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1、PatientPositionDuringAnesthesiaByDavidRoyGoddenCRNA,MSNLectureObjectivesGainanunderstandingofsafepositioningbasicsIdentifythepotentialnerveinjuriesfrommaskventilationStatethecorrecthandandarmpositioningforsupine,lateraldecubitusandpronepositions.Beabletorecitethepotentialnerveinjuriesofeachpatientpo
2、sition.Identifythecomplicationsofthesittingposition.ObjectivesContDefineandunderstandthehemodynamicsofeachpatientposition.Understandandbeabletoverbalize-thatmeansknowthoroughly-therespiratoryandautonomicresponsesofdifferingpatientpositionswhileawakeandundergeneralanesthesia.DiscussPostOperativeVisua
3、lLoss(POVL)CaseStudy:ComplicationsofPronepositionLookforKeyPointsPositioningisoftenacompromisebetweenwhatisrequiredforsurgicalexposureandpatientcomfort!Donotplacesedatedoranesthetizedpatientsinpositionsthattheyarenotcomfortablewithwhenawake.Ifindoubtaboutpatientssafetyhavethepatientassumetheposition
4、ontheORtablebeforeinductiontoseehowtheytoleratetheposition.PatientpositioningisthejointresponsibilityofORNursing,AnesthesiaandSurgery.Allthreeindividualsandgroupsthatrepresentthemwillbeheldliableiferrorsinpositioningcausepatientharm.Document!DocumentationofPositioningTheonlythingthatrepresentswhatwa
5、sdoneintheoperatingroominacourtoflawisyourtestimonyandyourdocumentation.Howmuchdoyouthinkyoucanrememberfromonecasetothenextandhowmuchofyour“storywillthecourtofficers“believewithoutyourcarefuldocumentationintheanesthesiarecord?Whattodocument?Pre-operativepatientlimitationsinmovementstrengthandnerveab
6、normalities.Doesthepatienthavenumbnesstinglingorlossofsensationtoanyextremitypre-operatively?Doesthepatienthavefootdrop?MaskInjuriesPotentialforcornealabrasionisalwayspresentwhenmaskventilatingpatients.Facestrapswhicharetightacrossthepatientsfacewithprolongedusemaycauseinjurytothefacialnerve.Whatare
7、thefivebranchesofthefacialnerverememberingthemnemonic,“TwozebrasbitmycatThebucalbranchismostlikelyinjuredwithafacestrapcompression.TemporalZygomaticBucalMandibularcervicalDorsalDecubitusPositionsGravityeffectsbloodflowandmuchofpulmonarymechanics.Humans,giraffesanddinosaursshareonethingincommon.Whati
8、sit?InthesupinepositiongravityequalizesbloodpressuregradientsbetweenheartandarteriesintheheadandlowerextremitiesCorrectAnatomicalPositionWhatistheventralsurface?WhatisthedorsalsurfaceNote:DorsaltodorsalandventraltoventralDorsalDecubitusPositionsHeadtilteitherupwardsordownwardswillchangethepressuregr
9、adients.Amovementof2.5cminverticalelevationwillchangethebloodpressure2mmHg.IntheparturientanIVbagundertherighthipwillshiftthegraviduterustotheleft.HaveyouheardofAorto-cavalsyndrome?HandpositioningLyingatattentionrequirescorrectarmandhandpositiontominimizethechancesofnerveinjuries.Armsaretobelessthan
10、90degreeslateralizedfromthethoraxincorrectanatomicalpositionlookingattheshoulders.Thiswillminimizethechanceofbrachialplexusinjury.ArmsatsideofbodymustbeincorrectdorsaltodorsalalignmentwiththearmssupinatedORpalmstowardthebodyisOKaswell.Theulnarnervepassesclosetothesurfaceoftheskininthemedialcondyleof
11、theelbow.Theolectranonwillprotectthenerveifplaceddownwards.Radialnerveinjuryispossiblewithetherscreencompressiontothelateralarm.Radialnerveinjurymayresultinwrist drop.WhatisSupinationCorrectanatomicalpositionislyingatattentionorPalmsareventralsurfacesoventraltoventralDorsaltodorsalmeanbackofhandstob
12、ack.HeaddownthingsLoweringtheheadwillincreasethepressureinthecerebralveinswhichmayleadtovascularheadache,congestionofnasalmucosaandconjunctivainhealthyindividuals.Thismayleadtoedemainthelarynxaswell.Thescleraisthewindowtothevocalcords!Headloweringinpatientswithintra-craniallesionswillexacerbatetheco
13、nditionraisingCPPandICP(whatstheformulaforthis?)AutonomicfunctionAorticarchandcarotidsinushousebarorecetorsthatarepartofthebodieshomeostaticmechanismtomaintainbloodpressurewithinanarrowrange.Increasedfiringofthereceptorswhenstretchedfromanincreaseinbloodpressureispartofanegativefeedbackloop.Theincre
14、asedfiringfromthebaroreceptorsenhancestheparasympatheticnervoussystemloweringbloodpressureandslowingtheheartrate.Rememberthis!Whatarethenervesresponsibleforthebaroreceptorreflexes?RespiratoryEffectsRespiratorymechanicswillsufferintheheaddownpositionhow?ReviewWestszonesofthelung.Normalexcursionofthed
15、iaphragminheaddownpositionisimpededandincreasetheworkofbreathing.Intheparalyzedmechanicallyventilatedpatient,higherpeakpressureswillberequiredforadequateventilation.SupinepatientsdevelopVQ mismatchduetovascularcongestioninthedorsalportionsofthelungandchangesincompliance.Thedorsallung(nowzone3)willha
16、vereducedcompliance.Passiveventilationtendstodistributegaspreferentiallytothemoreeasilydistensiblesubsternalunitswherepulmonarybloodflowvolumeisless(Barish,2006).MoreRespiratorythingsTopreventdevelopmentofsignificantV-Qimbalanceduringuseofcontrolledventilation,tidalvolumesmustbeusedthataregreatertha
17、ntheaverageamountthatissufficientforthespontaneouslybreathingconsciouspt.Compareandcontrasttheawakespontaneouslybreathingptandtheparalyzedmechanicallyventilatedptinthelateralposition.HowwouldyouattempttodecreasePeakpressuresduringmechanicalventilationintheparalyzedanesthetizedpatient?Hint:deepenanes
18、thetic,musclerelaxation,decreaseVtandincreaseRate,changeI:Eratiofrom1:2to1:1.5.ConsiderPressureControlventilationduetoitsdeceleratingwaveform.VariationsintheDorsalDecubitusPositionSupineotherwiseknownaslyingatattention.Placesstrainonlowersegmentsoflumbarspine.Lawnchairisamorephysiologicallytolerated
19、positionduetodecreasedstretchonlowerback.Frogleg(healtohealwithlateralizationofknees)forperonealexaminationsmayplaceexcessivestretchonback,hipsandpelvicstructures.Padunderknees.Complicationsofexcessivestretchmayinclude1)postoperativehipandbackpain;2)dislocatedhiporfractureofanosteoporoticfemur;3)obt
20、urator nerve injury.ComplicationsofDorsalDecubitusPressureAlopeciaduetoprolongedcompressionofhairfollicles.Mostalopeciaoccursbetweenthe3rdand28thpostoperativedaywhilere-growthusuallyoccurswithin3months(Barish,2006).Placementofgelpadordonutunderheadisworthwhile.Frequentrepositioningoftheheadiswarrant
21、ed.ComplicationsofDorsalDecubitusPressurepointreactionsoccurwhenbonyprominencesareunsupportedforprolongedperiods.Hypothermiaandhypotensionenhancetheischemicprocess.Theheals,elbowsandsacrumshouldbegelpadded.NOTE:Therearenostudiesprovingdecreasedincidenceofperipheralneuropathiesduetogelpadding.Backpai
22、nduetolossoflordosis.Lawnchairpositionbest.LithotomyPositionLithotomypositiontraditionallyhasbeenusedduringgynecologicandurologicsurgery.Thehipsareflexed80to100degreesandthehipsareabducted30to45degreesfrommidline.Hipflexiongreaterthan90degreesmaycausestretchoftheinguinalligamentsandimpingethelateral
23、 femoral cutaneousnerveswhichpassthroughtheinguinalligamentwhichleadstonumbness in the lateral thigh.Thelegsshouldbemovedintoandoutofpositionsimultaneously.Thekneesarebroughttomidlineandthelegsslowlyunflexedtothesupinepositionattheendofthesurgicalprocedure.ComplicationsinLithotomyLegelevationcausesi
24、ncreaseinvenousreturnandtransientriseinCOandICP.Alterations in pre-Load is most responsible for hemodynamic changes during anesthesia.AbdominalvisceraisdisplacedcephaladdecreasingVtandincreasingpeakpressures.Backpainfromlossoflordoticcurvatureofspineinlithotomyposition.LithotomyComplicationsDANGERto
25、fingers.Watchcarefullywhenhandsaretuckedandraisingorloweringfootboard.Injurytothecommonperonealnerve.ThisistheMOSTCOMMOMnerveinjurytothelowerextremitiesaccountingfor78%ofalllowerextremitymotorneuropathiescausedbycompressionofthenervebetweenthelateralheadofthefibulaand“candycanebarstirrups.Durationof
26、surgerygreaterthan2hoursisapredictorofincreasedincidenceoflowerextremityneuropathy.MoreComplicationsofLithotomyPositioningCompartmentsyndromeisararecomplicationbutoccursinlithotomypositionduetoinadequateperfusiontotheraisedextremity.Ischemia,edemaandthepossibilityofrhabdomyolysisoccursfromtheincreas
27、edpressureinthefascialcompartment.Foryounumberheads,compartmentsyndromeoccurredinabout1inamillionforpatientsinsupinepositionandabout1in9,000forptsinlithotomyposition.Whatdoyouthinkaboutlithotomy?Danger!LateralDecubituspositionLateraldecubituspositionisusedforsurgeriesonthorax,retroperitonealstructur
28、esorhip.V-Qmismatchincreasesduetogravitationalforces.Perfusionisgreatestindependentstructuresordownlungwhileventilationisbetterinnondependentlung.Useof“ChestRollincidentallymisnamedaxillaryroll.Thepresenceofthechestrollistopreventcompressioninjurytothebrachialplexus.Monitorthepulseinthedependentarmp
29、lease.LateralDecubituspositionNondependentarmis“airplanedorsupportedwithpillowsandnotallowedtobeabductedgreaterthan90degrees.Placepillowbetweenkneeswithdependentlegflexed.Pressurepointsincludeacromionprocess,iliaccrest,greatertrochanter,peronealnerveandlateralmaleolus.ComplicationsofLateralDecubitus
30、Eyeandearinjuries.Makesurethatdownsideearandeyeare“freefrompressure.Useadonutrollfortheear.UseoftheOpti-guardoreyeguardisconsideredusefulinlateralpositions.Neckflexionneedstobeavoided.Positionneckmidlinewithsupportingtowels.ComplicationsofLateralDecubitusSuprascapularnervestretchfromthecircumduction
31、ofthedependentshoulder.Thechestrollshouldpreventthis.Long thoracic nerveinjuryfromlateraldecubituspositionhasbeendocumented.Winging of the scapulaisthetypicalclinicalsign.TheserratusanteriormuscleissolelysuppliedbythelongthoracicnervewhichbranchesfromC5C6andC7.KidneyPositionKidneypositionisaflexedla
32、teraldecubituspositionwherethetableisflexedto“openupthelateralstructuresforsurgicalexposure.Flexpointshouldbeunderiliaccrestnotribcage.Stabilizethepatienttopreventmovementandshiftscaudadonthetablesothatthekidneyrestmaynotrelocateditselfintothedownsideflank.Ventilationissuesagainmayoccurduetodependen
33、tlungcompromiseandV-Qmismatching.PronePositioningPronepositionisprimarilyusedforsurgicalaccesstoposterioraspectofthespine,posteriorfossaofskull,buttocksandperirectalareasorposteriorportionsofthelowerextremities.Pronepositioningrequiresplanning.Inductionandintubationofthetracheaisaccomplishedwhilepat
34、ientissupineonstretcher.IVaccessisperformedaswellasarterialcatheterplacementpriortoturningproneonoperatingroomtable.WouldyouconsideruseofLMAorextubationintheproneposition?SupportingdevicesforProneTheheadissupportedusuallymidline.Mayfieldtongsareusedforcraniotomycasesintheproneposition.AtLACweusetheP
35、roneViewwithamirrortoseethefacialstructureswhilethepatientisprone.Turningtheheadtothesidemaybeusedbutlateralrotationoftheneckmaycompromisecarotidorvertebralarterialbloodflowandmayrestrictvenousdrainage.Eyeprotectionisrequired.SupportingdevicesforProneSupportofthethoraxwithfirmbolsterswhichareplacedu
36、nderthepatientssidesfromclavical to iliac crest.Thisallowsthebellytohangfreeandincreasesventilationwhilepreventingaorto-cavalcompression.Breastsareplacedmedialandcephaladwhilegenitalsareinsuredtobenoncompressed.ArmplacementinProneptsPlacementofthearmsiseitheratthesidesofthepatientorforwardalongsidet
37、heheadonpaddedarmboards.Paddingoftheelbowisrequired.Abductionofthearmsshouldbelimitedtolessthan90degreestopreventexcessivestretchofthebrachialplexus.Anklesmaybesupportedwithabendinthekneestoreducestretchtothelumbarspine.Calfcompressionstockingsareroutinelyusedtopreventvenousstasisorbloodpoolingwithr
38、eductioninDVT.ComplicationsofPronePositionPronepositionisoneofthemorechallengingpositionstotheanesthetist.Eyeandearinjuriesaremorecommoninthisposition.EyeprotectionwithOpti-guardiswarranted.Scleraledemaiscommoninpronepatients.Blindness.Permanentlossofvisioncanoccurafternonocularsurgicalproceduresesp
39、eciallyinpatientintheproneposition!Spinesurgerywithitsblood loss, hypotension and anemiamayallconspiretogethertoproduceoptic nerve ischemia.AdditionalProneProblemsNeckinjuriesduetomisalignment.Brachialplexusinjuriesduetoexcessivestretchormisalignmentofshoulders.Breastorgenitalinjuriescausingpainordy
40、sfunction.Notgood.Medialplacementofbreastsisrecommended.Abdominalcompressioninjuriesmaybealleviatedwiththeuseofbolsters.ProneProblemsKneeinjuriesareespeciallyprevalentintheobeseorinthosewithpathologicconditionsofthekneespreoperatively.Documentandpadthekneesheavily.Injurytothedorsumofthefeetisalsopos
41、sible.ThoracicOutletsyndrome.Howdoyoutestforit?DidyouforgetaboutPOVLintheProneposition?SittingPositionSeeattachedarticleinanesthesiapatientsafetynewsletter.Beachchairpositionmaycausedecreasedcerebralperfusion,CVA,andbraindeath-really.ApsfNewsletterarticleREADIT!Majorriskofsittingpositionishypotensio
42、n.SittingpositionandtheriskofAIREMBOLIS.MoreSittingPositionSittingpositionisoftenusedforoutpatientshouldersurgeryandposteriorfossaapproachesWhy!Whenotherpositionsarelessdangerous!Hemodynamiceffectscanbedramatic.Poolingofbloodinthelowerpartofthebodyandthesubsequentdecreaseincerebralperfusion.Remember
43、the2mmHgrule?TherewillbeaquestionaboutthisHintHint.Ofteninshouldersurgerywhileinthesittingpositionthesurgeon“requestshypotensionreallyitstrue!ComplicationsofSittingPositionPotentialcomplicationsduetoflexionoftheneckwhichcanimpedebotharterialandvenousbloodflowthroughtheneck.Flexionoftheendotrachialtu
44、bemayleadtoexcessivepressureonthetongueleadingtomacroglossia.Neckflexionmaybemeasuredandkepttoacceptablelimitswithtwofingerbreadthsdistancebetweenchinandsternum.Venousairembolismisaseriouscomplicationofsittingpositionandthereasonforitsrareuse.VenousAirEmbolismThislifethreateningconditionmayoccuranyt
45、imeasurgicalsiteisabovetheleveloftheheart.Therearenovalvesinthecerebralvenouscirculationandtheriskofvenousairembolismisconstantinthesitting positionwhentheoperativesiteevolvestheposteriorfossaormayoccurinspinal surgerywhenprone!Rememberthis!Venousairembolismmaybemanifestedascardiacdysrhythmias,arter
46、ialoxygendesaturation,pulmonaryhypertensionorfrankcardiacarrest.Actionstotakeifyoususpectanairembolismistoaskthesurgeonstofloodthefieldwithsalineandtoapplybonewaxtoboneyedges.Forfurtherdiscussionrefertoyourneurolecture.OverviewofNerveinjuriesTheClosedClaimsProjectconductedbytheASAevaluatedadverseane
47、stheticoutcomesin1990.UlnarneuropathyremainstheMOSTfrequent(28%)ofallnerveinjuriesfollowedbybrachialplexus(20%).Etiologyofperipheralnerveinjuriesremainslargelyunknown.Mostofthenerveinjuriestoulnarandbrachialplexusoccurredinpatientswithproperpositioningandadequatepadding.Ulnarneuropathyresultsinanina
48、bilitytoabductoropposethefifthfinger,deminishedsensationinthefourthandfifthfingersandeventual“clawhand.UlnarNeuropathyCurrentthinkingisthatulnarneuropathyismultifactorialandnotalwayspreventabledespiteroutineuseofarmboardsandpadding.Ulnarneuropathyismostcommoninoldermen,diabetesmellitus,vitamindefici
49、ency,alcoholism,cigarettesmokingandcancer.Prevention?Avoidexcessivepressureonthepostcondylargrooveofthehumerus,limitabductionofthearmtolessthan90degrees,keepthehandandforearmeithersupinatedorinaneutralpositionwithpalmsfacingthigh.BrachialPlexusInjuryThebrachialplexusissubjecttoinjuryduetostretchingo
50、rcompressionasaresultofitslongsuperficialcourseintheaxilla.Armabductiongreaterthan90degrees,lateralrotationofthehead,asymmetricretractionofthesternumanddirecttraumaallmaycontributetobrachialplexusinjury.Cardiacsurgeryandsternotomyisassociatedwithahigherincidenceofbrachialplexusinjury.Shoulderbracesh
51、avehistoricallybeenaculpritinbrachialplexusinjuryleadingtotheirrareuse.Thecompressionofproximalrootsorlateraldisplacementofthebracescanstretchtheplexuswhentheshouldersaredisplaced.Usenonslidingmattressinsteadofshoulderbraces.LowerExtremityNerveinjuryLithotomypositionisassociatedwithinjurytocommonper
52、onealandsciaticnerves.Thesciaticnervemaybestretchedwithexternalrotationofthelegorwithhyperflexionofthehipsandextensionoftheknees.TheSaphenousnervemaybeinjuredifthemedialkneeiscompressedLowerExtremityNerveInjuryThecommonperonealnervewhichisabranchofthesciaticmaybeinjuredwithcompressionbetweentheheado
53、fthefibulaandthemetalframeof“candycanestirrupswhenthepatientisinthelithotomyposition.ThisistheMostcommonnerveinjuryinlowerextremities!CommonperonealnerveinjuryresultsinFootDrop!MorenerveinjurystuffMediannerveinjurymaybecausedby“searchingforanIVintheanticubitalfossaresultingintheinabilitytoopposethum
54、bandthelittlefinger.ThepostoperativeneuropathythatmustbereferredtoaneurologistimmediatelyisanyMOTORdeficitfollowingsurgery.ThankyouforyourattentionandIamlookingforwardtoseeingyouintheOR.Sowhatisitlikeontheothersideofthatsteepmountain?CaseStudy:POVLinPronePositionA58yearoldanesthesiologisthaschronicb
55、ackpainandisscheduledforlaminectomyataUniversityMedicalSchoolTeachinghospital.Thecaseisscheduledfor6hoursbutrunsover-really?Ofcourse-thisisapronepositioncasewithover500mlofbloodloss.CaseStudyAfterthesuccessfulcompletionofthesurgerythepatienthasvisualcomplaintsincludingflashingcolors.Fundoscopicexamw
56、asnormal.Overthenextweeksavisualfieldofvisionlossof70percentisreported.CaseStudyDiscussion:WhatarethedataconcerningPOVL.Whatrolldoesanesthesiaplayintheinformedconsentforpronecases?WhatistheliabilityoftheanesthesiaproviderforPOVL?ReferencesapsfNewsletter,“BeachChairPositionDecreaseCerebralPerfusionVol22,No.2,25-40.apsfNewsletter,“Ifmyspinesurgerywentfine,whycantIsee?Vol23,No.1,1-20.Bararshallofit!MillersAnesthesia6thed.Chapter28.
