Exam 1 B
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Questions and Answers

What is a potential complication of the lateral decubitus position?

  • Increased perfusion to the non-dependent lung
  • Increased lung compliance in the dependent lung
  • Decreased pulmonary blood flow to the dependent lung
  • V/Q mismatch due to gravity (correct)

    • Why is it important to periodically extend the lower legs in a patient in the lithotomy position?

  • To reduce the risk of lower extremity compartment syndrome (correct)
  • To facilitate surgical access
  • To prevent back pain
  • To improve lung compliance

    • What is the purpose of the axillary roll in the lateral decubitus position?

  • To prevent the patient from rolling off the table (correct)
  • To place an arterial line
  • To support the non-dependent arm
  • To facilitate surgical access to the thorax

    • What is a potential complication of the lithotomy position?

    <p>Lower extremity compartment syndrome</p> Signup and view all the answers

    Why is it important to pad the legs and flex them slightly in the prone position?

    <p>To reduce the risk of compression of the SVC</p> Signup and view all the answers

    What is the purpose of the bolster in the prone position?

    <p>To support the thorax</p> Signup and view all the answers

    What is a potential complication of the prone position?

    <p>Compression of the SVC</p> Signup and view all the answers

    What is the term for the position where the patient lays on their non-operative side?

    <p>Lateral decubitus</p> Signup and view all the answers

    What is the term used to describe the damage to neural and vascular structures that occurs as a result of increased pressures and decreased tissue perfusion in muscles with tight, fascial borders?

    <p>Compartment syndrome</p> Signup and view all the answers

    What is the term used to describe the anterior part of the optic nerve that is susceptible to ischemia?

    <p>Anterior ION</p> Signup and view all the answers

    What is the formula used to calculate ocular perfusion pressure?

    <p>OPP = MAP - IOP</p> Signup and view all the answers

    What is the term used to describe the injury that occurs when blood flow returns to an area after a period of ischemia?

    <p>Reperfusion injury</p> Signup and view all the answers

    What is the purpose of using transesophageal echocardiography (TEE) in preoperative evaluation?

    <p>To evaluate for patent foramen ovale (PFO)</p> Signup and view all the answers

    What is the significance of the dual blood supply to the watershed region of the optic nerve?

    <p>It decreases the risk of ischemia</p> Signup and view all the answers

    What is the term used to describe the sound heard in venous air embolism?

    <p>Mill-wheel murmur</p> Signup and view all the answers

    What is the significance of lowering the legs every 2-3 hours in the lithotomy position?

    <p>To prevent compartment syndrome</p> Signup and view all the answers

    What is a characteristic of lung volume in the posterior region compared to the anterior region?

    <p>More lung volume is present</p> Signup and view all the answers

    What is the primary mechanism responsible for nerve injuries?

    <p>Transection, compression, and stretch</p> Signup and view all the answers

    What is a consequence of venous capillary pressure rise in nerve injuries?

    <p>Slowed ATP production</p> Signup and view all the answers

    Why are peripheral nerves susceptible to ischemia?

    <p>Due to their structure and lack of lymphatic drainage</p> Signup and view all the answers

    What is a factor that contributes to nerve injuries in patients?

    <p>Age, gender, and extremes in body habitus</p> Signup and view all the answers

    What is a complication of spinal cord injuries during flexion?

    <p>Increased vertebral venous pressure</p> Signup and view all the answers

    Why is it important to avoid hyperflexion during surgery?

    <p>To prevent spinal cord injuries</p> Signup and view all the answers

    What is the name of the phenomenon characterized by postoperative visual loss?

    <p>Postoperative Visual Loss (POVL)</p> Signup and view all the answers

    What is the gold standard for detecting intracardiac shunts?

    <p>TEE</p> Signup and view all the answers

    What condition is characterized by an abnormally large tongue and can occur with excessive neck flexion?

    <p>Macroglossia</p> Signup and view all the answers

    Which surgery position is associated with a risk of venous air embolism?

    <p>Sitting</p> Signup and view all the answers

    What is a potential complication when a patient undergoes robotic surgery in steep Trendelenburg position?

    <p>Laryngeal edema</p> Signup and view all the answers

    What is the correct term for air in the cranial cavity?

    <p>Pneumocephalus</p> Signup and view all the answers

    What term describes injury to an axon within an intact nerve sheath?

    <p>Axonotmesis</p> Signup and view all the answers

    Which of the following complications is associated with prolonged exposure that inhibits capillary flow over a bony prominence?

    <p>Pressure injuries</p> Signup and view all the answers

    Which nerves are most commonly injured in the lithotomy position?

    <p>Sciatic and common peroneal nerves</p> Signup and view all the answers

    What physiological change is observed in CO and BP during general anesthesia?

    <p>Both CO and BP generally decrease</p> Signup and view all the answers

    What can pose a risk to the vena cava in the lateral decubitus position?

    <p>Elevation of the kidney</p> Signup and view all the answers

    How does a sitting or lithotomy position with extreme knee flexion affect the femoral vessels?

    <p>Can cause occlusion of femoral vessels</p> Signup and view all the answers

    What cardiovascular complication may occur with the head-down tilt in lithotomy position?

    <p>Decrease in cardiac output (CO)</p> Signup and view all the answers

    What is the effect of large tidal volumes on intrathoracic pressures and CO?

    <p>Increase intrathoracic pressures and decrease CO</p> Signup and view all the answers

    Which technique can be used to prevent hemodynamic changes during surgery?

    <p>Nitrous-narcotic technique</p> Signup and view all the answers

    Which position can lead to postoperative vision loss due to increased intraocular venous pressure?

    <p>Prone position</p> Signup and view all the answers

    What is a common ECG change associated with venous gas embolism?

    <p>Tachyarrhythmias</p> Signup and view all the answers

    What is the primary mechanism of hemodynamic changes in venous gas embolism?

    <p>Decreased cardiac output</p> Signup and view all the answers

    What is the diagnostic significance of a loud, coarse, continuous 'mill wheel' murmur?

    <p>Venous gas embolism</p> Signup and view all the answers

    What is the purpose of using transesophageal echocardiography (TEE) in venous gas embolism?

    <p>To detect intracardiac air</p> Signup and view all the answers

    What is the initial management step in suspected venous gas embolism?

    <p>Notify the surgeon immediately</p> Signup and view all the answers

    What is the purpose of providing Valsalva maneuver in venous gas embolism?

    <p>To prevent further air from entering the heart</p> Signup and view all the answers

    What is a potential complication of venous gas embolism in the cranial arterial system?

    <p>Paradoxical embolism</p> Signup and view all the answers

    What is the acronym FART in the context of venous gas embolism management?

    <p>Flood, Aspirate, Remove, Turn</p> Signup and view all the answers

    What is the primary cause of brachial nerve injury during surgery?

    <p>Ischemia secondary to stretching</p> Signup and view all the answers

    Which position is typically used for shoulder surgeries?

    <p>Beach chair</p> Signup and view all the answers

    Why should N2O be discontinued during a gasp reflex?

    <p>To prevent air embolism</p> Signup and view all the answers

    Which nerve is most commonly injured during surgery?

    <p>Ulnar nerve</p> Signup and view all the answers

    Which complication is associated with the beach chair position?

    <p>Neurologic injury</p> Signup and view all the answers

    What condition can develop from tight wound closures in the abdomen?

    <p>Compartment syndrome</p> Signup and view all the answers

    What is a potential consequence of failing to keep 2 finger breaths between the mandible and sternum in the beach chair position?

    <p>ETT obstruction and tongue swelling</p> Signup and view all the answers

    In which position should the MAP be zeroed at the tragus?

    <p>Beach chair</p> Signup and view all the answers

    Which patient position is most commonly used and least harmful?

    <p>Supine (dorsal decubitus)</p> Signup and view all the answers

    What may occur due to prolonged time in the Trendelenburg position?

    <p>Swelling in face and airway</p> Signup and view all the answers

    Which factor is the primary reason for decreased FRC in the supine position?

    <p>Cephalad displacement of the diaphragm</p> Signup and view all the answers

    In which position is the risk of elbow compression leading to ulnar nerve injury minimized?

    <p>Supine with arms out less than 90 degrees and padded</p> Signup and view all the answers

    How does insufflation affect hemodynamics?

    <p>Causes an increase in pressure which can occlude the vena cava and impair preload</p> Signup and view all the answers

    What should be checked prior to starting insufflation in surgery?

    <p>Hemodynamics</p> Signup and view all the answers

    Which of the following positions increases preload and blood pressure?

    <p>Trendelenburg</p> Signup and view all the answers

    What condition necessitates the use of an NG/OG tube during the Trendelenburg position?

    <p>Stomach above the airway</p> Signup and view all the answers

    What effect does increased abdominal pressure have on pulmonary function?

    <p>Decreased FRC and decreased pulmonary compliance</p> Signup and view all the answers

    Which type of positioning is used for surgeries that involve the rectal or anal areas?

    <p>Jackknife position</p> Signup and view all the answers

    What is the appropriate FiO2 setting to increase functional residual capacity during patient positioning?

    <p>100%</p> Signup and view all the answers

    Which complication is most commonly associated with the use of Mayfield tongs?

    <p>Subdural tear and dural bleed</p> Signup and view all the answers

    What is a potential cause of postoperative blindness?

    <p>Ischemic optic neuropathy</p> Signup and view all the answers

    What is one of the main signs of venous air embolism during surgery?

    <p>Mill wheel murmur</p> Signup and view all the answers

    Which injury is caused by direct external pressure or an internal embolus in retinal artery occlusion?

    <p>Retinal artery occlusion</p> Signup and view all the answers

    What is a purpose of using albumin in patients during prone surgery?

    <p>Decrease third spacing</p> Signup and view all the answers

    What is the most common cause of postoperative vision loss in patients undergoing prone spine surgery?

    <p>Ischemic optic neuropathy (ION)</p> Signup and view all the answers

    What condition results from ischemia to part of the optic nerve?

    <p>Ischemic optic neuropathy (ION)</p> Signup and view all the answers

    What factor is associated with an increased risk of postoperative nerve injury?

    <p>Muscular physique</p> Signup and view all the answers

    Which of the following situations is typical for the occurrence of a venous air embolism?

    <p>Sitting craniotomy</p> Signup and view all the answers

    Which procedure most commonly results in corneal abrasions?

    <p>Prone spine surgery</p> Signup and view all the answers

    What is a common consequence of improper head positioning during surgery?

    <p>Central retinal artery occlusion (CRAO)</p> Signup and view all the answers

    What preventive measure should be taken when placing a central venous pressure (CVP) line to minimize the risk of venous air embolism?

    <p>Place the patient in Trendelenburg position</p> Signup and view all the answers

    Which factor does NOT contribute to the development of venous air embolism?

    <p>High oxygen administration</p> Signup and view all the answers

    What medication should you administer if the patient becomes bradycardic and hypotensive during insufflation?

    <p>An anticholinergic such as glycopyrrolate</p> Signup and view all the answers

    What is a cause of central retinal artery occlusion (CRAO) during surgery?

    <p>Decreased blood supply to retina</p> Signup and view all the answers

    What are some risk factors for POVL?

    <p>All of the above</p> Signup and view all the answers

    What is the preferred airway management technique in the Trendelenburg position?

    <p>Video laryngoscopy with ETT</p> Signup and view all the answers

    What surgeries would you place in a patient in Reverse Trendelenburg position?

    <p>Abdominal surgery</p> Signup and view all the answers

    What is the park bench surgical position?

    <p>Semi-prone</p> Signup and view all the answers

    What is an example of a surgery that requires a patient to be in the park bench position?

    <p>Posterior fossa surgery</p> Signup and view all the answers

    Which describes the V/Q mismatch that occurs in the lateral decubitus position on the nondependent lung?

    <p>V/Q mismatch with lower perfusion and lower ventilation in the nondependent lung</p> Signup and view all the answers

    What effect does placing a patient in the lateral position have on lung ventilation and perfusion?

    <p>Decreased ventilation of the dependent lung, but increased perfusion</p> Signup and view all the answers

    What occurs in one lung ventilation?

    <p>Collapse of the non-ventilated lung</p> Signup and view all the answers

    What is the role of hypoxic pulmonary vasoconstriction in one lung ventilation?

    <p>To redirect blood flow to well-ventilated areas of the lung</p> Signup and view all the answers

    What can an improperly positioned kidney rest compress?

    <p>All of the above</p> Signup and view all the answers

    What are risk factors for rhabdomyolysis in surgery?

    <p>All of the above</p> Signup and view all the answers

    How often should eye pressure checks be performed in the prone surgical position?

    <p>q 15 mins</p> Signup and view all the answers

    What is the purpose of the cuff leak test prior to extubation?

    <p>To predict the likelihood of post-extubation stridor</p> Signup and view all the answers

    What types of devices are used in the lithotomy position?

    <p>All of the above</p> Signup and view all the answers

    What position is associated with robot surgery

    <p>steep Trendelenburg</p> Signup and view all the answers

    Study Notes

    Surgical Positioning

    • Importance of proper positioning: preventing complications, ensuring patient safety, and facilitating surgical access
    • Key considerations:
      • Protection of noble structures (e.g., eyes, breasts)
      • Maintenance of adequate respiratory and cardiovascular function
      • Prevention of pressure injuries and nerve damage

    Supine Position

    • Most common surgical position
    • Complications:
      • Respiratory: decreased lung compliance, elevated intra-abdominal pressure
      • Cardiovascular: decreased cardiac output, increased systemic vascular resistance

    Lithotomy Position

    • Used for pelvic, urological, and gynecological surgeries
    • Complications:
      • Respiratory: decreased lung compliance, elevated intra-abdominal pressure
      • Cardiovascular: decreased cardiac output, increased systemic vascular resistance
      • Nerve injuries: sciatic and common peroneal nerves
      • Pressure injuries: ischial tuberosities, sacrum, and heels

    Prone Position

    • Used for spinal, posterior fossa, and posterior cervical surgeries
    • Complications:
      • Respiratory: decreased lung compliance, elevated intra-abdominal pressure
      • Cardiovascular: decreased cardiac output, increased systemic vascular resistance
      • Nerve injuries: ulnar and brachial plexus
      • Pressure injuries: chest, knees, and face

    Sitting Position

    • Used for posterior cervical spine and posterior fossa surgeries
    • Complications:
      • Respiratory: decreased lung compliance, elevated intra-abdominal pressure
      • Cardiovascular: decreased cardiac output, increased systemic vascular resistance
      • Venous air embolism (VAE)
      • Nerve injuries: brachial plexus
      • Pressure injuries: ischial tuberosities, sacrum, and heels

    Lateral Decubitus Position

    • Used for thoracic, retroperitoneal, and hip surgeries
    • Complications:
      • Respiratory: decreased lung compliance, elevated intra-abdominal pressure
      • Cardiovascular: decreased cardiac output, increased systemic vascular resistance
      • Nerve injuries: brachial plexus
      • Pressure injuries: dependent lung, chest, and knees

    Complications

    • Nerve injuries:
      • Compression: ulnar nerve, brachial plexus
      • Stretch: femoral nerve, sciatic nerve
      • Transection: surgical trauma
    • Pressure injuries:
      • Sacrum, heels, occiput (supine position)
      • Ischial tuberosities, sacrum, and heels (lithotomy position)
      • Chest, knees, and face (prone position)
    • Venous air embolism (VAE):
      • Sitting position, entrainment of air into an open flowing vein or dural sinus
      • Prevention: avoiding positioning above the level of the heart, mechanical ventilation, and occlusive pressure on CVP decannulation sites
    • Postoperative vision loss (POVL):
      • Ischemic optic neuropathy (ION), central retinal artery occlusion (CRAO)
      • Risk factors: prone spine operations, cardiopulmonary bypass, head and neck surgeries
      • Prevention: proper head positioning, avoidance of external pressure to the eye

    Prevention and Management

    • Prevention of complications:

      • Slow assumption of the surgical position
      • Nitrous-narcotic technique
      • Intravascular volume loading

    • Management of complications:

      • Recognition of signs and symptoms (e.g., VAE, POVL)
      • Treatment of VAE: flooding the surgical field, occluding air entry site, and aspirating air via right atrial catheter
      • Treatment of POVL: maintaining ocular perfusion pressure, avoiding hypotension and anemia### Detection of Venous Gas Embolism (VGE)

    • In awake patients, symptoms include coughing, dyspnea, bronchospasm, hypotension, altered mental status, and circulatory collapse

    • ECG changes include tachyarrhythmias, right heart strain pattern, and ST-T wave changes

    • Hemodynamic changes include systemic hypotension, increased CVP, and increased PA pressure

    • A loud, coarse, continuous “mill wheel” murmur on auscultation

    • Pulmonary signs and symptoms include crackles (rales) and wheezing, decreased ET CO2, and increased ET N2

    • Decreased arterial O2 saturation

    • EEG changes may be caused by cerebral hypoperfusion or paradoxical embolism to the cerebral circulation

    Diagnosis of VGE

    • Transesophageal echocardiography (TEE) detects air in cardiac chambers
    • Precordial Doppler ultrasound detects gas bubbles in right heart
    • Presence of gas bubble in aspirate from multiorifice CVP catheter
    • More than one means of detection should be used in high-risk cases

    Management of VGE

    • FART: flood, aspirate, remove nitrous, turn to lower site below heart, and turn to left side
    • Notify the surgeon immediately of possible VGE
    • Surgeon should check for possible entry sites in the wound
    • Attempt to aspirate gas from multiorifice CVP catheter
    • Administer 100% O2 and provide Valsalva maneuver
    • Infuse IV fluid rapidly and use vasopressors and inotropes as needed
    • Reposition the patient, if feasible

    Cardiovascular Changes

    • Venous return compromised by paralysis, neuraxial blockage, PPV, and general anesthesia
    • Sitting, reverse Trendelenburg, and Trendelenburg positions affect cardiovascular changes

    Patient Positioning

    • Supine (dorsal decubitus) is the most common and least harmful position for patients
    • FRC decreases from standing to supine
    • Pressure points in supine position: arms out, supinated or tucked
    • Frog leg position: hips and knees are flexed, and hips externally rotated
    • Trendelenburg and reverse Trendelenburg positions: used for laparoscopic or robotic surgery, affecting venous return, intraabdominal pressure, and FRC
    • Robot surgery: watch for face leaning or hitting, pad the face, and limit fluids after positioning

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    Positioning - lesson 2

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