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-When possible, position patient prior to anesthesia. (Let the patient decide what is comfortable). -Use supplemental padding/materials to disperse pressure points on body parts & soft tissues. -Many patient positions for surgery can lead to undesirable physiologic consequences.

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Positioning considerations

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Brachial plexus

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Most common postoperative nerve injury

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Multiple contributing factors, i.e. improper position, inadequate tissue perfusion, inflammatory reactions

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Definitive etiologies of peripheral neuropathies are unclear.

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may be related to venous congestion in optic canal d/t prone position.

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Position related perioperative vision loss

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may contribute to spinal cord ischemia and neurologic sequelae.

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Excessive spine flexion/extension in anesthetized patients

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Availability and operational status of equipment Availability of sufficient personnel to safely position the patient Evaluation of joint mobility and integrity of the cervical spine and bones Particular care with the elderly patient Existing medical conditions Risk of cardiovascular or respiratory compromise? Management of pressure points

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Major considerations for positioning

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-Potential for significant cardiovascular and pulmonary compromise. -Vulnerable to additional postural changes. -Blunted or obtunded reflexes prevent patients from repositioning themselves for comfort. -Rendering patients unconscious and relaxed may permit placement in position they may not have normally tolerated in an awake state.

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Anesthetic agents blunt natural compensatory mechanisms.

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Direct compression of neural & soft tissue may result in damage.

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Etiological mechanisms

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stretch, compression and disruption of blood flow.

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What are some positioning related causes of ischemia

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Altered inflammatory response postoperatively

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What is a cause of microvascular cause of peripheral neuropathy

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Opportunistic viral activation associated with central and peripheral neuropathies.

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What can immunosuppression lead to?

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-Depressive effects of anesthetic drugs. -Loss of muscle tone from drugs and position. -Abnormal intra-pulmonic and intra-thoracic pressures. -Abnormal intra-abdominal pressures. -Loss of Autonomic Nervous System control.

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Deep planes of anesthesia cause an increase in Respiratory and CV sequelae

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Positioning devices Preexisting pathology Body habitus Anesthesia technique Length of procedure >2 hours

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Risk factors for positioning injuries

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Table straps Leg solders Axillary Roll Bolsters (Bean bag) Fracture table post Shoulder braces Positioning frames Headrests

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Positioning devices

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Low-flow states Hepatic disease Diabetes mellitus Peripheral neuropathies Alcohol/Tobacco use Limited joint mobility

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Preexisting pathology

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Obesity Underweight Bulky musculature Malnutrition

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Body habitus

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Regional anesthesia Hypotensive technique General anesthesia

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Anesthesia technique

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Elevated diaphragm D/T decreased tone and additional rise of abdominal contents. Additional 15-20% reduction in Functional Residual Capacity (FRC). Chest wall & Lung compliance. Respiratory center depression leading to decreased TV & Increased RR.

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Respiratory considerations in the anesthetized patient

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Direct Myocardial depression. Depression of ANS chemical & pressure receptors.

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Cardiac considerations in the anesthetized patient

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brachial plexus ulnar nerve spinal cord lumbosacral nerve root sciatic and peroneal nerve

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Most frequent malposition injuries

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Patient limitations in movement and strength Preexisting numbness, tingling, or loss of sensation

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Documentation should include thorough preoperative evaluation. Includes:

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Type of position Placement/Check of specific body parts limbs, head, genitals, nose, eyes, etc Padding provided Periodic checks of pressure points

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Through documentation includes:

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Head up favors respiration. Head down favors circulation. Supine best for respiration and circulation as compared to other surgical position.

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Favorable positions

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supine

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Which position is most frequently used

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Patient may be positioned while awake Minimal physiologic insult Easy access to arms, eyes and mouth

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what are some advantages of supine positioning

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consider lumbosacral strain potential stretch/compression of brachial plexus

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Supine positioning considerations

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heels elbows occiput

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Potential pressure points while supine

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prolonged compression can produce hair loss combat this using gel donut

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what is a concern with occiput pressure points

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supine position

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Limit abduction of arms to less than 90° in supine, lateral, or prone positions. Avoid rotation and lateral flexion of head to the opposite side. Avoid steep Trendelenburg and shoulder braces; place braces only over acromioclavicular joints with arms tucked at patient's side. Avoid extension of the arm posterior to plane of the torso. Support arms in patients in the sitting position.

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prevention of brachial plexus injury

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the ulnar nerve is very superficial at the elbow and great care must be taken to protect it from injury

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What structure is very superficial at the elbow

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hypotension and hypoperfusion

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what factors increase risk of ulnar nerve injury

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remember s-UP-ination - palm UP

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supination

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Adduction of the arms may be required in many cases. Key: Position with palms facing the outer thigh- "attention" position.

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Supine, arms tucked

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Face straps - prolonged tightness across a patient's face, causing injury to the facial nerve

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What causes masking injury

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Temporal Zygomatic Buccal Mandibular Cervical

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branches of the facial nerve

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Buccal

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which branch is most likely to be injured by a face strap

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head down, knees flexed

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Trendelenburg

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shock/trauma or GYN/lower abdominal surgeries

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when would trendelenburg be used

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Head-down tilt aids blood return from lower extremities, but encourages reflex vasodialation congests vessels in the poorly ventilated lung apices increases intracranial blood volume

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what are some negatives associated with trendelenburg

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Exposure for lower abdominal surgery - used in combination with other positions (ie lithotomy) Access to head and arms. possible decreased aspiration risk. Increases venous return (albeit transient). - c. 1 liter auto-transfusion

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Advantages of Trendelenburg

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Higher inspiratory pressures, may be very difficult to ventilate the pt. Decreased Functional Residual Capacity. Decreased pulmonary compliance. Increased work of breathing. Endotracheal tube displacement. Cephalad shift of the mediastinum. Facial/airway swelling. Increased venous return Increased ICP Increased intraocular pressure

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Disadvantages of Trendelenburg

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Use of shoulder braces can compress the subclavian neurovascular bundle between the clavicle and 1st rib

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How does the risk of brachial plexus neuropathy increase with use of Trendelenburg

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Increased venous drainage in head and neck reduction in intracranial pressure reduced likelihood of passive regurgitation

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Benefits of Reverse Trendelenburg

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Hypotension Increased risk of venous air embolism (VAE) - when surgical site is above the level of the heart

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Complications associated with Reverse Trendelenburg

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Often used with trendelenburg

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Lithotomy

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Urology and Gyn procedures

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Uses of Lithotomy

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Access to head/airway. Access to arms. Increases circulating blood volume and preload.

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Advantages of Lithotomy

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Multiple opportunities for injury due to excessive rotation of hips. Potential increased with prolonged surgical time Decreasing Tidal Volume and increasing peak pressures. Increases aspiration risk in obese patients

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Disadvantages of Lithotomy

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Obturator Lateral Femoral Cutaneous Common peroneal Brachial plexus is still possible too

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What nerves are at risk of injury with lithotomy position

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Both limbs are simultaneously elevated and separated for surgical exposure and the reverse is true when returned to supine position . This minimizes the torsion stress on the lumbar spine

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Why would you need two attendants for positioning legs

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Semi-supine

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Used for shoulder surgery and posterior fossa approach for neurosurgery

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Uses of beach-chair, sitting, or semi-supine position

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Yes, it may cause decreased cerebral perfusion, CVA, and brain death

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Does beach chair position decrease cerebral perfusion

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In patients with major cardiovascular disease, due to induced sympathetic reflex hyperactivity

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When would you not use sitting position

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-Peripheral vasodilation leading to decreased CO, increased HR & SVR while CBF falls momentarily and then corrects. -Protect the ulnar and peroneal nerves. -Carefully flex the neck with the chin positioned a finger's breadth from the chest to prevent cervical vein obstruction.

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Concerns related to sitting position

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-Facilitates exposure -Enhances venous drainage -Decreases bleeding -Improved vital capacity, FRC, Diaphragmatic excursion -Decreased facial swelling (beneficial for long surgeries)

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Advantages of sitting

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-Postural hypotension -Edema of Face ; Neck (position dependent) -Flexion of endotracheal tube on the tongue -Midcervical Tetraplegia d/t hyperextension of the neck, can result in vascular compromise and ultimately paralysis below the 5th cervical vertebrae -Sciatic Nerve Injury

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Disadvantages of sitting

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associated with sitting position, although may occur in any position where surgical site is above the right atrium

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Venous Air Embolism

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-TEE (Gold standard) -Doppler -ETCO2 -Esophageal stethoscope

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Detection of VAE

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ETCO2 - changes of even 2 mmHg can be an indicator

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Which method of detection for VAE is most convenient and practical

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Left Lateral Decub + Reverse T-burg Aspiration of Volume of Air from R Atrium

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Treatment of VAE

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Most difficult to execute

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Prone position

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Rectal, Back, Spine surgery

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Uses for prone position

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-Assure that eyes ; ears are free of pressure. -Keep arm abduction ; 90° or tuck arms at patient's side. -Support the patient at the chest and hips so the abdomen hangs free to limit inferior vena cava obstruction, improve lung expansion. -In the kneeling position, pad knees carefully. -Protect the endotracheal tube, consider a drying agent to decrease oral secretions. -ensure correct position of patient's breasts and genitalia (men)

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Prone position concerns

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every 5 minutes. Consider facial pillow vs turn head to side

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How frequently should you check your patient's eyes in prone position

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ETT - Can't reintubate prone, not prudent to extubate prone either. LMA? Restrictive Respiratory Pattern. Increased peak inspiratory pressures. Barotrauma Increased work of breathing. Obese patients may require positioning that allows the abdomen to hang free. - Improves oxygenation ; V/Q mismatch.

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Disadvantages of prone position

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Rectal surgery

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Prone - Jackknife

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Increased Risk w/Prone Position Etiology - Ischemic Optic Neuropathy (89% of cases occur in Prone position) -Decreased Perfusion (increased venous congestion in optic canal) -Increased IOP -Exacerbated by anemia and hypotension

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Postoperative visual loss

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Use of Wilson surgical bed frame Extensive Surgery in Prone Position -Length of surgery Obesity Increased blood loss Male gender Lower percent of colloid administration

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Risk factors for postoperative visual loss

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Used for Thoracic, renal, ; orthopedic procedures Whatever side is down determines the name of position - right lateral decubitus

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Lateral Decubitus

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Maintain good body alignment

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Concerns for Lateral Decubitus

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Dependent Eye and Ear Injury Postoperative neck pain- Support neck to ensure head neutral alignment. Suprascapular Nerve - Circumduction stretch injury in dependent shoulder- Prevent with axillary pad to thorax caudad to axilla. Long Thoracic Nerve - Thought to result from viral neuropathy and lateral flexion of the neck may cause stretch injury.

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Disadvantages of Lateral Decubitus

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Ensure eye is closed, adequate padding of the orb. Ensure pinna is flat and padded.

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How would you prevent eye and ear injury in lateral decub position

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FRC is decreased ; supine. -Decreased FRC in dependent lung. -Increased FRC in nondependent lung. -Increased risk of atelectasis (dep. lung). Gravity causes increased perfusion of the dependent lung, resulting in a V/Q mismatch. -Dependent lung is better perfused and less ventilated than the nondependent lung and vice versa. Difficult to re-intubate.

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Respiratory concerns r/t lateral decub

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BP cuff ; Arterial Line -Make sure that the patient is not lying directly on the EKG leads. -Einthoven's triangle - may not get an accurate EKG reading or increased artifact.

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Problems with monitoring devices r/t lateral decub

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answer

Kidney position

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