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Basics - Positioning
Lecture 2. Basics of Anesthesia
| Question | Answer |
|---|---|
| The underlying pathological mechanisms behind nerve injuries are (there are 6): | Stretch Compression Generalized ischemia Metabolic derangement Laceration Direct trauma |
| According to the ASA Closed Claims Project database, ______ is the second most common class of injury | perioperative nerve injury (16%) |
| Which patients are at increased risk for nerve injuries? (there are 6) | Obese patients Thin patients Diabetic Peripheral vascular disease Peripheral neuropathy An anatomic variable (eg, cervical rib) |
| Goals that Anesthetists should have when positioning the patient (there are 5): | Maximize surgical exposure. Prevent injury. Maintain physiologic functioning. Provide access for patient assessment, monitoring, and anesthetic intervention. Allow return to preoperative levels of health and activity. |
| The most commonly used position for all surgical procedures is: | supine |
| What is the most common positional injury pf the upper extremities? | postoperative ulnar neuropathy |
| Supine position is also called _______ or ______ | dorsal recumbent or horizontal |
| Cardiovascular changes related to supine position includes Bainbridge reflex, which is ... | Increase in HR secondary to Increased right-sided filling pressures, which increases cardiac output. Baroreceptors stimulated to decrease HR and PVR; BP returns to normal. |
| Ventilator changes include a decrease in FRC, which is _______ + ________, and can lead to __________ (3 things) | - FRC = expiratory reserve volume (1200 mL) + residual volume (1200 mL)(volume of gas that remains in the lungs after passive exhalation) - atelectasis, postoperative hypoxia and infection |
| With general anesthesia the diaphragm and intercostals relax, which causes a ____ to _____% decrease in FRC | 15 - 20% |
| In supine positioning: Spontaneous ventilation favors _______ lung segments. Controlled ventilation favors _______ lung segments. | dependent; independent |
| The most common ocular injury is..... | corneal abrasions |
| Edentulous patients, those with large faces, or requiring two hands for a proper mask fit can incur additional pressure on the _____ nerve during masking. | facial nerve |
| The motor root of the _____ nerve may also be damaged from traction on the angle of the mandible | facial |
| Extreme flexion at the elbow also leads to damage of what nerve? | ulnar nerve |
| Brachial plexus is formed by which nerves? | C5 - C8, T1 |
| How is the brachial plexus divided? | Roots (5) branches off into trunks (3), which branch off into divisions (6), which branches off into cords (3), which branches off into terminal branches (5) |
| The brachial plexus responsible for the motor innervation of .... | all of the muscles of the upper extremity |
| The brachial plexus supplies ... | all of the cutaneous innervation of the upper limb, except the area of the axilla and dorsal scapula. |
| The second most common postop neurological injury is to the ... | brachial plexus |
| Which 3 structures are relatively close in proximity to the brachial plexus, therefore predisposing the brachial plexus to risk of compression against these structures? | relatively fixed first rib, clavicle and humerus |
| Pronated arm causes damage to _______ nerve | ulnar |
| Abduction of the arm greater than 90 degrees causes risk to ________, which causes inability to ______ (abduct or adduct) | brachial plexus, abduct |
| The ulnar nerve originates from the _____ (dorsal or ventral) nerve root of ______ and the _____ (dorsal or ventral) nerve root of ______. | ventral nerve roots of C8 & T1; dorsal nerve root of C8 |
| How many perioperative nerve injuries involve the ulnar nerve? | more than a quarter |
| Risk factors associated with increased risk of ulnar nerve injury are (there are 6): | Hypotension Use of automated blood pressure cuffs Subclinical diabetes or other unrecognized medical illness Local anesthetic toxicity Manipulations of the brachial plexus during surgery Stretch or compression during surgical positioning |
| The blood supply to the ulnar nerve is susceptible to compression from the tubercle of _______, due to the artery’s _____(superficial or deep) course in the _____(proximal or distal) forearm. | coronoid process superficial proximal |
| Ulnar injury causes inability to _____ or ____ the 5th finger, decreased sensation over both surfaces of the _____ and _____ fingers, resulting in ______ hand | abduct or oppose medial ring & pinky fingers claw hand |
| Injury to radial nerve results in (4 things): | Wrist drop Inability to extend the metacarpophalangeal joints Weakness in abduction of the thumb Decreased sensation over dorsal surfaces of the lateral first, middle, and ring fingers |
| Injury to the _____ nerve may occur during an IV start either by the needle or extravasation of the drug | median |
| Injury to the median nerve results in (2 things): | Inability to oppose the 1st and 5th digits Decreased sensation on the palmar surface of the lateral first, middle, and ring fingers. |
| Injury to the musculocutaneous nerve results is (2 things): | Inability to flex the arm Decreased sensation over the ventral surface of the forearm |
| Decreased sensation on the palmar surface of the lateral first, middle, and ring fingers is from injury to the ______ nerve. Decreased sensation over dorsal surfaces of the lateral first, middle, and ring fingers is due to injury to the _____ nerve | median nerve, radial nerve |
| Lying supine has what affect on the lumbar spine? How can this be treated? | loss of lumbar curve Provide a small support device (roll, pad) in the lumbar region before induction may help retain lordosis and make patient with known lumbar distress more comfortable |
| Crossing of legs causes damage to the ______ of the dependent leg in an anesthetized patient | superficial peroneal nerve |
| Crossing of legs causes damage to the ______ of the independent (top) leg in an anesthetized patient | sural nerve |
| After supine, the most commonly used position is: | lithotomy |
| Lithotomy position is used for what patients (there are 3)? | for patients undergoing urological, GYN, and colorectal procedures |
| Legs must be elevated and lowered simultaneously to prevent ... (3 things) | hip disarticulation, torsion injury to relaxed muscles and ligaments, and spinal injury |
| How is vital capacity affected in lithotomy position? What is vital capacity? | decreased Vital capacity (4800 mL) = inspiratory reserve volume (3100 mL) + tidal volume (500 mL) + expiratory reserve volume (1200 mL) |
| What cardiovascular changes occur when legs are elevated in lithotomy position? When legs are lowered in lithotomy position? | Autotransfusion from leg vessels increases circulating blood volume and preload. Increases 100-250 mL per lower extremity elevated. Lowering the legs has the opposite effect; causes hypotension. |
| The _____ and ______ are particularly at risk of compression injury as they wind round the neck of the fibula and medial tibial condyle | common peroneal nerve and saphenous nerve |
| In lithotomy position extreme flexion of the hip joints can cause neural damage by (2 things): | Stretch - sciatic and obturator nerves. Direct pressure - compression of the femoral nerve as it is passes under the inguinal ligament |
| #1 lower extremity nerve to be damaged intraoperatively is: | common peroneal nerve |
| Injury to this nerve is from Hip flexion of > 90 degrees, which results in arterial or venous occlusion & nerve palsy | femoral nerve |
| Injury to this nerve is occurs with hip flexion, which results in weakness or paralysis of adduction of the thigh. Damage during difficult forceps delivery or excessive flexion | obturator nerve |
| _______ injury is due to stretching, most likely to occur if improperly positioned in lithotomy | sciatic nerve |
| ______ injury is from compression of medial aspects of calf rest on stirrups | saphenous nerve |
| Injury to this nerve results in foot drop, inability to evert the foot, sensory loss to dorsal area of foot, loss of dorsal extension of toes | Common peroneal nerve |
| Injury to this nerve results in weak plantar flexion, paresthesias of posterior calf, sensory deficit to sole, toes, and lateral foot | Posterior tibial nerve |
| Injury to this nerve can occur in the lithotomy position when compressed by stirrups with excessive pressure on the posterior aspect of the knee | Posterior tibial nerve |
| In lithotomy position _______ is a condition in which increased tissue pressure within a limited tissue space compromises the circulation. | compartment syndrome |
| Compartment syndrome probably due to (3 things): | A decrease in perfusion pressure caused by a combination of the weight of extremities against the supportive devices. Reduction in compartment capacity. Elevation of the lower limb above the heart. |
| The most consistent factor in development of compartment syndromes is: | the duration of the procedure |
| Compartment syndrome can lead to (3 things): | muscle necrosis, myoglobinuria & eventual renal damage |
| The cardiovascular change(s) that occurs due to trendelenberg positioning is/are: | Activation of baroreceptors = decreased CO, PVR, HR, and BP. |
| 3 respiratory changes related to trendelenberg positioning are: | Decrease in lung capacities from the shift of the abdominal visera. Increased V/Q mismatching, which results in atelectasis. Increased likelihood of aspiration |
| What affects does trendelenberg positioning have on ICP, CBF and IOP in patients with glaucoma? | Increase in ICP Decrease in CBF d/t venous congestion. Increase in IOP in patients with glaucoma |
| What nerve injury can occur due to trendelenberg positioning? | brachial plexus |
| What 2 nerve injuries can occur due to extreme trendelenberg positioning if the arms become loose? | plexus injury or radial nerve injury |
| Cardiovascular changes related to reverse trendelenberg include decrease in ____, ___, and ___; and increase in ___, ____, and ____ | Preload, CO, and arterial BP decrease. Baroreceptors increase sympathetic tone, HR, and PVR |
| Reverse trendelenberg has an increased risk for _______ if operative site above the level of the heart | venous air embolism |
| 3 respiratory changes that occur with reverse trendelenberg are: Spontaneous ventilation requires _____ (more/less) work. FRC ______ (decreases/increases) V/Q mismatch _____(does/does not) occur | Spontaneous ventilation requires less work. FRC increases. V/Q mismatch occurs. |
| What affects does reverse trendelenberg have on CPP and CBF? | CPP and CBF may decrease |
| What 3 procedures are done in sitting position? | shoulder surgery, posterior fossa craniotomies, and cervical surgery |
| What are the cardiovascular changes associated with sitting position? | Pooling of blood in the lower body decreases central blood volume. CO and arterial BP fall despite an increase in HR and SVR |
| What affects does the sitting position have on CBF? | CBF decreases |
| 3 respiratory changes that occur with sitting position are: Lung volumes and FRC ______ (decrease/increase) Work of breathing ______(decreases/increases) V/Q mismatch _____(does/does not) occur | Lung volumes and FRC increase. If hips are flexed and elevated the diaphragm shifts cephalad and WOB increases. V/Q mismatch occurs |
| A positioning concern related to sitting position is _______ from stretch on spinal cord when the head is flexed; and ____ (increased/decreased) autoregulation of spinal cord under GA and in the sitting position | Quadriplegia decreased autoregulation |
| To prevent jugular vein obstruction while in the sitting position we must maintain a space of ____ fingers between the mandible and neck | Two |
| With venous air embolus (VAE) ____ displaces ____ in the pulmonary vasculature | air displaces blood |
| If venous air embolus (VAE) occurs patient is to be placed in what position? | Place patient in T-berg position on his/her left side |
| Air that enters the skull but does not leave is called _______ | Tension pneumocephalus |
| The presence of air or gas within the cranial cavity (Associated with disruption of the skull, after head trauma, tumors of the skull base, or after neurosurgery) is called _____ | Pneumocephalus |
| The position that is also known as ventral decubitus is ______ | prone position |
| For procedures on the neck or back, the occipital or postero-lateral cranium, sacral, perianal or perineal the patient will be in _____ | prone position |
| Cardiovascular changes related to prone position are: | Femoral vein and IVC compression, which may decrease preload, CO, and BP |
| What respiratory changes are caused by the patient being in prone position? How is it treated? | Compression of abdomen and thorax restricts diaphragm movement, which decreases total lung compliance and increases WOB. With placement of chest rolls = improved pulmonary mechanics |
| In prone position the arms are placed ____ or ____ | in goal post position or at the patient's sides |
| A specialized table for the prone position that allows the thorax and abdomen to hang freely is the ___________ | Jackson Table |
| _____ Frame is placed over OR table and facilitates venous drainage from lower extremities | Wilson Frame |
| 3 potential eye complications from the prone position are: | corneal abrasion, blindness or edema |
| 5 potential causes of blindness from prone position are: | Obesity, Wilson frame, prolonged surgical time, hypotension, hypovolemia. |
| In the prone position excessive head rotation can reduce flow in both the _____ and ______ systems on either the ipsilateral or contralateral sides | carotid and vertebral systems |
| The nerve injury that can occur in the prone position is: | brachial plexus |
| Side lying position is also known as: | Lateral Decubitus Position |
| This position is used for procedures in which surgical access to the hemithorax, kidney, retroperitoneal space is needed. Also used for EGDs, ERCPs and colonoscopies, etc | Lateral Decubitus Position |
| In lateral decubitus position, how is ventilation & perfusion affected in an awake pt vs intubated pt? | Awake pts: dependent lung will have increased perfusion & ventilation Anesthetized pts: dependent lung will have increased perfusion, but decreased ventilation = V/Q mismatch |
| In lateral decubitus position there is ____ increased/decreased) FRC and _____ (increased/decreased) volume in both lungs | Decreased FRC Decreased volume both lungs |
| What affects does lateral decubitus position have on CO & BP? | CO unchanged unless venous return is obstructed (ex kidney rest). BP may fall as a result of decreased vascular resistance. |
Created by:
Thommy413
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