Barry-Positioning
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| Drugs and gases induce a state in which the pt loses the ability to? | to compensate for position changes; Generalized vasodilation with GA alters vasoconstriction in areas that may normally shift blood flow as needed
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| Pt’s will lose their _________________ to prevent neuromuscular injuries | normal protective reflexes; ALWAYS DOCUMENT PREOPERATIVE NUEROLOGICAL S/S
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| If head, neck or whole body moves you must recheck and document what? | breath sounds
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| the biggest physiologic consequence of position changes | hypotension
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| What is the cause of hypotension in intraoperative position changes? | Anesthesia blunts the compensatory SNS reflexes that would normally minimize the BP changes associated with position changes
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| In supine postion, FRC is decreased by? | 20%
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| In the supine position, how is FRC decreased? | Abdominal contents limit movement of the diaphragm and decreased muscle tone from GA
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| Obese and pregnant patients should be tilted to which side? | left side
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| Pressure on occiput can cause? What should you do to prevent this? | alopecia, pad back of head
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| What pulmonary changes happen in the supine position causing hypoxia? | Small airways close sooner, VQ changes cause shunting, Gravity increases blood flow (perfusion) to Lung Zone III (dorsal)
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| Which nerve injury is #1 in anesthesia related nerve injuries? | Ulnar nerve injury (ulnar nerve very superficial)
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| How is does ulnar nerve injury happen? | Compression at nerve between table and medial epicondyle (groove in elbow)
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| How do you prevent ulnar nerve injury? | Prevent by supination and avoid hypotension and hypoperfusion; Pad arms properly
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| What clinical manifestation occur with ulnar nerve injuries? | Manifested by inability to abduct the 5th finger Weakness/ atrophy of hand muscles “claw-hand”
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| Brachial plexus nerve injury is created by? | excessive external rotation or abduction of arm
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| How do you avoid a brachial plexus injury? | Avoid > 90 degree abduction, Watch lateral head rotation If prone watch flexion and abduction of arms overhead; Lateral position requires an axillary roll which avoids compression of humerus into axilla
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| Which position causes further pressure upwards on diaphragm from abdominal contents and further decreases lung expansion? | Trendelenburg
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| Activation of baroreceptors caused by Trendelenburg position manifests what clinical conditions? | inhibits systemic vasoconstriction(SNS) & enhances vagal tone
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| Which position causes increases in ICP by decreasing venous drainage, increased IOP (pt with glaucoma), and increased risk of aspiration? | Trendelenburg
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| What is Mendelson Syndrome? | chemical pneumonia caused by aspiration during anaesthesia, especially during pregnancy
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| What is the most common problem with the lithotomy position? | nerve injuries
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| Common peroneal nerve damage occurs from? | compression of lateral aspect of fibula head (improper padding against stirrups)
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| Common peroneal nerve damage manifests as? | foot drop (neuro consult)
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| An increased risk of injury in lithotomy position (including ischemia and edema) occurs at ____ hours. | greater than 4
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| T or F. Lithotomy position can auto transfuse up to 500cc of blood. | T
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| T or F. Lithotomy position does not impair ventilation. | F. It can impair ventilation due to upward pressure.
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| Excessive angulation of the thigh on the abdomen causes which nerve injury? | Femoral nerve injury
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| Femoral nerve injury manifests itself clinically as? | decreased sensation on anterior thigh and inability to flex your hip
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| Lithotomy position can cause injury to which nerves? | FOPPS. (Femoral, Obturator, Peroneal (common), Saphenous, and Sciatic Nerves)
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| Nerve injury caused by excessive flexion of the thigh to the groin? | Obturator Nerve
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| Nerve injury caused by compression of the medial aspect of the legs against the stirrup supports? | Saphenous Nerve
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| Which nerve is stretched by excessive external rotation of the leg when placing the patient into lithotomy position? | Sciatic Nerve
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| Compression of the lateral aspect of the legs at the head of the fibula against the stirrup supports causes which nerve injury? | Peroneal (common) Nerve
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| Chest rolls in the prone position should be placed? | from below clavicles to iliac crest
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| Chest rolls placed properly allows? | adequate lung expansion and help alleviate pressure on abdomen
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| In prone position, what must you do to flex knees and prevent pressure on toes? | pillow under lower legs and ankles
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| What kind of bite block must you use in prone position? | taped rolled up gauze
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| Compression of the abdominal viscera causes? | Pooling of blood in extremities Decreased preload, CO, BP, SV
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| T or F. Prone position can cause increased SVR and PVR. | True.
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| T or F. Prone position causes decreased total lung compliance and decreased work of breathing. | False. Prone position caused decreased total lung compliance and increased work of breathing.
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| How often in prone position you must check and document the face and eyes are free of pressure? | every 15 minutes
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| hypothermia, hypovolemia, and pressure on eyes can cause what? | ION- Ischemic optic neuropathy
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| T or F. Prone position can cause blindness from retinal ischemia. | True.
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| T or F. Reverse Trendelenburg causes a decrease in CO, preload, and ABP. | True.
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| T or F. In Reverse trendelenburg baroflexes causes a decrease in sympathetic tone, HR and PVR. | False. Reverse trendelenburg causes an increase sympathetic tone, HR and PVR.
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| T or F. Reverse trendelenburg causes increased FRC and decreased work of breathing. | True.
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| An ______ must be placed just below axilla to avoid compression of the neurovascular bundle in lateral decubitus position. | axillary roll
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| Which arm should you put your pulse oximeter on in lateral decubitus position? and why? | O2 monitor on dependent arm to make sure perfusing; also check radial pulse of dependent hand to assure perfusion
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| In lateral decubitus position mechanical ventilation favors which lung? | Mechanical ventilation favors the nondependent lung
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| T or F. in the lateral decubitus position, perfusion is gravity-dependent. | True.
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| What is hypoxic pulmonary vasoconstriction? | physiological phenomenon in which pulmonary arteries constrict a normal physiological condition in which the presence of hypoxia without hypercapnia, redirects blood flow to alveoli with a higher oxygen content.
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| T or F. The normal hypoxic pulmonary vasoconstriction response is blunted under general anesthesia. | True.
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| Why can a clinically significant V/Q mismatch develop in the lateral decubitus position? | Blunting of the hypoxic pulmonary vasoconstriction response. Ventilation decreases in dependant lung due to decreased compliance (compression by weight of abdominal contents), perfusion increases in dependant lung (gravity).
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| Normal V/Q ratio: | is 0.8 (4L/5L)
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| A V/Q mismatch of infinity is caused by: | No perfusion and alveolar dead space
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| A V/Q mismatch of zero is caused by: | No ventilation and intrapulmonary shunt (R to L)
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| What position is used most often for posterior fossa, cervical spine, shoulder or neck surgery? | Sitting
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| Venous air embolism is caused in which position? | sitting position
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| What can decreases the incidence of pulmonary emboli? | Positive pressure ventilation
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| A sudden decrease in ETCO2 (PaCO2 goes up), decr. Sats, arrythmias, decr. BP and a millwheel murmur is indicative of what? | venous air emboli
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| A venous air emboli can be detected by? | Detection by listening to heart sounds with doppler at R 2nd intercostal space
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| T or F. If venous air embolism is suspected continue surgery and give volume. | False. Treatment includes giving volume but surgery must be stopped. Surgeon must flood surgical field with saline and bone wax.
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| T or F. Treatment of venous air embolism includes vasopressors to counteract hypotension, and 100% O2 with no nitrous oxide. | True.
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| T or F. If patient has CVP and trying to retract a venous air embolism, place patient in right lateral reverse trendelenburg. | Fasle.Left lateral reverse trendelenburg.
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| T or F. If patient has no CVP place patient in right lateral reverse trendelenburg position to prevent air embolism to enter right atrium and pulmonary circulation. | True.
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| T or F. Pneumocephalus is a complication of sitting position. | True.
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| T or F. Paraplegia/quadraplegia (compression in lumbar, cervical, groin) can be a complication of the sitting position. | True.
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| T or F. Ocular compression and also edema of face, tongue, neck are not complications of the sitting position. | False. Ocular compression and edema of face, tongue, neck ARE complications of the sitting position.
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| What nerve can you damage can occur from placing excessive pressure from fingers on mandible? | Facial nerve.
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| Res Ipsa Loquitur | "First do no harm"
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| The brachial plexus in prone position is injured by? | Excessive abduction (>90°) of arm in prone position when arm is used as a lever during turning
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| The brachial plexus in supine position is injured by? | In supine/T-burg position when shoulder braces are pressing medially against the root of the neck
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| S/S of nerve injury to the brachial plexus | Weak arm function
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| The radial nerve is injured by? | Compression against underlying humerus when lateral upper arm is compressed on operating room table
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| S/S of nerve injury to the radial nerve | Inability to extend the wrist, Inability to abduct the thumb, Wrist drop, Decreased sensation over the dorsal surface of the lateral three and one half fingers
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| The ulnar nerve is injured by? | Compression between medial epicondyle of the humerus and the sharp edge of the bed or head frame
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| S/S of nerve injury to the ulnar nerve | Sensory loss in fifth digit, Claw hand
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| The median nerve is injured by? | Indiscriminate probing (fishing) in the antecubital fossa during venipuncture
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| S/S of nerve injury to the median nerve | Loss of sensation of finger tips from thumb to mid-point of ring finger, Inability to oppose the first and fifth digits, Decreased sensation on palmar surface of the lateral three and one-half fingers
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| The musculocutaneous nerve is injured by? | Compression injury which is rare because of depth of nerve
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| S/S of nerve injury to the musculocutaneous nerve | Inability to flex forearm
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| The intercostobrachial nerve is injured by? | Surgery in the axillary region
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| S/S of nerve injury to the intercostobrachial nerve | Numbness or dysthesia of the upper, inner arm
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| The medial cutaneous nerve is injured by? | Compression at the cubital fossa
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| S/S of nerve injury to the medial cutaneous nerve | Loss of sensation over the medial forearm
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| The sciatic nerve in sitting position is injured by? | In sitting position, pressure on the ischial tuberosities
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| The sciatic nerve in lithotomy position is injured by? | n lithotomy position, thigh and nerves are externally rotated and knees are extended Excessive hip flexion resulting in nerve stretch
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| The sciatic nerve can also be injured by? | Intramuscular Injections
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| The femoral nerve in lithotomy position is injured by? | In lithotomy position, extreme abduction of the thighs with external rotation of the hip Compression at pelvic brim by retractor or excessive angulation of the thigh
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| S/S of femoral nerve injury | Decreased or absent knee jerk and loss of flexion of hip and extension of the knee; Decreased sensation over superior aspect of thigh and medial and anteromedial side of leg
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| S/S of sciatic nerve injury | Weakness of all skeletal muscles below the knee and diminished sensation over lateral half of the leg and almost all of the foot Foot drop Pain or numbness of lower leg, thigh or foot
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| The saphenous nerve in lithotomy position is injured by? | In lithotomy position, damage occurs when medial aspect of lower leg is suspended outside an unpadded support
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| S/S of saphenous nerve injury | Parasthesias along the medial and anteromedial side of calf
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| The common peroneal nerve in lithotomy position is injured by? | In lithotomy position, pressure of vertical support pole for the leg or inadequate padding of metal knee supports, which impact the popliteal fossa
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| The common peroneal nerve in supine position is injured by? | In supine position, prolonged pressure in popliteal fossa by pillows or leg
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| S/S of common peroneal nerve injury | Foot drop Loss of dorsal extension of toes Inability to evert the foot
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| The obturator nerve is injured by? | Damaged during difficult forceps delivery or by excessive flexion of the thigh to the groin
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| S/S of obturator nerve injury | Inability to adduct the leg; Diminished sensation over the medial side of the thigh
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| The anterior tibial nerve is injured by? | Plantar flexion of feet for extended periods of time
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| S/S of anterior tibial nerve injury | Foot drop
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| The Lateral Femoral Cutaneous nerve is injured by? | Nerve entrapment at inguinal ligament due to expanding abdominal girth
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| S/S of lateral femoral cutanous nerve injury | Pain and dysthesia over lateral thigh
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