Podcast
Questions and Answers
What is a potential complication of the lateral decubitus position?
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?
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?
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?
What is a potential complication of the lithotomy position?
Why is it important to pad the legs and flex them slightly in the prone position?
Why is it important to pad the legs and flex them slightly in the prone position?
What is the purpose of the bolster in the prone position?
What is the purpose of the bolster in the prone position?
What is a potential complication of the prone position?
What is a potential complication of the prone position?
What is the term for the position where the patient lays on their non-operative side?
What is the term for the position where the patient lays on their non-operative side?
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?
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?
What is the term used to describe the anterior part of the optic nerve that is susceptible to ischemia?
What is the term used to describe the anterior part of the optic nerve that is susceptible to ischemia?
What is the formula used to calculate ocular perfusion pressure?
What is the formula used to calculate ocular perfusion pressure?
What is the term used to describe the injury that occurs when blood flow returns to an area after a period of ischemia?
What is the term used to describe the injury that occurs when blood flow returns to an area after a period of ischemia?
What is the purpose of using transesophageal echocardiography (TEE) in preoperative evaluation?
What is the purpose of using transesophageal echocardiography (TEE) in preoperative evaluation?
What is the significance of the dual blood supply to the watershed region of the optic nerve?
What is the significance of the dual blood supply to the watershed region of the optic nerve?
What is the term used to describe the sound heard in venous air embolism?
What is the term used to describe the sound heard in venous air embolism?
What is the significance of lowering the legs every 2-3 hours in the lithotomy position?
What is the significance of lowering the legs every 2-3 hours in the lithotomy position?
What is a characteristic of lung volume in the posterior region compared to the anterior region?
What is a characteristic of lung volume in the posterior region compared to the anterior region?
What is the primary mechanism responsible for nerve injuries?
What is the primary mechanism responsible for nerve injuries?
What is a consequence of venous capillary pressure rise in nerve injuries?
What is a consequence of venous capillary pressure rise in nerve injuries?
Why are peripheral nerves susceptible to ischemia?
Why are peripheral nerves susceptible to ischemia?
What is a factor that contributes to nerve injuries in patients?
What is a factor that contributes to nerve injuries in patients?
What is a complication of spinal cord injuries during flexion?
What is a complication of spinal cord injuries during flexion?
Why is it important to avoid hyperflexion during surgery?
Why is it important to avoid hyperflexion during surgery?
What is the name of the phenomenon characterized by postoperative visual loss?
What is the name of the phenomenon characterized by postoperative visual loss?
What is the gold standard for detecting intracardiac shunts?
What is the gold standard for detecting intracardiac shunts?
What condition is characterized by an abnormally large tongue and can occur with excessive neck flexion?
What condition is characterized by an abnormally large tongue and can occur with excessive neck flexion?
Which surgery position is associated with a risk of venous air embolism?
Which surgery position is associated with a risk of venous air embolism?
What is a potential complication when a patient undergoes robotic surgery in steep Trendelenburg position?
What is a potential complication when a patient undergoes robotic surgery in steep Trendelenburg position?
What is the correct term for air in the cranial cavity?
What is the correct term for air in the cranial cavity?
What term describes injury to an axon within an intact nerve sheath?
What term describes injury to an axon within an intact nerve sheath?
Which of the following complications is associated with prolonged exposure that inhibits capillary flow over a bony prominence?
Which of the following complications is associated with prolonged exposure that inhibits capillary flow over a bony prominence?
Which nerves are most commonly injured in the lithotomy position?
Which nerves are most commonly injured in the lithotomy position?
What physiological change is observed in CO and BP during general anesthesia?
What physiological change is observed in CO and BP during general anesthesia?
What can pose a risk to the vena cava in the lateral decubitus position?
What can pose a risk to the vena cava in the lateral decubitus position?
How does a sitting or lithotomy position with extreme knee flexion affect the femoral vessels?
How does a sitting or lithotomy position with extreme knee flexion affect the femoral vessels?
What cardiovascular complication may occur with the head-down tilt in lithotomy position?
What cardiovascular complication may occur with the head-down tilt in lithotomy position?
What is the effect of large tidal volumes on intrathoracic pressures and CO?
What is the effect of large tidal volumes on intrathoracic pressures and CO?
Which technique can be used to prevent hemodynamic changes during surgery?
Which technique can be used to prevent hemodynamic changes during surgery?
Which position can lead to postoperative vision loss due to increased intraocular venous pressure?
Which position can lead to postoperative vision loss due to increased intraocular venous pressure?
What is a common ECG change associated with venous gas embolism?
What is a common ECG change associated with venous gas embolism?
What is the primary mechanism of hemodynamic changes in venous gas embolism?
What is the primary mechanism of hemodynamic changes in venous gas embolism?
What is the diagnostic significance of a loud, coarse, continuous 'mill wheel' murmur?
What is the diagnostic significance of a loud, coarse, continuous 'mill wheel' murmur?
What is the purpose of using transesophageal echocardiography (TEE) in venous gas embolism?
What is the purpose of using transesophageal echocardiography (TEE) in venous gas embolism?
What is the initial management step in suspected venous gas embolism?
What is the initial management step in suspected venous gas embolism?
What is the purpose of providing Valsalva maneuver in venous gas embolism?
What is the purpose of providing Valsalva maneuver in venous gas embolism?
What is a potential complication of venous gas embolism in the cranial arterial system?
What is a potential complication of venous gas embolism in the cranial arterial system?
What is the acronym FART in the context of venous gas embolism management?
What is the acronym FART in the context of venous gas embolism management?
What is the primary cause of brachial nerve injury during surgery?
What is the primary cause of brachial nerve injury during surgery?
Which position is typically used for shoulder surgeries?
Which position is typically used for shoulder surgeries?
Why should N2O be discontinued during a gasp reflex?
Why should N2O be discontinued during a gasp reflex?
Which nerve is most commonly injured during surgery?
Which nerve is most commonly injured during surgery?
Which complication is associated with the beach chair position?
Which complication is associated with the beach chair position?
What condition can develop from tight wound closures in the abdomen?
What condition can develop from tight wound closures in the abdomen?
What is a potential consequence of failing to keep 2 finger breaths between the mandible and sternum in the beach chair position?
What is a potential consequence of failing to keep 2 finger breaths between the mandible and sternum in the beach chair position?
In which position should the MAP be zeroed at the tragus?
In which position should the MAP be zeroed at the tragus?
Which patient position is most commonly used and least harmful?
Which patient position is most commonly used and least harmful?
What may occur due to prolonged time in the Trendelenburg position?
What may occur due to prolonged time in the Trendelenburg position?
Which factor is the primary reason for decreased FRC in the supine position?
Which factor is the primary reason for decreased FRC in the supine position?
In which position is the risk of elbow compression leading to ulnar nerve injury minimized?
In which position is the risk of elbow compression leading to ulnar nerve injury minimized?
How does insufflation affect hemodynamics?
How does insufflation affect hemodynamics?
What should be checked prior to starting insufflation in surgery?
What should be checked prior to starting insufflation in surgery?
Which of the following positions increases preload and blood pressure?
Which of the following positions increases preload and blood pressure?
What condition necessitates the use of an NG/OG tube during the Trendelenburg position?
What condition necessitates the use of an NG/OG tube during the Trendelenburg position?
What effect does increased abdominal pressure have on pulmonary function?
What effect does increased abdominal pressure have on pulmonary function?
Which type of positioning is used for surgeries that involve the rectal or anal areas?
Which type of positioning is used for surgeries that involve the rectal or anal areas?
What is the appropriate FiO2 setting to increase functional residual capacity during patient positioning?
What is the appropriate FiO2 setting to increase functional residual capacity during patient positioning?
Which complication is most commonly associated with the use of Mayfield tongs?
Which complication is most commonly associated with the use of Mayfield tongs?
What is a potential cause of postoperative blindness?
What is a potential cause of postoperative blindness?
What is one of the main signs of venous air embolism during surgery?
What is one of the main signs of venous air embolism during surgery?
Which injury is caused by direct external pressure or an internal embolus in retinal artery occlusion?
Which injury is caused by direct external pressure or an internal embolus in retinal artery occlusion?
What is a purpose of using albumin in patients during prone surgery?
What is a purpose of using albumin in patients during prone surgery?
What is the most common cause of postoperative vision loss in patients undergoing prone spine surgery?
What is the most common cause of postoperative vision loss in patients undergoing prone spine surgery?
What condition results from ischemia to part of the optic nerve?
What condition results from ischemia to part of the optic nerve?
What factor is associated with an increased risk of postoperative nerve injury?
What factor is associated with an increased risk of postoperative nerve injury?
Which of the following situations is typical for the occurrence of a venous air embolism?
Which of the following situations is typical for the occurrence of a venous air embolism?
Which procedure most commonly results in corneal abrasions?
Which procedure most commonly results in corneal abrasions?
What is a common consequence of improper head positioning during surgery?
What is a common consequence of improper head positioning during surgery?
What preventive measure should be taken when placing a central venous pressure (CVP) line to minimize the risk of venous air embolism?
What preventive measure should be taken when placing a central venous pressure (CVP) line to minimize the risk of venous air embolism?
Which factor does NOT contribute to the development of venous air embolism?
Which factor does NOT contribute to the development of venous air embolism?
What medication should you administer if the patient becomes bradycardic and hypotensive during insufflation?
What medication should you administer if the patient becomes bradycardic and hypotensive during insufflation?
What is a cause of central retinal artery occlusion (CRAO) during surgery?
What is a cause of central retinal artery occlusion (CRAO) during surgery?
What are some risk factors for POVL?
What are some risk factors for POVL?
What is the preferred airway management technique in the Trendelenburg position?
What is the preferred airway management technique in the Trendelenburg position?
What surgeries would you place in a patient in Reverse Trendelenburg position?
What surgeries would you place in a patient in Reverse Trendelenburg position?
What is the park bench surgical position?
What is the park bench surgical position?
What is an example of a surgery that requires a patient to be in the park bench position?
What is an example of a surgery that requires a patient to be in the park bench position?
Which describes the V/Q mismatch that occurs in the lateral decubitus position on the nondependent lung?
Which describes the V/Q mismatch that occurs in the lateral decubitus position on the nondependent lung?
What effect does placing a patient in the lateral position have on lung ventilation and perfusion?
What effect does placing a patient in the lateral position have on lung ventilation and perfusion?
What occurs in one lung ventilation?
What occurs in one lung ventilation?
What is the role of hypoxic pulmonary vasoconstriction in one lung ventilation?
What is the role of hypoxic pulmonary vasoconstriction in one lung ventilation?
What can an improperly positioned kidney rest compress?
What can an improperly positioned kidney rest compress?
What are risk factors for rhabdomyolysis in surgery?
What are risk factors for rhabdomyolysis in surgery?
How often should eye pressure checks be performed in the prone surgical position?
How often should eye pressure checks be performed in the prone surgical position?
What is the purpose of the cuff leak test prior to extubation?
What is the purpose of the cuff leak test prior to extubation?
What types of devices are used in the lithotomy position?
What types of devices are used in the lithotomy position?
What position is associated with robot surgery
What position is associated with robot surgery
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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
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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)
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In awake patients, symptoms include coughing, dyspnea, bronchospasm, hypotension, altered mental status, and circulatory collapse
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ECG changes include tachyarrhythmias, right heart strain pattern, and ST-T wave changes
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Hemodynamic changes include systemic hypotension, increased CVP, and increased PA pressure
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A loud, coarse, continuous “mill wheel” murmur on auscultation
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Pulmonary signs and symptoms include crackles (rales) and wheezing, decreased ET CO2, and increased ET N2
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Decreased arterial O2 saturation
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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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