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Positioning in anaesthesia
Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics PhD (physio)
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Goals Avoid pressure on the chest cavity To maintain circulation
To prevent nerve damage To maintain patient’s airway To provide adequate exposure of the operative site To provide comfort and safety to the patient
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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
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Supine
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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 .
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Supine
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Step off effect
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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 ??
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Head rotation putting brachial plexus under traction Excess abduction of upper limb Forearm pronation putting pressure on ulnar nerve in ulnar groove
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CVS in supine MAP, heart rate (HR),venous return rises
peripheral vascular resistance decrease cardiac output and stroke volume increase. Offset anaesthetic action
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RS 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.
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loss of the natural lumbar lordosis
associated with postoperative low back pain. The occiput, sacrum and heel are at risk of developing pressure sores
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Supine with pads and arms by the side with pads
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Lawn Chair Position
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Lawn Chair Position modification of the standard supine position
the lower and upper halves of the body are slightly elevated in relationship to the hips Better venous drainage , better muscle relaxation
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beach chair position
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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
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Trendelenburg
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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.
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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 18 September 2018
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Trendelenburg The stomach also lies above the glottis
Visualize the larynx before extubation.
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Reverse trendelenburg
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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.
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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
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Lithotomy This position is most often used for
genitourinary, gynecologic, and colorectal Procedures. Hips flexed 100 deg deg. abduction at the hips . Knees 90 approx 30 deg
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ARMS – side and tucked in
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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
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Low and standard
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High and hemi
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Exaggerated and tilted
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Various lower limb fixations
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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
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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)
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MAP at various levels
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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
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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.
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Nerve injuries in lithotomy
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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)
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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
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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
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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.
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Prone position Minimal neck flexion anterior flexion, abducted and
nipple genital Minimal neck flexion anterior flexion, abducted and externally rotated No pressure in axilla Abdomen free Face in soft headring with no pressure on eyes and nose Elbow padded
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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.
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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
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Prone position Complete obstruction of the contralateral
vertebral blood flow with rotation of the head >80 Beware in old CVAs ‘Concorde’ position with the neck flexed and the chin approximately one finger-breadth from the sternum
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Prone position with Wilson frame
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Mirror type
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Horse shoe adapter , may field head pins
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Relton-Hall frame
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Wilson laminectomy frame
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Park bench position- 3 quarter prone
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The prone jackknife position
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The prone jackknife position
is often used for anorectal surgery. is first placed prone, and all pressure points 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.
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Knee chest position sigmoidoscopies or lumbar laminectomies
Severe hypotension is seen due to pooling of blood in the legs
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The Andrews kneeling frame with Wiltse's thoracic jack in use
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Watson jones ortho table
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Watson jones ortho table
Brachial plexus injury Due 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
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This table also !!
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The lateral decubitus position
surgery involving the thorax, retroperitoneal structures, hip.
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The lateral decubitus position
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The lateral decubitus position
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The lateral decubitus position
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The lateral decubitus position
V/Q mismatch Maximal ocular complications BP check up especially in kidney position Nerve injuries
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Sitting Venous air embolism Not frequently used Craniotomy
Venous return decrease and cardiac output decrease HR no change Venous air embolism
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Sitting
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Sitting overall increase in ventilation with increased VC and FRC.
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Pressure points
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Nerve injuries- overall
ulnar neuropathy has been found in as many as 26% of patients undergoing open-heart surgery lower extremity neuropathy occurred in 1.5% of patients in the lithotomy position. The incidence of ulnar neuropathy is estimated at 0.46% after noncardiac surgery
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Overall mechanism of nerve injuries
(i) stretch, (ii) compression, (iii) generalized ischaemia, (iv) metabolic derangement.
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all predispose to perioperative nerve injury
Peripheral vascular disease, diabetes, hereditary neuropathy, and anatomic variation (eg, cervical rib),
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Brachial plexus
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Ulnar nerve in flexion
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Suprascapular nerve stretch
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Wedge in pregnant A rare complication of this positioning is sciatic neuropathy, suggesting that time in this position should be minimized Early intervention within 48 hours with EMG studies no significant difference in the incidence of ulnar neuropathy in patients undergoing general anaesthesia, regional anaesthesia or sedation.
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Double crush phenomenon
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Effects of Positioning - Obese Patients
Lateral: Well tolerated Correct sizing and placement of axillary roll is important Ensure that pendulous abdomen does not hang over side of OR bed Head-Up: (Reverse Trendelenburg/Semi-recumbent) Most safe Weight of abdominal contents unloaded from diaphragm Use of well-padded footboard to prevent sliding
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Ocular injuries The frequency of eye injury during anaesthesia and surgery is very low (<0.1% of anaesthetics), As little as 10 min Corneal abrasions, periorbital,and conjunctival edema, ocular hemorrhage, vitreous loss, retinal detachment, central retinal artery occlusion, ischemic optic neuropathy
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Causes Patient movement, chemical irritation from prep solutions,
direct trauma from face mask, pressure from the laryngoscopic blade, pressure effects on the globe from lateral and prone positioning, (duration ) intraoperative hypotension, and anemia
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Contributing patient comorbid conditions
hypertension, diabetes, obesity, smoking history, hypercholesterolemia, alcohol abuse, atherosclerosis, anemia, Graves disease, and renal transplantation Tape ok !!! Ointment ??
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Don’t Forget: Good positioning starts with an assessment
Prevent surgical team members from leaning Arm board pads should be level with table pads Cushioning of all pressure points is a priority - Procedures longer than 2 ½ to 3 ?? During a longer procedure, shifting the patient, adjusting the table, or adding/removing a positioning device assess extremities at regular intervals for signs of circulatory compromise Documentation of the positioning process- accurate and complete
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Summary Change – check all Cardiac Respiratory Nerve injuries
Pressure sores Visual loss Follow up for some days
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Comfortable position
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Uncomfortable position
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Uncomfortable position but happy
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Thank you all
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