Positioning in anaesthesia - PowerPoint Presentation

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Positioning in anaesthesia - PPT Presentation

Dr S Parthasarathy MD DA DNB MD Acu Dip Diab DCA Dip Software statistics PhD physio Goals Avoid pressure on the chest cavity To maintain circulation To prevent nerve damage ID: 935117

pressure position prone nerve position pressure nerve prone lithotomy head positioning lateral venous supine neuropathy ulnar injuries surgery table

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Slide1

Positioning in anaesthesia

Dr. S. Parthasarathy

MD., DA., DNB, MD (

Acu

Dip.

Diab

. DCA, Dip. Software statistics

PhD (

physio

)

Slide2

Goals

Avoid pressure on the chest cavity

To maintain circulation

To prevent nerve damageTo maintain patient’s airway To provide adequate exposure of the operative siteTo provide comfort and safety to the patient

Slide3

Positions – common

Patient is not aware of the damage and he cant tell that my eye is getting compressed

supine,

lithotomy, sitting,head-down,

prone,

lateral

decubitus

Slide4

Supine

Slide5

Supine

We spent most of our life like this

Be careful

patients with morbid obesity, mediastinal masses, poor cardiac function and term parturients prone to

aortocaval

compression

Slide6

Supine

Slide7

Step off effect

Slide8

Supine

prolonged contact of the back of the head may result in alopecia

ulnar

neuropathy is the most common- males 0.25 % may be delayed

upto

3 days

Brachial plexus, femoral

cutaneous

nerves are next common.

Brachial or

ulnar

Slide9

Head rotation

putting brachial

plexus under

traction

Excess abduction of

upper limb

Forearm

pronation

putting pressure on

ulnar

nerve in

ulnar

groove

Slide10

CVS in supine

MAP, heart rate (HR),venous return rises

peripheral vascular resistance decrease

cardiac output and stroke volume increase.

Offset

anaesthetic

action

Slide11

cephalad

movement of the abdominal contents.

The main complications are airway obstruction and decreased tidal volumes The resulting reduction in functional residual capacity (FRC) is detrimental to gas exchange

increase in ventilation–perfusion mismatching and decrease in pulmonary compliance.

Slide12

loss of the natural lumbar lordosis

associated with postoperative low back pain.

The occiput, sacrum and heel are at risk of developing pressure sores

Slide13

Supine with pads and arms by the side with pads

Slide14

Lawn Chair Position

Slide15

Lawn Chair Position

modification

of the standard supine position

the lower and upper halves of the body are slightly elevated in relationship to the hipsBetter venous drainage , better muscle relaxation

Slide16

beach chair position

Slide17

beach chair position beach chair position is associated with the risk for cerebral

underperfusion

Blood pressure must be maintained at a level that guarantees a perfusion pressure of 60 to 70 mm Hg measured at the level of the foramen magnum

Slide18

Trendelenburg

Slide19

Trendelenburg

Central blood volume increase by 1

litre

. swelling of the face, conjunctiva, larynx, and tongue ?? postoperative upper airway obstruction. The cephalic movement of abdominal viscera against the diaphragm also decreases functional residual capacity and pulmonary compliance.

Slide20

29 November 201320

Effects of

Trendelenberg

’ s position

↑ CVP

↑ ICP

↑ IOP

↑ myocardial work

↑ pulmonary venous pressure

↓ pulmonary compliance

↓ FRC

Swelling of face, eyelids, conjunctiva & tongue

observed in long surgeries

Slide21

Trendelenburg

The stomach also lies above the glottis

Visualize the larynx before

extubation.

Slide22

Reverse trendelenburg

Slide23

Reverse Trendelenburg position(head-up tilt)

to facilitate upper abdominal surgery by shifting the abdominal contents

caudad

. This position is popular because of the growing number of laparoscopic surgeries.

slipping on the table,

monitoring of arterial blood pressure.

Slide24

Reverse Trendelenburg position

hypotension and increased risk of venous air embolism (VAE).

the position of the head above the heart reduces perfusion pressure to the brain

Slide25

Lithotomy

This position is most often used for

genitourinary, gynecologic, and colorectal

Procedures.Hips flexed 100 deg 30-40 deg. abduction at the hips

. Knees 90 approx 30 deg

Slide26

ARMS – side and tucked in

Slide27

Martin and Warner have proposed a standardized classification

low,

standard,

high,hemi, exaggerated,

tilted

Martin JT, Warner MA (

Eds

): Positioning in Anesthesia and Surgery, 3rd edition. Philadelphia, WB Saunders

, 1997

Slide28

Low and standard

Slide29

High and hemi

Slide30

Exaggerated and tilted

Slide31

Various lower limb fixations

Slide32

Lithotomy

coordinated positioning of the lower extremities by two assistants to avoid torsion of the lumbar spine.

Both legs should be raised together, flexing the hips and knees simultaneously.

Slow removal

Hands beware

Slide33

lithotomy from the supine position

Unanticipated stimulation of the carina with

bronchospasm

or endobronchial intubation may result.In the

lithotomy

position, calf compression is almost inevitable and this predisposes to venous

thrombo

embolism and compartment syndrome ( surgery > 5 hours)

Slide34

MAP at various levels

Slide35

Lithotomy

Lower extremity compartment syndrome is a rare complication associated with the

lithotomy

position. perfusion to an extremity is inadequate, resulting in ischemia, edema

extensive

rhabdomyolysis

from increased tissue pressure within a

fascial

compartment

Slide36

Nerve injuries

injury to the common

peroneal

nerve was the most common lower extremity motor neuropathy, representing 78% of nerve injuries. A potential cause of the injury was the compression of the nerve between the lateral head of the fibula and the bar holding the legs.

Slide37

Nerve injuries in lithotomy

Slide38

Exaggerated Lithotomy

Extreme flexion of the hip joints can cause

neural damage by stretch (sciatic and obturator

nerves)

direct pressure (compression of the femoral nerve as it is passes under the inguinal ligament)

Slide39

Hemodynamics and RS

preload increases, transient increase in cardiac output

Cerebral venous and intracranial pressure in otherwise healthy patients.

causes the abdominal viscera to displace the diaphragm cephalad

, reducing lung compliance and potentially resulting in a decreased tidal volume

Slide40

The frog-leg position

hips and knees are flexed

hips are externally rotated with the soles of the feet facing each other,

allows access to the perineum, medial thighs, genitalia, and rectum. Care must be taken to minimize stress and postoperative pain in the hips and prevent dislocation by supporting the knees appropriately

Slide41

The prone or ventral

decubitus

position

used primarily for surgical access to the posterior fossa of the skull,

the posterior spine,

the buttocks and

perirectal

area,

and the lower

extremities.

Slide42

Prone position

Minimal neck

flexion

Face in

soft

headring

with

pressure

on eyes

and nose

Elbow

padded

No pressure in

axilla

Abdomen

free

anterior flexion, abducted and

externally rotated

genital

nipple

Slide43

Abdomen pressure in prone

inferior vena

caval

compression,reduced venous return and subsequent poor cardiac output.Associated pulmonary problems are caused by an increase in

transdiaphragmatic

pressure leading to reduced thoracic compliance.

Slide44

RS – better

An increase in FRC, changes in diaphragmatic excursions and improved ventilation–perfusion matching can significantly improve oxygenation in the prone position.

for treatment of refractory

hypoxaemia and in early ARDS 70–80% of patients turned prone initially benefit from improved oxygenation

Slide45

Prone position

Complete obstruction of the

contralateral

vertebral blood flow with rotation of the head >80Beware in old CVAs ‘Concorde’ position with the neck flexed and the chin approximately one finger-breadth from the sternum

Slide46

Prone position with Wilson frame

Slide47

Mirror type

Slide48

Horse shoe adapter , may field head pins

Slide49

Relton-Hall frame

Slide50

Wilson laminectomy frame

Slide51

Park bench position- 3 quarter prone

Slide52

The prone jackknife position

Slide53

The prone jackknife positionis often used for

anorectal

surgery.

is first placed prone, and all pressurepoints are padded. The patient is situated on the table such that when the table is anteflexed

the apex of the

inverted “V” is at the patient’s inguinal

region.

Slide54

Knee chest position

sigmoidoscopies

or lumbar

laminectomies

Severe hypotension is seen due to pooling of blood in the legs

Slide55

The Andrews kneeling frame with Wiltse's

thoracic jack in use

Slide56

Watson jones

ortho

table

Slide57

Watson jones

ortho

table Brachial plexus injuryDue to > than 90* extension of the upper limb

Lower extremity compartment syndrome

Due to long surgeries & compression

Pudendal

nerve injury

Due to pressure of the

perineal

post

Slide58

This table also !!

Slide59