Positioning.txt

• 1. supine
• 2. prone
• 3. lateral
• 4. lithotomy

swelling of tissues within a muscular compartment which causes damage to neural and vascular structures

fasciotomy

fascia is cut away to relieve pressure or tension

• 1. the surgeon requests for patient to be hypotensive
• 2. blood loss
• 3. decreased tolerance to anesthesia meds

• 1. prolonged procedures
• 2. surgical positions
• 3. elevation of extremities
• 4. intraoperative hypotension
• 5. increasing age
• 6. extremes of body habitus (very high or low body weight)

tissue necrosis which leads to myoglobinuria then acute renal failure

end result -- amputation

• -superficial nerves
• -nerves with a long course (such as brachial plexus)
• -nerves in areas where they are poorly covered by overlying tissue

poor positioning and poor padding during surgery


but it can also occur when properly positioned and padded if increased risk factors

ulnar and brachial plexus

peroneal nerve

it is your responsibility to keep track of timing on tourniquets... make sure to chart when they are up and down.. notify the surgeon when the tourniquet needs to be released

Ulnar neuropathy

hyperextension of the elbow and compression on the nerve

they are unable or abduct to oppose the fifth finger

they have decreased sensation in the 4th and 5th fingers

eventually they will present with atrophy of the hand muscles -- claw hand

palm up

sensory deficit noted in ulnar distribution

bc it is so long and superficial, it is easily susceptible to stretching or compression due to its length

• most often occurs when:
• 1.  the arm is abducted >90 degrees
• 2.  there is lateral rotation of the head,
• 3.  sternal retraction and
• 4. direct trauma/compression

direct pressure on nerve

wrist drop, inability to abduct the thumb or extend the metacarpphalangeal joints

IV insertion into the AC area

this is rare

the patient will be unable to oppose the first and fifth digits, patient will also have decreased sensation over the palmar surface of the lateral three and half fingers

peroneal and sciatic neuropathy

stretching of sciatic nerve with external rotation of the leg, hyperflexion of the hips, extension of the knees

common peroneal nerves is often compressed between the head of the fibula and fetal frame of the stirrups

footdrop, inability to extend the toes in the dorsal direction, unable to evert the foot

during lower abd. surgeries with excessive retraction, difficult forceps delivery, or excessive flexion of the thigh to the groin

will have decreased flexion of hip, decrease extension of knee, loss of sensation of superior aspect of thigh and medial/anteromedial side of leg

• will have inability to adduct the leg
• will have decreased sensation over medial thigh

transient

only require assurance

3-12 months

to get full  movement and sensation back

supine

2" above the knees while not impeding circulation

should be able to place one hand under belt

decreases perfusion and causes damage

dorsal recumbent

procedures of the head, neck, extremities and chest

let the patient position themselves before induction

bc anesthesia blocks the normal spinal curvature and muscles...this is why you should pad the lumbar spine

it helps increase comfort for patient

• -increase venous return (in comparison to standing)
• -increased preload->increased CO->increased BP

• -decreased FRC and TLC in comparison to a standing or sitting position
• -shift of the diaphragm towards the head
• -decreased elastic recoil and decreased A-P diameter
• -flexion of the head which can cause displacement of the ETT

• 1. put the patient to sleep on the stretcher
• 2. turn the gas up and turn the o2 to 100%
• 3. then move the patient over to the OR table after securing the ETT good!

• -two are placed lengthwise under the axilla and along the sides of the chest from the clavicle to the iliac crests (to raise the weight of the body off the abdomen and thorax)
• -one roll is also placed at the iliac or pelvic level
• -should also have pillow under feet

basically support them from the clavicle to the iliac crest and all bony areas

the position of the breasts and male genitalia

must be free from pressure and torsion

**you should also check the position of the dependent eye and nose if the patients head is facing to the side as well as monitoring of the ETT to ensure good position

procedures of the spine, posterior fossa, buttocks or rectum

the shoulders should be position higher than the head

• flat back prone position
• jackknife position
• sitting prone position

• abducted more than 90 degrees
• will damage the brachial plexus

the arms can be tucked parallel to the trunk

or they can be slightly pronated and lateral to the head

armboards should be lower than the shoulders

• decreased CO
• avoid pressure over the abdomen
• avoid extreme flexion of the hips

• -FRC will be decreased compared to sitting but less than that of the supine position
• -if the abdomen can hang freely
•              -the patient will have better diaphragmatic excursion
•              -there will be less pressure on the abdominal/thoracic region
• -this position allows for increased oxygenation --better ventilation-perfusion ratios

• 1. optic nerve ischemia (due to alterations in perfusion pressure, hypotension, hypovolemia, emboli and increased IOP)
• 2. venous air embolism
• 3. brachial plexus injury
• 4. facial edema (remember---if swollen on the outside..will be swollen on the inside too...be aware of this when planning to extubate)

occurs due to negative pressures that develop if surgical site is higher than the heart

a central venous catheter tip is place at the junction of the IVC and RA to withdraw air from VAE

procedures requiring access to any perineal structures (gyno, urological, colo-rectal)

make sure to position them at the same time...if not you could cause trauma

use two people to do this

only one leg is elevated instead of the typical lithotomy position where both legs are elevated

sometimes used for orthopedic surgeries

rare!

their fingers...when raising the foot section of the bed... you can crush their fingers if the arms are left to the side

if you place the arms out from the side this allows easier access -- using armboards is recommended

once you have an airway

if you go ahead and pull the patient down it will be hard for you to intubate the patient...especially if they are a difficult airway. 

always recheck the tube placement, listen for breath sounds, ensure that all monitors are attached properly and are reading correctly...then once that patient is finally in a position for the procedure...secure the tube how you want it!

• 1. central blood volume will be increase (blood flows down the legs to the abdomen
• 2. this position doesn't effect healthy adults
• 3. this position can be detrimental if combined with trendelenburg in a patient with cardiac issues
• 4. if the patient has PVD there is increased risk for hypoperfusion, ischemia, and compartment syndrome
• 5. if the patient is hypovolemic, they may not have symptoms until the legs are lowered back into a neutral position--may develop severe hypotension

• 1. this position is very similar the symptoms seen in the supine position (increased venous return so increased CO and ICP)
• 2. further decrease in FRC if patient in trendelenburg as well
• 3. diaphragm displacement

• 1. hip dislocation (occurs when legs raised individually)
• 2. hip/back pain
• 3. femoral nerve or lumbosacral plexus stretch injury
• 4. arterial or venous occlusion or nerve palsy due to kinking of nerve structures
• 5. impaired venous outflow
• 6. compartment syndrome (due to stirrups)
• 7. peroneal nerve injury

procedures involving the thorax, kidneys, posterior or lateral spine, craniotomies requiring access to lateral or posterior cranium, and some orthopedic surgeries

it is put under patient and they are wrapped in it, it is hooked to suction, the air is sucked out, the bag will harden, it is then used as a holding device to keep the patient in place on the bed

the depended leg is flexed at the knee and hip..the nondependent leg stays straight.. a pillow should be placed between the legs

the dependent arm is typically supinated on a padded armboard, abducted less than 90 degrees

the nondependent arm should be parallel with the dependent arm, level with the shoulder on an arm holding device or with pillows/blankets between the two arms

• under the dependent thorax
• slightly caudad to axilla---not in the axilla

• 1. bp changes are usually minimal
• 2. hypotension is possible with severe flexion (lowering of the legs in comparison to the upper body)

1. mediastinum will shift toward the dependent lung, decreasing the FRC in that lung as well as compliance and ventilation

ventilation-perfusion mismatch occurs because gravity pulls blood to the dependent lung but the independent lung is receiving the oxygenation

• 2. abdominal contents will force the diaphragm towards the head
• 3.

• 1. nerve injury (brachial, ulnar and peroneal are the most common)
• 2. damage to the dependent eye
• 3. rhabdo (caused by placing positioning devices against muscle rather than bony prominences)

procedures of the posterior fossa, cervical spine, breast reconstruction and shoulder surgeries

• 1. endobronchial intubation
• 2. jugular venous obstruction

there should be 2 fingerbreaths between the neck and mandible to prevent endobronchial intubation

• 1. there are increased risk of profound hemodynamic effects depending on the level of elevation of the torso (ex. blood will pool in the lower extremities, decreased CI, CVP, PAWP, increased SVR)
• 2. risk for threatened intracranial perfusion (hypocarbia, increased ICP, hypoperfusion due to hypotension)

decreases

0.75

at the circle of willis

due to air entering the venous system

negative pressure gradient between veins at the operative site and right atrium

mill-wheel murmur

TEE

do a TEE

can also use a precordial Doppler -- 3rd to 6th intercoastal spaces, right of the sternum (this is equally as sensitive as TEE in detecting, but less useful in localizing), a bovi may also pick this up.

• quadriplegia
• pneumocephalus

ischemic optic neuropathy

vision loss

32

20% above preop

ISCHEMIC OPTIC NEUROPATHY

HIGH VENOUS PRESSURE OR EDEMA FORMATION

MAP-CVP OR ICP (WHICHEVER IS HIGHEST)

CAN BE USED TO ESTIMATE THE POSITION OF THE BASE OF THE BRAIN