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85 Cards in this Set

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What are the types of pt positions in OR?
*dorsal decub
*lateral decub
*ventral decub
what are the different dorsal decub positions?
*supine (tberg/reverse tberg)
*frog leg
*lithotomy
what are the lateral decub positions?
*semiprone
*flexed lateral (jackknife)
what are the different ventral decub positions?
*prone
*prone jackknife
*prone kneeling
If a pt is hemodynamically unstable, what should you do with their position?
delay until pt is stable
What are the respiratory changes in dorsal decub?
*gravity inc perfusion to dependent lung fields
*dec FRC (r/t abdominal viscera on diaphragm)
what are th cv changes in dorsal decub?
*horizontal supine - minimal
*supine w/head up or down - --> presure gradient to heart
in dorsal decub, venous return changes are r/t?
intrathoracic pressure changes from respirations
what happens to a pt in tberg?
*inc pressure in cerebral veins
*inc ICP, CVP, IOP
*congestion in nares, eyes
*inc preload --> inc PSNS flow and dec HR/CO
what nerves are activated in aortic and carotid baroreceptor response to inc preload?
*vagus (CN VI)
*glossopharyngeal (CN IX)
tberg can cause what pulm changes?
*atelectasis
*V/Q mismatch
*dec FRC
*dec pulm compliance
*poss upper airway obstruction
what happens to pt in reverse tberg?
*BLE venous pooling
*dec preload/CO/systemic perf
*inc SNS tone/HR/PVR
*inc FRC
what are the uses of tberg?
*hypotension
*better surgical exposure of abd
*prevent venous air emboli
what has been shown to improve MAP in pt tberg that does not affect CO/pulm fxn/ICP?
*raising the legs
what are the variations in lithotomy position?
*std
*low
*high
*exaggerated
what does std lithotomy look like?
*thighs flexed 90deg
*knees bent/parallel to floor
*arms @ side/on armboards <90deg
what happens to a pt in std lithotomy in CV?
autotransfusion of volume from legs inc preload/CO
when is std lithotomy used?
*gyne
*uro
what is a pt @ risk for when std lithotomy position is complete and pt going to PACU?
*hypotension when pt placed supine
what happens to pulm status in std lithotomy?
*dec VC
*dec FRC
*dec TV
when might a low lithotomy position be used?
lap hyster
what is the difference in hip flexion b/w low and std lithotomy?
*low > 30-45%
*std > 90deg
why is high lithotomy used?
*to improve access to perineum
what makes high lithotomy different from std/low?
*thighs flexed 90deg
*over trunk
*legs almost fully extended
how is an exaggerated lithotomy position achieved?
in stages
*what is an adverse effect of exaggerated lithotomy?
*a/w high incidence of LE compartment syndrome
does exaggerated lith improve ventilation?
NO
it restricts ventilation
what are the complications of dorsal decub positions?
*postural hypotentsion
*pressure alopecia
*ischemic necrosis of bony areas
*backache
*nerve palsies
what is the most common nerve injury in lithotomy?
common peroneal nerve
(a/w candy cane support)
what are some common traits that can cause common peroneal nerve injury?
*candy cane support
*smokers
*low BMI
*surgery >2hrs
what is compartment syndrome in lithotomy?
*inadequate perfusion to extremity --> ischemia, edema & rhabdo from tissue pressure
what OR table position can cause digit amputation?
lithotomy when table foot raised back
what kind of changes would you expect if a pt is in lateral decub?
*venous pooling BLE r/t legs below heart
*extreme flexion can compromise venous return
what happens to dependent lung perfusion in lateral decub?
*decrease compliance
*atelectatsis
*non dependent lung underperfuse & overventilated
*overall there is a V/Q mismatch
what are some variations to lateral decub?
*semisupine or semiprone
*semilateral
what is important about the semiprone position?
*dependent arm supported
*nondependent arm in arm rest
*place pulse ox on nondependent arm to assure adeq circ
*most accurate NIBP in depen arm
what is the purpose of lateral jackknife?
widen intercostal spaces to facilitate thoracotomy incision
during lateral jackknife, what happens to pt's thighs?
*table is flexed so they become lateral to trunk
what is a kidney rest?
*elevation of the pt under the dependent iliac crest to increase lateral flexion
*improves access to upside kidney
what are the complications of lateral decub?
*back/neck pain
*compartment syndrome
*contusion/folding of dep ear
*inc IOP r/t dep eye ischemia
*suprascapular nerve injury (r/t axillary in wrong position)
what does the prone position allow?
*access to post fossa/spine/butt/post LE/perirectal area
what must be checked after pt is turned prone?
*BBS
*ETT placement
what should you check on the pt when the pt is prone?
*eyes
*nose
*airway
should be checked throughout case
what supporting devices should be used when pt is prone?
*mayfield tongs
*chest rolls
*prone pillows
how should the head be placed in prone?
*neutral
*to the side
what happens to MAP if pt kept horizontal (prone)?
unchanged
what happens if a pt is not positioned correctly in prone?
*dec preload
*cephalad mvmt of diaphragm
*dec FRC/compliance
*inc PAWP
what happens to the pt if the head is extremely flexed in prone?
dec cerebral venous return (2-3 fingerbreadths b/w chin & chest avoids this)
What are some complications to eyes when pt prone?
*ION > ischemic optic neuropathy
*central retinal artery occlusion
how many cases have been registered w/ASA in prone blindness?
79 cases
what type of positioning is most common in cases where blindness occurred?
prone
53 of 79 pts had spinal surgery
which is more prevelant in blindness when prone (ION or central retinal artery)
ION 83% to CRA 13%
what is the likelihood that pt's will recover sight after ION?
44% of pts recovered vision
what are the risk factors for prone position blindness?
*long spinal surgery
*massive blood loss
*intraop hypotension
*excessive crystalloid
*anemia
*hemodilution
*venous congestion
*edema of the head
what are the pt risk factors in prone position blindness?
*HTN
*DM
*morbidly obese
*atherosclerosis
*smoking
what should the MAP remain during spinal surgeries?
70 - 100
*if pt is HTN, then try to maintain toward higher end
what kind of nerve injury can happen when pt prone?
brachial plexus
r/t > abduction of arm >90deg
turning head, compression from chest rolls
what could happen to cerebral perfusion during prone positioning?
*impaired
r/t head/neck rotation & neck flexion (extreme)
why is the sitting position used?
*post cervical
*post fossa
*shoulders
what are the CV changes during sitting position?
*BLE pooling --> hypotension
*SNS/renin-angio-aldos system activation
*dec atrial pressures
where is the most accurate reading of CPP during sitting position?
*Circle of Willis is where MAP should be measured
what are some complications of sitting position?
*postural hypotension
*air embolus
*midcervical tetraplegia
decribe what to look for if a pt gets an air embolus while in sitting position?
*surg field above heart
*foam
*inefficient CO
*pulm HTN
*dec gas exchange
what happens if a pt has a PFO and gets an air embolus?
*goes to left side of heart and out to circulation
*dysrhythmia/cardiac arrest
what size are most air emboli?
small
*usually do not have complications
how are air emboli detected?
*early w/precordial doppler US
describe midcervical tetraplegia?
*paralysis below C5
*hyperflexion of neck r/i compromised blood flow
what might be some s/s of midcervical tetraplegia?
*venous & lymph obstruction from prolonged & extreme neck flex
what is a pneumocephlus?
air in the brain
what are the clinical signs of pneumocephalus?
similar to inc ICP
what are the causes of ulnar neuropathy?
*elbow flexion
*male
*external compression
*dec adipose tissue in elbow
what is the process of ulnar neuropathy?
*cubital tunnel retinaculum (CTR) compression
what are the s/s of ulnar neuropathy?
*numbness
*tingling
*pain
how do you avoid ulnar neuropathy?
*keep hands/arms supine or neutral
*pad elbows
how does radial nerve injury happen?
compression at lateral aspect of the arm below the lateral epicondyle of the humerus
what are the s/s of radial nerve injury?
*wrist drop
*weakness of abduction of thumb
*loss of senstaion b/w thumb and index finger
*inability to extend distal phalanx of thumb
how does the median nerve dysfxn come about?
iatrogenic trauma to the nerve @ the AC fossa during venipuncture
what are other ways of the median nerve dysfxn happen?
stretch of the median nerve during elbow extension
what are the s/s of median nerve dysfxn?
*inability to completely extend elbow
*numness over the dorsal and palmar areas of the distal phalanges of the 1st & 2nd fingers
where is the anterior interosseous nerve?
branch of the median nerve in the upper forearm
how is the anterior interosseous nerve get damaged?
compression from a tight arm restraint on the supinated arm
how does the anterior interosseous nerve present?
resembles compartment syndrome d/t ischemic injury; requires surgical decompression
what is sensory neuropathy?
*frequently tansient
*should resolve by postop day #5
*avoid postures that could aggravate
*neuro consult should be done if symptoms persist
what is motor neuropathy in the post op period?
*immediate neuro consult
*EMG studies
what doe EMG studies do to diagnose postop neuropathy?
*assess location of lesion
*measure muscle response to nerve stim
*response evaluated on degree of muscle contraction