (chest) roll which avoids compression of humerus into axilla

Answer 104

Scapular winging Serratus anterior muscle that is supplied by the long thoracic nerve that branches immediately from C5-C7, sometimes C8 Long thoracic nerve palsy allows the dorsal protrusion of the scapula Traumatic in nature Viral/inflammatory?

Answer 105

Manifestations depend on which nerves are injured in the plexus: Median – “Ape hand” deformity, inability to oppose thumb - Muscular men with large biceps are susceptible to median nerve injury if the arm is fully extended during surgery Axillary – inability to abduct the arm Ulnar – “Claw hand” deformity Musculocutaneous – inability to flex forearm Radial – wrist drop

Answer 106

Abduction of the arm on the arm board \> 90 degrees Head of the humerus into the axillary neurovascular bundle Compression and stretch injury Compression or occlusion of vessels with decreased perfusion Mastectomy

Answer 107

Mostly in men between 20 and 40 years old Men with large biceps and decreased flexibility Prevents complete extension at the elbow Creates a shortening of the median nerve over time Usually motor dysfunction and don’t readily resolve Around 80% with motor dysfunction are still there 2 years after initial onset IVs in the antecubital area Things to think about: Stretch of the nerve: nerves become ischemia if stretched \>5% of their resting length which can kind penetrating arterioles and exiting venules decreasing perfusion pressure Arm support

Answer 108

When muscular men are anesthetized, their arms are fully extended at the elbow and placed on armboards Full extension of the elbow stretches chronically contracted median nerves and promotes ischemia (at the level of the elbow) Very important to support/pad the forearm and hand to prevent full extension

Answer 109

More common that median neuropathies Injured more often by direct compression (in contrast to median nerve injury due to stretch) Radial nerve injury is usually compression of the nerve in the mid-humerus area (arising from roots C6-8 and T1) Things to think about: Surgical retractors: compression of radial nerve by bars used to hold abdominal retraction holders Lateral position (impinged by overhead arm boards) Unsupported arms/ poles/ repeated cycling of the BP cuff

Answer 110

Can be injured if compressed against spinal groove of humerus and other object (ie. Either screen or excessive cycling NIBP Symptoms include wrist drop, weakness of abduction of thumb and loss of sensation in web space between thumb and index finger.

Answer 111

Common peroneal Sciatic nerve Obturator nerve Lateral femoral cutaneous nerve Femoral nerve

Answer 112

Great care must be exercised when placing the hip in unusual positions. Excessive flexion or abduction can injure the lateral femoral cutaneous or obturator nerves respectively.

Answer 113

Hip abduction \>30 degrees can cause strain on obturator nerve Obturator passes through the pelvis and out the obturator foremen Excessive hip flexion of thigh can cause compression Excessive traction in abdominal Sx Motor dysfunction is common Inability to adduct the leg with decreased sensation over the medial side of the thigh

Answer 114

Prolonged hip flexion \>90 degrees can cause ischemia One third of the nerve’s fibers pass through the inguinal ligament as it passes through the thigh (originates at L2-3) Hip flexion \>90 degrees causes lateral displacement of the anterior superior iliac spine and stretch of the inguinal ligament Nerve fibers are compressed by the stretch and can become ischemic and dysfunctional This nerve carries \*\*\***only sensory fibers**\*\* so no motor disability occurs But can have disabling pain and dysesthesias of the lateral thigh

Answer 115

Can be stretched with external rotation of the leg Sciatic and its branches (common peroneal and tibial nerves) cross the hip and knee joints and are stretched by hyperflexion of the hips and extension of the knees

Answer 116

Usually associated with direct pressure of the lateral leg, just below the knee, where the peroneal wraps around **head of the fibula** Injured by leg holders (candy cane) that hold the leg and foot Impinge the nerve around the head of the fibula Can cause prolonged foot drop and trouble ambulating

Answer 117

May be injured when the medial tibial condyle is compressed by leg supports May be injured during difficult forceps delivery or by excessive flexion of the thigh to the groin

Answer 118

Most changes are related to gravitational effects on cardiovascular and respiratory systems Changes in position redistribute blood within the venous, arterial, and pulmonary vasculature Pulmonary mechanics also change with varying body positions

Answer 119

Changing from erect to supine increases venous return and stroke volume Parasympathetic stimulation regulate heart rate and contractility to adjust to increased preload Obesity (wedge under Rt hip), pregnancy, and abdominal tumors can reduce venous return (preload) when in the supine procedure

Answer 120

The Frank-Starling law states that the force or tension developed in a muscle fiber depends on the extent to which the fiber is stretched. In a clinical situation, when increased quantities of blood flow into the heart (increasing preload), the walls of the heart stretch.

Answer 121

In supine position, functional residual capacity and total lung capacity are reduced due to changes to the diaphragm This is exaggerated in obese patients Anesthesia and muscle relaxants further reduce these volumes due to diaphragm position with relaxation Trendelenburg position also reduces lung volumes Any position that limits movement of the diaphragm, chest wall or abdomen may increase atelectasis and intrapulmonary shunt

Answer 122

_Four basic surgical positions:_ Supine Prone Lithotomy Lateral _Variations_ Trendelenburg Reverse Trendelenburg Fowlers Jackknife High and low Lithotomy

Answer 123

Patient on back Arms on arm boards or tucked Check orientation of arm (arms \< 90 degrees) Make sure arm is supinated (palm up) Place additional padding under elbow if able Check fingers Check IV lines and SaO2 probe FRC is decreased by 20% Abdominal contents limit movement of the diaphragm Decreased muscle tone from GA Small airways close sooner  hypoxia VQ changes cause shunting hypoxia Obesity and pregnancy problems Compression of the IVC Pressure on occiput alopecia Pad back of head Check often in long cases Keep hips and knees slightly flexed Blanket/ pillow under knees Legs uncrossed Heels, occiput and elbows padded Cervical, thoracic and lumbar spines should be in straight alignment Arms If at side must be padded and tucked Watch fingers !!!!! On arm boards Padded, palms up (supinated) less than 90 degree angle

Answer 124

Peripheral neuropathies which can occur in any position Backache Ischemic pressure injuries Pressure Alopecia Prolonged compression of hair follicles produce hair loss Pain and swelling where the occiput has been supporting weight in the head down position Associated with tight face mask straps, hypotension and hypothermia Pressure-Point issues Hypothermia and vasoconstrictive hypotension Heels, sacrum and elbows

Answer 125

Restraint too tight Pressure compresses the anterior interosseous nerve (branch of the median nerve) in the upper forearm Can resemble compartment syndrome in the lower extremity

Answer 126

Brachial plexus neuropathy Sternal retraction Long Thoracic Nerve Injury Axillary trauma from humeral head Radial nerve compression Median Nerve Dysfunction Ulnar Nerve Neuropathy Back pain Compartment syndrome

Answer 127

Positioned on side often with assistance of supports or bean bag Arms parallel and padded Maintain good anatomical alignment Pillow between legs and feet Keep bottom leg flexed to stabilize the trunk Chest roll placed Check radial pulse of dependent arm

Answer 128

Support placed caudad to the downside axilla Axillary Roll??? Lifts the thorax enough to relieve pressure on the axillary neurovascular bundle Helps prevent decreases in blood flow to the hand and arm Questionable Decrease shoulder pain after postop

Answer 129

Flexion should be under the iliac crest Chest roll Neck neutral Pillow between knees and flexed Padding under ankles/feet

Answer 130

Flip the table so the flank and thorax are horizontal Feet/legs below the atria causing pooling of blood Lumbar stress Thoracotomy Not very common For Kidney surgery: Lateral jackknife with elevated kidney rest

Answer 131

VQ mismatching: Dependent lung: Underventilated More perfusion Nondependent lung: Overventilated Less perfusion Causes incr. VQ mismatching hypoxia

Answer 132

Patient is supine with arms extended laterally \<90 degrees Each lower extremity is flexed at the hip (about 90 degrees) and knees bent parallel to the floor **Extremities should be elevated and lowered slowly and together** Seen most often in GYN and Urology cases Hip flexion \>90 degrees can increase stretch of the inguinal ligaments

Answer 133

Various types of stirrups Candy cane Allen stirrups Knee cradles Move legs at same time when positioning patient in and out of lithotomy

Answer 134

**Low:** About 30-45 degrees Reduces perfusion gradients **High**: Suspend the patients feet high with stirrups Patient’s legs almost fully extended on the thighs flexed 90 degrees or more on the trunk Significant uphill gradient for arterial perfusion to the feet Avoid hypotension Stretch of sciatic nerve Compression of femoral canal by inguinal ligament **Exaggerated** Pelvis flexed ventrally on the spine, thighs forcibly flexed on trunk and lover legs aimed skyward Associated with compartment syndrome

Answer 135

Can auto transfuse up to 500 cc of blood Remember this will shift back when legs go down and can cause a decrease in BP Can impair ventilation due to upward pressure More prominent in obese pt’s Nerve injuries !!!! Most common problem with lithotomy Injuries: Sciatic, common peroneal, femoral, saphenous and obturator Hand injury (fingers in bed)

Answer 136

Common peroneal nerve damage Occurs from compression of lateral aspect of fibula head (improper padding against stirrups) FOOT DROP Elevate and flex simultaneously Avoids stretching of one side of the nerve \> 4 hrs in lithotomy increases risk of injury Ischemia, edema to skin and muscles

Answer 137

Femoral nerve injury Excessive angulation of the thigh on the abdomen Excessive traction during abdominal Sx Decreased flexion of the hip Decreased extension of the knee Loss of sensation over superior aspect of the thigh and medial or anteromedial side of the leg

Answer 138

In the immediate postoperative period, she developed compartment syndrome of the right hand that required multiple fasciotomies and multidisciplinary management by plastic surgery, orthopedics, and rehabilitation medicine. Acute compartment syndrome of the hand is a potentially devastating and infrequent condition observed after trauma, arterial injury, or prolonged compression of the upper limb

Answer 139

Perfusion to an extremity is inadequate Characterized by ischemia, hypoxic edema, elevated tissue pressure within fascial compartments and extensive rhabdomyolysis Lateral position(arm) and lithotomy (legs) Associated with: Systemic hypotension and loss of driving pressure to the extremity (elevation) Vascular obstruction from excessive flexion, knee or pelvic retractors External compression from straps Lithotomy for \>5 hours common factor

Answer 140

Used for posterior fossa of the skull, posterior spine, buttocks and perirectal and lower extremities (Achilles) Head neutral ET tube placement and patency Check bilateral eyes/ears for pressure points Head turned Check dependent eye/ear ETT placement Be aware of potential vascular occlusion Arms at side or “surrender position” \< 90 degrees to prevent stretching of brachial plexus

Answer 141

Need multiple people to assist Disconnect all lines/monitors if possible Patient is log rolled gently so there are no abnormal movements or twisting of body parts Using normal ROM arms are placed beside the pt’s head or brought down to the sides of the body Chest rolls from below clavicles to iliac crest Provide adequate lung expansion and help alleviate pressure on abdomen Protect male genitalia and female breasts Full monitoring reinstituted ASAP, ET tub positioning reconfirmed

Answer 142

Pillow under lower legs and ankles help flex knees and prevent pressure on toes Head on special pillow with cut out area free of pressure on face/eyes Head positioned to side may impair drainage on one side or neutral Elastic stockings and active compression to minimize pooling of venous blood Cardiac: Compression of abdominal viscera Pooling of blood in extremities Decreased preload, CO, BP, SV Increased SVR and PVR Pulmonary Decreased total lung compliance Increased work of breathing ETT dislodgement Other Check and document face and eye free of pressure every ? min Blindness from retinal ischemia ION- Ischemic optic neuropathy Corneal abrasions

Answer 143

Cholecystectomy, head and neck procedures Shifts the abdominal contents caudad Prevent patients from slipping off the table May have hypotension may result in decreased venous return and perfusion to brain Facilitates exposure, aids in breathing (increased FRC)

Answer 144

Causes further pressure upwards on diaphragm from abdominal contents and further decreases lung expansion Increases ICP by decreasing venous drainage Increased IOP (pt with glaucoma) Activation of baroreceptors ^ pressure; ^ baroreceptor discharge; inhibits systemic vasoconstriction(SNS) & enhances vagal tone Increased risk of aspiration Mendelson syndrome: aspiration of \> 25cc of gastric contents with a pH of \< 2.5

Answer 145

Further increases translocation of blood to central compartment (along with lithotomy) Intracranial and intraocular pressure increases What should you think about before extubation? Facial and upper airway edema (Can the patient breath around the ET tube with the cuff deflated) What pulmonary changes can occur? Decrease in pulmonary compliance, FRC and vital capacity Shoulder braces and brachial plexus injury

Answer 146

What is the most common injury to the eye? Corneal abrasion What are some other injuries to the eye? Chemical injury, direct trauma (pressure and crush), blurred vision

Answer 147

Flexion of the head may move the endotracheal tube toward the carina; extension moves it away from the carina. A general rule is that the tip of the endotracheal tube follows the direction of the tip of the patient’s nose. Sudden increases in airway pressure or oxygen desaturation may be caused by mainstem bronchial intubation.

Answer 148

Awake- MAP, SV, CO, PaO2 all decrease Alveolar-arterial oxygen gradient and pulmonary and vascular resistance all increase An autonomic response helps compensate for the above by increasing SVR by up to 50-80% Cerebral perfusion pressure decreases by about 15%

Answer 149

General Anesthesia: * The autonomic response is inhibited by general anesthesia causing vasodilation and decreased CO * GA causes vasodilation, myocardial depression, and impaired venous return that further impairs cerebral blood flow

Answer 150

Flexion of the head may obstruct the internal jugular and cause cerebral venous engorgement or hypoperfusion (swelling in the face, eyes) Extension of the head can impair cerebral blood flow causing cerebral ischemia, obstruction of ET and pressure on the tongue

Answer 151

Cerebral vasculature dilates and constricts to maintain constant blood flow to the brain CPP = MAP – ICP (or CVP) Autoregulation occurs when MAP in between 50 and 150 m Hg Poorly controlled HTN the curve is shifted higher to the right

Answer 152

Supine: BP in arm is similar to CPP in the absence of ICP Beach chair: MAP and BP in the arm is higher than Cerebral perfusion Monitored at external auditory meatus (represents the base of the brain) which is about 20 cm above the heart (15 mm Hg difference) Cuff site (blindness and stroke due to inaccurate BP ) 1 mm Hg decrease/1.35 cm height (20 cm ~ 15 mmHg change)

Answer 153

Potential complications from sitting position **Venous air emboli** Need to take measures to detect and extract VAE Hypotension (fluids, vasopressors, decrease agent) Brainstem manipulations resulting in hemodynamic changes Risk of airway obstruction Decrease venous return (stockings or compression devices) Macroglossia (avoid chin against chest)

Answer 154

Hyperflexion of the neck, with or without rotation of the head Stretching of the spinal cord resulting in compromise of the vasculature of the midcervical region Paralysis below the general level of the 5th cervical vertebra Sitting position Prolonged head flexion for intracranial surgery in the supine position

Answer 155

VAE: venous air embolism Caused by open venous system above level of the heart Atmospheric pressure \> venous pressure and vein sucks air in Detection by listening to heart sounds with Doppler at R 2nd intercostal space A sudden decrease in CO2, hypoxia, arrhythmias, hypotension and a millwheel murmur (usually a late sign)

Answer 156

Stop the problem Flood area with water if necessary 100% O2 and Stop N2O Aspirate from CVP Durant’s position Vasopressors Get ready to do CPR

Answer 157

Can cause pressure damage over nose Facial nerve damage from fingers over mandible Face straps can cause injury or even necrosis to face, ears and eyes and alopecia

Answer 158

Corneal abrasions are the most common Chemical irritation from preparation solutions Direct trauma from face mask Pressure from the hands while intubating Pressure effects from lateral and prone position Poor eye taping techniques Blindness more rare Etiology probably ischemic optic neuropathy Large volume blood loss Prolonged hypotension Duration of surgery Prone or lateral position Edema Patient’s at Risk DM Smokers Obese ETOH abuse Anemic HTN Consent ALL Patient’s at Risk

Answer 159

Acute venous congestion of the optic canal Wilson Frame Head is lower than the heart Obesity can increase intraabdominal pressure in prone patients Long durations All the above can contribute: to venous congestion in the optic canal reduction of optic nerve perfusion pressure perioperative visual loss. Thought about possibility of visual loss. People need to know it’s a possibility during consent… prone spine surgery- does pt want to know about it 80% of pts want to know… Closed practice claims 5% are for the eye- ( most common is corneal abrasion. ION ischemic – neuropathy .8 % and corneal is just 1%. Done surgery if only ive known about blindness I would not have done the procedure. Had to describe it – who will bear responsibility – surgeon cant be pt didn’t understand and anesthesia would check to make sure they understand if didn’t would not start till pt understood. Rare event ION place extreme stroke even death above vision.

Answer 160

Reduce venous congestion in the optic canal Keep head above the heart or at the same level Colloids vs Crystalloids Reduce intra-abdominal pressure Limiting duration of surgery

Answer 161

Avoid positions that permit stretching of the nerves Avoid pressure to areas that carry nerves prone to injury (ulnar cubital tunnel, peroneal) Padding and support should distribute weight over wide areas Patients position should be neutral whenever possible Anesthesia and muscle relaxants increase malposition injuries Extremes of weight is obviously a risk ASK the patient what is comfortable

Answer 162

Patients with a history of back pain or previous surgery Patients with history of knee and hip arthroplasty Neck pain Shoulder pain Rheumatoid arthritis Anyone that complains of pre-existing injury…. ALWAYS CHART WHAT YOU DID (patient positioned for comfort in stirrups before induction, neck neutral, hands padded per patient request and comfort)