Exam 3 - Positioning in the OR
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| What are the 3 goals of positioning? | Maximize: surgical exposure, access to patient, recovery
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| Maximal access of the patient allows for what 3 things? | Maintenance of ventilation/airway, administration of drugs, monitoring VS
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| What are 3 ways to prevent nerve injuries? | Anticipate problems, proper planning, communicate abnormal findings
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| What are the effects of positioning injuries? | Prolonged hospitalization and recovery, psychological trauma, permanent disability, increased cost
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| Of closed claims analysis, how many nerve injuries were CRNA related vs. not CRNA related? | 68% CRNA related, 32% not CRNA related
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| Of the nerve injuries directly related to CRNA care, what percentage of cases were found to be inappropriate to standards of care? | 52%
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| What are the 4 primary methods of nerve injury? | Compression, stretch, transection, kinking
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| What are some different injuries related to compression and why do they occur? | Soft tissue, nerves, and vascular structure injuries occur due to compression over an extended period of time; caused by increased tissue resistance to venous capillary outflow and decrease in pressure gradient b/w capillaries and tissue
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| Where do stretch injuries often occur? | Superficial nerves w/a long course
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| Identify a scenario whereby transection injuries can occur? | Surgical trauma
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| When do kinking nerve injuries occur? | A nerve is pinched between 2 immovable structures (i.e. exaggerated lithotomy)
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| When do compression injuries occur? | When a nerve is forced against a bony prominence or a hard surface
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| Describe the process of tissue ischemia. | 1) decreased tissue blood flow 2)anaerobic metabolism produces and accumulates acid byproducts 3)membrane Na-K pump failure 4)increased intracellular Na leads to increased osmotic gradient and edema
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| What is a common component of all peripheral nerve injuries? | Tissue ischemia
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| In an ischemic environment, decreased production of _______ leads to the failure of the Na-K pump. | ATP
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| What are 4 causes of compartment syndrome? | Prolonged operation, hypotension, extremity elevation, body habitus
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| What is compartment syndrome? | Potentially life threatening complication causing neural and vascular damage due to swelling of the muscular compartment
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| What is the definitive treatment for compartment syndrome? | fasciotomy
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| What situations may occur if compartment syndrome is not diagnosed and treated? (5) | Permanent neuromuscular damage, tissue necrosis, myoglobinuria, ARF, amputation, death
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| What are two scenarios that lead to the development of compartment syndrome? | Increased pressure and decreased tissue perfusion in muscles with tight fascial borders
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| When does tissue swelling typically occur? | When blood flow returns following a period of ischemia
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| Compartment syndrome has also been dubbed a _______. | Reperfusion injury
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| What are 4 common causes of compartment syndrome? | Trauma, embolic phenomena, tumors, vascular insufficiency
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| What are pre-disposing perioperative factors for compartment syndrome? | Tight wound closure, expanding hematoma, prolonged surgery, external compression
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| A higher incidence of compartment syndrome has been reported in what surgical positions? | Lithotomy, lateral decubitus
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| What are the 2 surgical factors that contribute to nerve injuries? | Positioning devices, length of surgery
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| A surgical length of greater than _________ hours increases the risk for nerve injury. | 4
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| What are anesthetic factors that contribute to nerve injuries? | GA, NMB, hypotensive techniques, neuraxial/peripheral blocks
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| Why does GA pose a risk for positioning injuries? | Patient cannot verbalize or move in response to painful stimuli
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| What two types of drugs lend towards stretch injuries d/t increased mobility of joints? | NMBs and volatile anesthetics
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| Name the surgical positions where gravity affects blood flow. | Sitting, lithotomy, T-burg
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| The majority of nerve injuries are r/t what 3 factors? | Block technique, needle trauma, hematoma
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| It (is/is not) acceptable to extend the extremities of patients with multiple contractures. | Is not
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| The presence of paresthesia means that a medication (should/should not) be injected. | should not
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| What does the presence of paresthesia indicate? | Needle is in the nerve root
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| What are body habitus factors that contribute to nerve injuries? | Over/under- weight, muscular
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| For women, a BMI < ______ is associated with increased likelihood of ulnar nerve injury. | 22
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| What pre-existing conditions increase the risk for nerve injuries? | PVD, peripheral neuropathy, smoking, subclinical ulnar nerve entrapment, thoracic outlet syndrome
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| A muscular body habitus is associated with what type of surgical injuries? | Ulnar nerve injury and compartment syndrome
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| Describe the difference between under- and over- weight patients and surgical injuries. | Underweight may develop decubiti or nerve damage d/t lack of adipose tissue over bone; overweight is d/t large tissue masses putting pressure on dependent body parts
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| Nerve injury and pre-existing neuropathies are more common in patients with what disease? | diabetes
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| What is the most common metabolic cause of spontaneous isolated femoral neuropathy? | diabetes
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| What are the most common upper extremity nerve injuries? | Ulnar (#1) and brachial plexus (#2)
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| What is the most common lower extremity nerve injury? | Common peroneal
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| Ulnar neuropathy is a well-known complication of what type of surgery? | cardiac
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| Elbow flexion compresses the ulnar nerve in what structure? | cubital tunnel
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| Elbow flexion stretches the cubital tunnel between what two bony structures? | Medial epicondyle, olecranon
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| Ulnar nerve injuries are more frequently associated with (males/females), especially over the age of ______. | Males; 50
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| Identify the vertebrae of origin for the brachial plexus. | C5-C8, T1-T2
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| STUDY SLIDE 19 |
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| STUDY SLIDE 21 |
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| The nerve roots merge to form what 3 structures? | Superior (upper), middle (middle), inferior (lower) trunks
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| What do the 3 nerve trunks subdivide into? | 3 anterior and 3 posterior divisions
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| The 3 anterior and 3 posterior divisions run (anterior/posterior) to the clavicle. | posterior
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| The patient is vulnerable to brachial plexus injuries if the arms are _______, the shoulders are _________, or the head is ________. | abducted, depressed, rotated
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| STUDY SLIDE 23 |
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| (Supination/Pronation) increases pressure over the ulnar nerve. | pronation
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| What are the positioning recommendations to prevent ulnar nerve injury in anesthetized patients? | Use of padding, supinate arms, abduction <90 degrees with armboards
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| What are 5 different positioning devices? | Straps, stirrups, shoulder braces, arm boards, axillary rolls
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| Table straps or leg holding devices are associated with what type of nerve injury? | Lateral femoral cutaneous nerve (thigh)
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| Common peroneal nerve injury has been attributed to the use of what type of positioning device? | Crutch stirrups
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| Brachial plexus injuries have been reported with what two positioning devices? | Falling armboards, shoulder braces in steep T-burg
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| Leg holding devices for arthroscopy is associated with what type of nerve injury? | Lateral femoral cutaneous nerve
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| What is the purpose of repositioning and massaging the head in the supine patient? | Prevents alopecia of the occiput
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| What is the cause of backaches in the supine position and what can be done to prevent it? | Caused by abolition of lumbosacral curve; place folded sheet or bag of IVF under the lumbar spine
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| Crossed legs in the supine position may lead to what two nerve injuries and in which legs? | Damage to the superficial peroneal nerve in the dependent leg and damage to the sural nerve in the superior
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| What devices can evenly distribute body weight following lengthy procedures? | Gel pads or mattresses
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| Armboards should be angled less than _________ degrees. | 90
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| What direction should the thumbs be pointed if the patient's arms are resting at the sides? | up
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| What two respiratory factors are decreased in the supine position? | FRC and chest wall muscle tone
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| What does bending the hips and knees improve for the supine patient? | venous return
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| Which surgical position produces the least amount of physiologic changes? | supine
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| What are 4 drawbacks to T-burg? | Doesn’t predictably improve CO in low BP/low volume patients, decreased stroke volume from viscera pressing on the heart, compresses lung bases, may increase ICP
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| What benefit does the prone position have over the sitting position in its use for intracranial procedures? | Less risk for VAE
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| What are the CV effects of the prone position and why? | Compression of the inferior vena cava and aorta d/t cephalad displacement of the diaphragm
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| What major vessels are compressed in the prone position? | Inferior vena cava and aorta
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| Placing padding underneath the shoulders of a prone patient prevents stretching of the _________ nerve. | Brachial plexus
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| Placing padding between the elbow and the armboard in the prone patient helps prevent ____________ nerve damage. | Ulnar
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| Pressure on the abdomen from the prone position may cause what 3 complications? | Impede venous return, increase venous pressures, inhibit diaphragmatic movement
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| In reference to spinal cord surgery, what is the benefit of positioning devices that allow for the abdomen to hang freely? | Decreased inferior vena cava pressures, which prevents engorgement of spinal venous plexuses (epidural veins)
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| The ______ Table improves diaphragmatic excursion in the prone position. | Jackson
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| How does rotation of the head negatively affect blood flow? | May obstruct jugular venous drainage
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| What devices can be used to support the had of the prone patient w/cervical arthritis? | Prone pillow or Mayfield headrest
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| What ocular complications are associated with the prone position? | Corneal abrasions and POVL
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| In the absence of a Jackson Table, what can be used to relieve abdominal pressure in the prone patient? | Chest rolls placed from clavicle to iliac crest
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| What are two variations of prone positioning? | Jack-knife, kneeling
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| What surgical position is associated with the most significant circulatory and ventilatory effects? | Lateral decubitus
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| Compression of which vessel may occur with lateral decubitus, especially in conjunction with a kidney rest? | Inferior vena cava
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| Lateral decubitus is used for surgeries involving what areas of the body? | Thorax and kidneys
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| What effect does lateral decubitus have on the lungs? | Underventilation of dependent lung and increased compliance of nondependent lung
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| What structures compress the dependent lung in lateral decubitus? | Abdominal contents and mediastinum
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| Lateral decubitus positioning may lead to _____ mismatch, with an increase in bloodflow to the (dependent/nondependent) lung. | V/Q; dependent
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| What should periodically be checked in the lateral decubitus patient? | Radial artery; pulse Ox on dependent hand can also assess perfusion
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| What are the angles for true and modified sitting positions? | 90=true, 45=modified
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| What are the CV changes associated with the sitting position? | Decreased CO, CVP, PAWP
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| How much does MAP decrease with sitting position? | 0.75mmHg per cm of elevation
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| What is the most serious complication with the sitting position and why? | VAE b/c of negative pressure gradient b/w R atrium and veins and the operative site
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| The supine and lithotomy both cause _______ displacement of the diaphragm and viscera. | cephalad
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| What are the principle nerve injuries of the lithotomy position? | Sciatic, common peroneal, femoral, saphenous, obturator
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| What are three steps to take in caring for the patient in lithotomy? | Padding b/w metal brace and patient’s leg, elevate and lower both legs simultaneously, thigh flexion of no more than 90 degrees prior to lateral rotation of stirrups
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| Prolonged lithotomy of > _____ hrs may result in compartment syndrome. | 4
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| When are peripheral nerve injuries more likely to occur during procedures requiring what type of anesthesia? | GA
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| What are the usual causes of post-op neuropathy? | Position-related compression or stretch
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| What are types of studies that can be done with a peripheral nerve injury? | Conduction, velocity, and EMG studies
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| Acute injury will appear _______ days after the onset of symptoms. | 18-21
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| How long does it take to recovery from a peripheral nerve injury? | 3-12mos
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| What is the most common post-op neuropathy? | Ulnar nerve injury
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| What is the prevalence of ulnar nerve injury after cardiac surgery? | 38%
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| Bending the elbow narrows the _________ and compresses the _______ nerve. | cubital tunnel; ulnar
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| Bending the elbow narrows the _________ and compresses the _______ nerve. Cubital tunnel; ulnar | supinated; up
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| How does ulnar nerve injury manifest itself? | 1)inability to abduct or oppose the fifth finger 2)diminished sensation over medial one and half fingers 3)atrophy of intrinsic muscles of the hand
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| Claw hand is associated with what type of nerve injury? | Ulnar
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| What are two reasons the brachial plexus is prone to injury? | Long superficial axillary course and proximity to movable bony structures
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| Name two bony structures that may cause brachial plexus injury? | Clavicle and humerus
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| What is the second most commonly injured nerve in the upper body? | brachial plexus
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| Shoulder braces may compress the brachial plexus between which bones? | Clavicle and first rib
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| A compression injury of the brachial plexus may occur if a shoulder brace is not placed over the _______ joint. | acromioclavicular
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| Which surgical position has the highest prevalence for brachial plexus injuries? | Lateral decubitus
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| How do sternal retractors affect movement of the clavicle and 1st rib? | Clavicle moves posterior, 1st rib moves up
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| What steps should be taken in cardiac surgery to minimize brachial plexus injury? | Caudad placement of retractors and avoidance of prolonged and asymmetric chest retraction
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| Where should an axillary roll be placed in order to prevent brachial plexus injury? | Slightly caudad, not directly underneath the axilla
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| The radial nerve may be injured if pressure is applied to it while it transverses the ________. | Spiral groove of the humerus
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| What are the manifestations of radial nerve injury? (3) | Wrist drop, weakened thumb abduction, decreased sensation over the dorsal surface of the thumb, 1st and 2nd fingers
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| The median nerve runs over what important anatomical feature? | Antecubital fossa
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| What are the primary causes of median nerve injury? | IV placement or extravasation
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| Sodium pentothal (is/is not) caustic to veins. | is
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| “Ape hand” deformity is associated with what nerve injury? | Median
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| What positions are the thumb and index finger arrested in with median nerve injury? | Adduction and hyperextension
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| What thumb functions are lost with median nerve injury? | Opposition and flexion
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| Where should an axillary roll be placed in order to prevent brachial plexus injury? | Slightly caudad, not directly underneath the axilla
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| The radial nerve may be injured if pressure is applied to it while it transverses the ________. | Spiral groove of the humerus
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| What are the manifestations of radial nerve injury? (3) | Wrist drop, weakened thumb abduction, decreased sensation over the dorsal surface of the thumb, 1st and 2nd fingers
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| The median nerve runs over what important anatomical feature? | Antecubital fossa
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| What are the primary causes of median nerve injury? | IV placement or extravasation
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| Sodium pentothal (is/is not) caustic to veins. | is
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| “Ape hand” deformity is associated with what nerve injury? | Median
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| What positions are the thumb and index finger arrested in with median nerve injury? | Adduction and hyperextension
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| What thumb functions are lost with median nerve injury? | Opposition and flexion
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| Where does decreased sensation occur with median nerve injuries? | Palmar aspect of the lateral 3 ½ fingers
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| Compression injury of the sciatic nerve occurs due to the nerve passing under the _______ muscle. | Piriformis
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| What are the two points of fixation of the sciatic nerve and what two movements increases the distance b/w these points? | Sciatic notch and fibula; external rotation of the leg or knee extension
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| What is the longest and widest single nerve of the human body? | sciatic
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| What are the two branches of the sciatic nerve? | Tibial and common peroneal
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| Sciatic nerve injury occurs due to improper placement of the patient in what surgical position? | lithotomy
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| IM injection into the ______ could cause sciatic nerve injury. | buttocks
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| IM injections in the OR should be placed in the ________ aspect of the _______. | lateral; thigh
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| How is sciatic nerve injury manifested? | Weakness of all skeletal muscles below the knee; diminished sensation over the lateral half of the leg and almost all of the foot
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| What does damage to the common peroneal nerve reflect? | Compression between the head of the fibula and metal brace in the lithotomy position
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| What is the most frequently injured nerve in the lower body? | Common peroneal
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| How does injury to the common peroneal nerve manifest? | Foot drop, loss of dorsal extension of the toes, inability to evert the foot
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| Foot drop is indicative of nerve injury to the ________. | common peroneal nerve
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| Anterior tibial nerve injury may manifest post-op if the feet are ___________ for extended periods of time. | plantar flexed
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| Where should a roll be placed for patients in the sitting position to prevent anterior tibial nerve injury? | Under the anterior aspect of the ankle to maintain extension
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| What are two possible causes of a femoral nerve injury? | Compression by retractor blade (laparotomy) or by excessive angulation (lithotomy)
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| What are the 3 manifestations of a femoral nerve injury? | Decreased knee jerk, loss of hip flexion, loss of knee extension
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| Where does decreased sensation occur with a femoral nerve injury? | Superior aspect of the thigh, medial and anterior medial side of the leg
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| A pelvic fracture may cause _________ nerve injury. | femoral
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| What does the saphenous vein branch from? | femoral nerve
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| Where does pain occur with a saphenous nerve injury? | Medial knee and leg pain
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| Compression of the saphenous nerve against the _______ can result in injury. | medial tibial condyle
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| How does obturator nerve injury manifest? | Loss of leg adduction, decreased sensation over medial thigh
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| In what scenarios can an obturator nerve injury occur? | Difficult forceps delivery, excessive flexion of thigh to groin
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| Pressure necrosis of the groin can occur with what orthopedic table? | Chick Table (hip surgery)
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| What are high-risk surgeries for POVL? | Cardiac and prone spinal surgeries
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| The retina supplies axons to the _____ nerve. | optic
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| What are the 4 divisions of the optic chiasm? | Intraocular, intraorbital, intracannicular, intracranial
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| Where do the retina and optic nerves receive their blood supply? | Through the central retinal and ciliary arteries
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| Arteries that supply the retina and optic nerve arise from the ______. | Internal carotid
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| What important function do retinal and ciliary arteries lack? | Autoregulation in the presence of hypoperfusion
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| What are two pre-existing conditions that affect autoregulation and increase the risk for POVL? | DM and HTN
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| Thrombosis of the central retinal artery, which may lead to permanent blindness, can be caused by what factors? | Prone position, deliberate/accidental hypotension, increased intraocular pressure
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| Trauma of the appendages most often occurs with the _____. | Fingers
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| What is the most likely cause of trauma to the fingers in patient positioning? | Foot of the table is returned to horizontal position in lithotomy
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| Face masks can place pressure on the _________ branch of the facial nerve. | Buccal
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| What does injury to the buccal branch of the facial nerve result in? | Paresthesia of the orbicularis oris muscle
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| What nerve can be compressed by the ETT and how does this injury manifest? | Suborbital
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| Decreased sensation over the forehead and pain in the eye may be due to injury of what nerve? | Suborbital
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| Compression of what part of the mandible can cause facial nerve damage? | Ascending ramus
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