Week #11 as a CRNA Student- Yoga Patients!

by admin

Positioning Down & Dirty

Sometimes the positions we put our patients into on the operating tables can rival an advanced pose of any yoga master.

There are many members of the surgical team that are additionally responsible for ensuring patient safety in these “poses” but as Nurse Anesthetists- we advocate for our patient’s safety by aiding to prevent nerve injury, ischemia, and arguably most important to us- a loss of our airway.  (Noooooo!)  Today I’m going to share with you some brief concerns and pointers associated with each position.  There are also cardiovascular changes and respiratory changes that occur with the different positions but we will save that for later…

Supine

The patient is lying on their back.  This is a very common position used for cases on the stomach, chest, arms/legs, and anterior neck (thyroid, cervical procedures, etc.).  The most common nerve injury in this position is injury to the ulnar nerve.

We try to avoid this by carefully tucking the arms into the body with the hands UP in the supine position.  A great way to remember that supine is PALMS UP is to think “SOUPine” like you’re holding a bowel of soup.  Since our arms are tucked in tight, we won’t have access to them during the procedure so it is a good idea to start a second IV just in case the first one peters out.  On the posterior body, we worry about pressure points- the sacrum, any bony prominences (like thin people with bony spines), and also the back of the head.  We don’t want to give our patients a big bald spot back there!  Head should be kept in a neutral position.

Prone

The patient is lying on their stomach for procedures involving the back, rectum (hemorrhoids) and sometimes ankle procedures and posterior craniotomies.  The upside down nature of the case usually means that the patient is going to be intubated with an ETT.  Makes sense right?  You wouldn’t want to risk putting an LMA in and then flipping the patient and having it come out.  How would you reintubate a patient when they’re lying on their stomach- especially in the middle of a surgical procedure?  Sounds like a nightmare.  SO- we put in an ETT and TAPE IT SECURELY!  For these procedures, there is usually a special table used to help support the patients chest and prevent compression of the stomach and major blood vessels.  (Jackson table and Wilson frame are a few examples.)  We want to avoid injury to the eyes so the eyes are properly padded.  There is a risk of blindness with this position from inadequate perfusion and pressure on the eyes.  Arms are be tucked into sides or out at 90 degree angles in what we love to call “Superman” arms.

Lateral

The patient lies on one side at a partial tilt or a full tilt.  You see this for some hip or leg cases, kidneys, shoulders and thorax.  Pressure points are any bony prominences on the side of the body in contact with the OR table (hip, knee, ankle, shoulder).  Patient is usually placed on a bean bag or other stabilizing aid.  To protect the dependent arm, we use an axillary roll to decompress the shoulder- but we are careful not to put the support directly in the axilla.  This could further compress nerve bundles.  Even though the patient is on their side and access to the airway is challenging, this doesn’t necessarily mean the patient has to be intubated, especially if the surgeon requests a partial tilt.

Lithotomy

Patient is supine with legs raised at varying levels of hip flexion (low, standard, high, or exaggerated).  The more the hips are flexed, the more likely the patient is to have femoral nerve injury.  As a general rule, try to avoid flexion greater than 90 degrees.  As you can imagine, the lithotomy position is mainly for gynecologic cases or cases that require access to peroneal anatomy.  There are different types of stirrups used to support the legs.  The most common injuries in this position are to the lower extremity nerves like the saphenous and peroneal nerves that run along the outside of the legs.  When moving the patient into position, both legs are moved at the same time to prevent hip dislocation.

Candy Cane Stirrups

Beach Chair

Sounds fun right?  You may see beach chair with shoulder arthroscopic cases.  The Nurse Anesthetist usually gets displaced by the surgeon at the head of the bed so you have to make sure your ETT is secure.  Since the surgery is above the level of the heart, perfusion is important.  Remember that the mean arterial pressure from your BP cuff on the arm will be lower than that in the brain because the brain is above the level of the heart.  If you have an arterial line, place your transducer at the tragus of the ear to better measure adequate brain perfusion.

Trendelenburg aka T-burg

Patient is flat on the OR table, but the head is down and the feet are up.  Gravity pushes abdominal contents into the diaphragm and also increases venous return.  Nerve injury to the brachial plexus can be associated with the use of shoulder braces.  Be aware that the patient may have airway swelling due to increased venous pressure in the upper body, especially if the case is long.

Sitting

This term describes any procedure where the patient’s torso is elevated higher than the legs, usually it’s 45 degrees.  You may see this with neuro cases, c-spine cases, shoulders and breasts but I am under the impression that this position is not as popular as it once was.  If head is flexed toward chest, make sure you can still get 2 fingers between the neck and jaw.  Stretching of the spinal cord in this position can lead to quadriplegia and anytime the surgical field is above the level of the heart, the patient is at risk for venous air embolism.

 

Hope you enjoyed this post!  Send any questions or comments to admin “at” CRNAAcademy.com

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