Lecture 2. Basics of Anesthesia
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| The underlying pathological mechanisms behind nerve injuries are (there are 6): | Stretch
Compression
Generalized ischemia
Metabolic derangement
Laceration
Direct trauma
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| According to the ASA Closed Claims Project database, ______ is the second most common class of injury | perioperative nerve injury (16%)
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| 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)
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| 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.
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| The most commonly used position for all surgical procedures is: | supine
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| What is the most common positional injury pf the upper extremities? | postoperative ulnar neuropathy
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| Supine position is also called _______ or ______ | dorsal recumbent or horizontal
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| 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.
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| 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
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| With general anesthesia the diaphragm and intercostals relax, which causes a ____ to _____% decrease in FRC | 15 - 20%
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| In supine positioning: Spontaneous ventilation favors _______ lung segments. Controlled ventilation favors _______ lung segments. | dependent; independent
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| The most common ocular injury is..... | corneal abrasions
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| 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
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| The motor root of the _____ nerve may also be damaged from traction on the angle of the mandible | facial
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| Extreme flexion at the elbow also leads to damage of what nerve? | ulnar nerve
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| Brachial plexus is formed by which nerves? | C5 - C8, T1
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| 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)
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| The brachial plexus responsible for the motor innervation of .... | all of the muscles of the upper extremity
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| The brachial plexus supplies ... | all of the cutaneous innervation of the upper limb, except the area of the axilla and dorsal scapula.
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| The second most common postop neurological injury is to the ... | brachial plexus
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| 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
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| Pronated arm causes damage to _______ nerve | ulnar
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| Abduction of the arm greater than 90 degrees causes risk to ________, which causes inability to ______ (abduct or adduct) | brachial plexus, abduct
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| 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
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| How many perioperative nerve injuries involve the ulnar nerve? | more than a quarter
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| 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
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| 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
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| 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
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| 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
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| Injury to the _____ nerve may occur during an IV start either by the needle or extravasation of the drug | median
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| 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.
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| Injury to the musculocutaneous nerve results is (2 things): | Inability to flex the arm
Decreased sensation over the ventral surface of the forearm
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| 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
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| 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
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| Crossing of legs causes damage to the ______ of the dependent leg in an anesthetized patient | superficial peroneal nerve
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| Crossing of legs causes damage to the ______ of the independent (top) leg in an anesthetized patient | sural nerve
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| After supine, the most commonly used position is: | lithotomy
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| Lithotomy position is used for what patients (there are 3)? | for patients undergoing urological, GYN, and colorectal procedures
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| Legs must be elevated and lowered simultaneously to prevent ... (3 things) | hip disarticulation, torsion injury to relaxed muscles and ligaments, and spinal injury
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| 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)
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| 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.
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| 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
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| 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
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| #1 lower extremity nerve to be damaged intraoperatively is: | common peroneal nerve
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| Injury to this nerve is from Hip flexion of > 90 degrees, which results in arterial or venous occlusion & nerve palsy | femoral nerve
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| 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
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| _______ injury is due to stretching, most likely to occur if improperly positioned in lithotomy | sciatic nerve
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| ______ injury is from compression of medial aspects of calf rest on stirrups | saphenous nerve
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| 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
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| Injury to this nerve results in weak plantar flexion, paresthesias of posterior calf, sensory deficit to sole, toes, and lateral foot | Posterior tibial nerve
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| 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
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| In lithotomy position _______ is a condition in which increased tissue pressure within a limited tissue space compromises the circulation. | compartment syndrome
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| 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.
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| The most consistent factor in development of compartment syndromes is: | the duration of the procedure
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| Compartment syndrome can lead to (3 things): | muscle necrosis, myoglobinuria & eventual renal damage
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| The cardiovascular change(s) that occurs due to trendelenberg positioning is/are: | Activation of baroreceptors = decreased CO, PVR, HR, and BP.
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| 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
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| 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
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| What nerve injury can occur due to trendelenberg positioning? | brachial plexus
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| What 2 nerve injuries can occur due to extreme trendelenberg positioning if the arms become loose? | plexus injury or radial nerve injury
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| 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
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| Reverse trendelenberg has an increased risk for _______ if operative site above the level of the heart | venous air embolism
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| 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.
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| What affects does reverse trendelenberg have on CPP and CBF? | CPP and CBF may decrease
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| What 3 procedures are done in sitting position? | shoulder surgery, posterior fossa craniotomies, and cervical surgery
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| 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
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| What affects does the sitting position have on CBF? | CBF decreases
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| 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
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| 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
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| To prevent jugular vein obstruction while in the sitting position we must maintain a space of ____ fingers between the mandible and neck | Two
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| With venous air embolus (VAE) ____ displaces ____ in the pulmonary vasculature | air displaces blood
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| 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
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| Air that enters the skull but does not leave is called _______ | Tension pneumocephalus
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| 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
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| The position that is also known as ventral decubitus is ______ | prone position
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| For procedures on the neck or back, the occipital or postero-lateral cranium, sacral, perianal or perineal the patient will be in _____ | prone position
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| Cardiovascular changes related to prone position are: | Femoral vein and IVC compression, which may decrease preload, CO, and BP
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| 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
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| In prone position the arms are placed ____ or ____ | in goal post position or at the patient's sides
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| A specialized table for the prone position that allows the thorax and abdomen to hang freely is the ___________ | Jackson Table
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| _____ Frame is placed over OR table and facilitates venous drainage from lower extremities | Wilson Frame
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| 3 potential eye complications from the prone position are: | corneal abrasion, blindness or edema
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| 5 potential causes of blindness from prone position are: | Obesity, Wilson frame, prolonged surgical time, hypotension, hypovolemia.
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| 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
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| The nerve injury that can occur in the prone position is: | brachial plexus
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| Side lying position is also known as: | Lateral Decubitus Position
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| 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
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| 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
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| In lateral decubitus position there is ____ increased/decreased) FRC and _____ (increased/decreased) volume in both lungs | Decreased FRC
Decreased volume both lungs
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| 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.
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