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PRESENTER – DR. SAIKAT MITRA
MODERATOR – DR. SHOBHA
PUROHIT
SMS MEDICAL COLLEGE, JAIPUR
INTRODUCTION
 Aim of optimal positioning is to provide best surgical access & ↓potential risk to
the patient.
 Safe posi...
POSITIONING AIDS/ SUPPORTS
 Pin (“Mayfield”) head holder
 Radiolucent pin head holder
 Horseshoe head rest
 Foam head ...
Mayfield head holder
Radiolucent pin head holder
Vacuum mattressHorseshoe head restFoam head support
FRAMES
 Spinal surgery frames optimizes venous return.
 ↑ risk of air embolism.
Relton-Hall (four-poster)frameWilson-typ...
POSITIONS
 Supine
 Lateral (Park bench)
 Semi-lateral (Jannetta)
 Prone
 Sitting
INTRODUCTION
 Commonest position; also known as ‘dorsal decubitus position’.
 Used for cranial procedures, carotid end-a...
PRESSURE POINTS
ARM POSITION
 May be abducted or adducted (tucked).
 Abduction limited < 900 to minimize brachial plexus injury by cauda...
ARM POSITION
Arm position using the arm board.
Abduction of arm is limited to < 900. Arm
is supinated and elbow is padded....
LAWN CHAIR POSITION
 Head-up posture accomplished by adjusting operating table to a
chaise lounge (lawn chair) position.
...
LAWN CHAIR POSITION
TRENDELENBURG POSITION
 Associated with tilting a supine patient head down.
 Often used to increase venous return during...
HARMFUL EFFECTS
 ↑ CVP, ICP, IOP.
 Respiratory system –
 Abdominal viscera moves cephalad against diaphragm → ↓FRC &
pu...
PRECAUTIONS
A. Extra-care to prevent from slipping cephalad on the surgical table due to
effect of gravity.
 Techniques –...
REVERSE TRENDELENBURG POSITION
 Also known as ‘head-up tilt’.
 Precautions -
 Preventing the patients from slipping on ...
HEAD DURING SUPINE POSITION
 Neutral or rotated → frontal, temporal or parietal access.
 Neutral → Bifrontal craniotomy ...
PRECAUTIONS
 Extremes of head rotation impairs jugular venous drainage →
shoulder roll attenuate this problem.
 Extreme ...
COMPLICATIONS OF SUPINE
POSITION
1. Pressure alopecia -
 Cause –
Ischemia of hair follicles due to prolonged head immobil...
COMPLICATIONS
2. Backache -
 Cause –
Normal lumbar lordotic curvature is lost during general anaesthesia with
muscle rela...
PERIPHERAL NERVE INJURY
 As per ASA Closed Claims database (1970 – 2010):–
 Ulnar neuropathy (21%)
 Brachial plexus (20...
BRACHIAL PLEXUS INJURY
 Brachial plexus (primarily C8
and T1 nerve roots)
susceptible to injury
because:-
 Long superfic...
INTRODUCTION
 Used for access to posterior parietal lobes, occipital lobes and lateral
posterior fossa, including tumors ...
ARM POSITION
 Arms are kept in front of the patient.
 Dependent arm rests on a padded arm board perpendicular to the
tor...
Axillary roll is placed well away from
axilla to prevent compression of axillary
artery and brachial plexus.
POSTIONING
 Head must be in neutral position to prevent excessive lateral rotation of
neck and stretch injuries to brachi...
Picture showing placement of arms and head.
Additional padding is under headrest to ensure
alignment of head with spine. H...
PRECAUTIONS
 Pulse should be monitored in dependent arm to detect early compression
of axillary neurovascular structures....
PHYSIOLOGICAL CHANGES
 Respiratory system:-
 Non-dependent lung → well ventilated, poorly perfused.
&
 Dependent lung →...
POTENTIAL PRESSURE POINTS
PARK-BENCH OR
THREE QUARTER PRONE POSITION
 Modification of lateral position.
 Provides better access to posterior fossa...
SEMILATERAL POSITION
 Named after the neurosurgeon who popularized its use for
microvascular decompression of 5th cranial...
INTRODUCTION
 Also known as ‘ventral decubitus position’.
 Used for spinal cord, occipital lobe, craniosynostosis & post...
1
• When general anaesthesia is planned, all intravenous
accesses are obtained & trolley is kept parallel and
adjacent to ...
4
• With the help of entire operating room staff, patient is
turned prone onto the surgical table.
5
• Neck is kept in lin...
7
• Disconnecting BP cuffs, arterial and venous lines
present on outside arm that rotates furthest is
recommended to avoid...
POSITIONING
10
• ET tube position and adequate ventilation
immediately reassessed after the move.
11
• Legs should be padd...
ARMS POSITION
 Both arms may be kept along the patient’s sides and tucked in
neutral position or placed in the “stick-em ...
Prone position with Wilson frame
HEAD POSITION
 Head may be turned laterally, if neck mobility is adequate.
 Patients with cervical arthritis or cerebrov...
 Horseshoe headrest supports only forehead and malar regions and allows
excellent access to the airway.
 Mayfield rigid ...
TAKE CARE OF ABDOMEN & THORAX
 Aim of posterior spinal surgery - ↓venous pressure to minimize bleeding
and facilitate sur...
PRESSURE POINTS
PRECAUTIONS
 Use of wire-reinforced ET tube to avoid kinking and obstruction as it
exits patient’s mouth during prone pos...
 Prevention of patient movement when head is held in rigid pins →
skidding out of pins can result in scalp lacerations/ce...
 Modification of prone position.
 Used for cervical spine & posterior fossa procedures.
 Neck flexion, reverse Trendele...
1. Postoperative vision loss (POVL) –
Retinal ischemia Ischemic optic neuropathy (ION) (more common)
COMPLICATIONS
Blindne...
2. Macroglossia –
 Flexion of neck frequently required to facilitate surgical access → ↓AP
dimension of hypopharynx → com...
INTRODUCTION
 Used for posterior cervical spine and posterior fossa surgeries.
 Infrequently used.
 Advantages –
 Exce...
PHYSIOLOGY
 Cardiovascular system:-
↓ VR, Stroke volume, Cardiac output, Cardiac index
 MAP – unchanged
 ↑ SVR, PVR
 ...
POSITIONING
 More commonly patient positioned in modified recumbent position.
 Head may be fixed in Mayfield head pins.
...
 Legs should be kept as high as possible (usually with pillows under
knees) to promote venous return.
 Knees are slightl...
Patient is typically semi-
recumbent rather than sitting.
A –
The head-holder support is
correctly positioned so that
the ...
PRESSURE POINTS
CARE OF HEAD & NECK
 Excessive cervical flexion may occur with head fixed in pins –
 Impede both arterial and venous blo...
 Careful vigilance of BP.
 MAP should be corrected to head level → zeroing arterial pressure
transducer at interaural pl...
 Maintaining at least 2 fingers’ distance between mandible and sternum
is recommended.
 Patients should not be positione...
COMPLICATIONS
1. Cardiovascular instability
2. Venous air embolism
3. Paradoxical air embolism
4. Pneumocephalus
5. Macrog...
ANY
QUESTIONS??
Positioning in  neurosurgical procedures
Positioning in  neurosurgical procedures
Positioning in  neurosurgical procedures
Positioning in  neurosurgical procedures
Positioning in  neurosurgical procedures
Positioning in  neurosurgical procedures
Positioning in  neurosurgical procedures
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Different positioning in neurosurgical procedures with the aim to provide best surgical acess and decrease patient related risk.

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Positioning in neurosurgical procedures

  1. 1. PRESENTER – DR. SAIKAT MITRA MODERATOR – DR. SHOBHA PUROHIT SMS MEDICAL COLLEGE, JAIPUR
  2. 2. INTRODUCTION  Aim of optimal positioning is to provide best surgical access & ↓potential risk to the patient.  Safe positioning requires planning and good communication between anaesthetist and surgeon.  Skilled personnel are required at the beginning & end of surgical procedure to facilitate safe positioning.  Knowledge of physiological changes associated with positioning can help predict potential problems.  All equipments should be secured and rechecked after every change in position.  Head-up posturing (150 - 200) to improve cerebral venous drainage.  Many complications do not reveal themselves for up to several days after surgery.
  3. 3. POSITIONING AIDS/ SUPPORTS  Pin (“Mayfield”) head holder  Radiolucent pin head holder  Horseshoe head rest  Foam head support (e.g., Voss, O.S.I., Prone-View)  Vacuum mattress (“bean bag”)  Wilson-type frame  Andrews (“hinder binder”)-type frame  Relton-Hall (four-poster) frame
  4. 4. Mayfield head holder Radiolucent pin head holder Vacuum mattressHorseshoe head restFoam head support
  5. 5. FRAMES  Spinal surgery frames optimizes venous return.  ↑ risk of air embolism. Relton-Hall (four-poster)frameWilson-type frame
  6. 6. POSITIONS  Supine  Lateral (Park bench)  Semi-lateral (Jannetta)  Prone  Sitting
  7. 7. INTRODUCTION  Commonest position; also known as ‘dorsal decubitus position’.  Used for cranial procedures, carotid end-arterectomies & anterior approaches to cervical and lumbar spine.  Haemodynamic reserve best maintained (as entire body is close to the heart level).  Variations: a) Lawn chair position, b) Frog-leg position, c) Trendelenburg & d) Reverse Trendelenburg position.  As compensatory mechanisms are blunted by anaesthesia → Trendelenburg or Reverse Trendelenburg positions cause significant cardiovascular alterations.
  8. 8. PRESSURE POINTS
  9. 9. ARM POSITION  May be abducted or adducted (tucked).  Abduction limited < 900 to minimize brachial plexus injury by caudad pressure in axilla from humerus head.  Hand and forearm are kept supinated or in neutral position with palm toward body to reduce external pressure on spiral groove of humerus and ulnar nerve.  When arms are adducted, they are usually held alongside the body with a “draw sheet” that passes under the body, over the arm, and is then tucked directly under the torso (not the mattress).  Elbows and any protruding objects (i.v. fluid lines and stopcocks) are padded.
  10. 10. ARM POSITION Arm position using the arm board. Abduction of arm is limited to < 900. Arm is supinated and elbow is padded. Arm tucked at patient side and is in neutral position with palm to hip. Elbow is padded and arm is well supported by the mattress.
  11. 11. LAWN CHAIR POSITION  Head-up posture accomplished by adjusting operating table to a chaise lounge (lawn chair) position.  Advantages:  Promotes cerebral venous drainage  Decreases stress on back, hips and knees.  Venous drainage from lower extremity improves (legs are slightly above heart level). FLEXION + PILLOW UNDER KNEES + SLIGHT REV. TRENDELENBERG
  12. 12. LAWN CHAIR POSITION
  13. 13. TRENDELENBURG POSITION  Associated with tilting a supine patient head down.  Often used to increase venous return during hypotension.  Named after 19th century German surgeon – Friedrich Trendelenburg. Trendelenburg position and reverse Trendelenburg position
  14. 14. HARMFUL EFFECTS  ↑ CVP, ICP, IOP.  Respiratory system –  Abdominal viscera moves cephalad against diaphragm → ↓FRC & pulmonary compliance → ↑ V/P mismatch.  CVS –  ↑ VR → ↑ C.O.  Central redistribution of blood may lead to volume overload in the failing heart.  Stomach lies above glottis → ↑ Aspiration.  Prolonged head-down → lead to swelling of face, conjunctiva, larynx & tongue → ↑ postoperative upper airway obstruction.
  15. 15. PRECAUTIONS A. Extra-care to prevent from slipping cephalad on the surgical table due to effect of gravity.  Techniques – 1. Antiskid bedding 2. Knee flexion 3. Shoulder braces 4. Beanbag cradling & 5. Padded cross-torso straps. B. To avoid compression of brachial plexus by torso against shoulder girdle.  Shoulder braces & beanbag pads → ↑ risk of injury to upper & middle trunk of brachial plexus. C. Due to ↑ risk of upper airway obstruction → air leak test or visualizing larynx before extubation must be carried out.
  16. 16. REVERSE TRENDELENBURG POSITION  Also known as ‘head-up tilt’.  Precautions -  Preventing the patients from slipping on the table.  Frequent monitoring of arterial blood pressure → hypotension may result from ↓ VR.  Head is positioned above heart → ↓ perfusion pressure to brain.  Complications – 1. Hypotension 2. ↑Venous air embolism
  17. 17. HEAD DURING SUPINE POSITION  Neutral or rotated → frontal, temporal or parietal access.  Neutral → Bifrontal craniotomy and transsphenoidal approach to pituitary.  Flexion → interhemispheric approach to lateral or third ventricle.  Slight extension → subfrontal approach.
  18. 18. PRECAUTIONS  Extremes of head rotation impairs jugular venous drainage → shoulder roll attenuate this problem.  Extreme flexion causes kinking of ET tube → ↑airway pressures (keep a distance of 1 or 2 finger breadths between chin & chest during flexion).  Flexion + reverse Trendelenburg position →↑risk of VAE {esp. in bifrontal craniotomy which traverses SSS}
  19. 19. COMPLICATIONS OF SUPINE POSITION 1. Pressure alopecia -  Cause – Ischemia of hair follicles due to prolonged head immobilization with its full weight falling on a limited area (usually occiput).  Precautions –  Lumps such as those caused by monitoring cable connectors should not be placed under the head.  Prevention of hypothermia and hypotension during surgery.  Ample cushioning of head & periodic rotation of head to redistribute the weight.
  20. 20. COMPLICATIONS 2. Backache -  Cause – Normal lumbar lordotic curvature is lost during general anaesthesia with muscle relaxation due to their effects on tone of paraspinous muscles.  Precautions –  Patients with extensive kyphosis, scoliosis or h/o back pain → extra padding of spine/slight flexion at hip and knee. 3. Peripheral nerve injury –  Ulnar neuropathy is most common. 4. ↑ risk of aspiration of gastric contents.
  21. 21. PERIPHERAL NERVE INJURY  As per ASA Closed Claims database (1970 – 2010):–  Ulnar neuropathy (21%)  Brachial plexus (20%)  Spinal cord (19%)  Lumbosacral nerve roots or cord (17%)  Ulnar neuropathy –  Classic site of injury → exposed ulnar groove behind medial epicondyle of humerus.  Here nerve is exposed to both direct trauma from sides of operating table and indirect trauma from stretch.  Precaution - Pronation makes ulnar nerve very vulnerable, while supination keeps it in a more protected position.
  22. 22. BRACHIAL PLEXUS INJURY  Brachial plexus (primarily C8 and T1 nerve roots) susceptible to injury because:-  Long superficial course via axilla with 2 points of fixation - cervical vertebrae and axillary fascia.  Lies in close proximity to relatively fixed first rib, clavicle and humerus and get compressed between these structures.  Precautions – Arm abduction limited < 900 Avoid shoulder braces Head in midline
  23. 23. INTRODUCTION  Used for access to posterior parietal lobes, occipital lobes and lateral posterior fossa, including tumors at CP angle and vertebral/basilar arteries aneurysms.  Patient rests on non-operative side; balanced with anterior and posterior support (bedding rolls or deflatable beanbag) with flexed dependent leg.
  24. 24. ARM POSITION  Arms are kept in front of the patient.  Dependent arm rests on a padded arm board perpendicular to the torso.  Non-dependent arm is supported over folded bedding or suspended with armrest or foam cradle.  Neither arm should be abducted > 900.  Axillary roll is placed between chest wall and bed just caudal to dependent axilla to prevent compression of dependent neurovascular bundle (should never be placed in the axilla).
  25. 25. Axillary roll is placed well away from axilla to prevent compression of axillary artery and brachial plexus.
  26. 26. POSTIONING  Head must be in neutral position to prevent excessive lateral rotation of neck and stretch injuries to brachial plexus → this requires additional head support.  Dependent ear should be checked to avoid folding and undue pressure.  Eyes should be securely taped before repositioning.  Dependent eye must be checked for external compression frequently.  A pillow or other padding is placed between knees with dependent leg flexed to minimize excessive pressure on bony prominences & stretch of lower extremity nerves.
  27. 27. Picture showing placement of arms and head. Additional padding is under headrest to ensure alignment of head with spine. Headrest is kept away from dependent eye.
  28. 28. PRECAUTIONS  Pulse should be monitored in dependent arm to detect early compression of axillary neurovascular structures. Vascular compression and venous engorgement in the dependent arm may affect pulse oximetry reading. ↓SpO2 is an early warning sign of compromised circulation.  Hypotension measured in dependent arm may be due to axillary arterial compression.  When kidney rest is used, it must be properly placed under dependent iliac crest to prevent inadvertent compression of IVC.
  29. 29. PHYSIOLOGICAL CHANGES  Respiratory system:-  Non-dependent lung → well ventilated, poorly perfused. &  Dependent lung → well perfused, poorly ventilated (due to lateral weight of mediatinum & disproportionate cephalad displacement of abdominal contents) ↑ V/Q mismatch  Cardiovascular system:-  Minimal decrease in MAP; HR unchanged.
  30. 30. POTENTIAL PRESSURE POINTS
  31. 31. PARK-BENCH OR THREE QUARTER PRONE POSITION  Modification of lateral position.  Provides better access to posterior fossa (compared to lateral position).  Placing patient sufficiently superiorly on operating table such that dependent arm hangs over edge of table & secured with a sling.  Trunk is rotated 15⁰ from lateral position into semiprone position & supported with pillows.  Lower extremities should be slightly flexed and pillow placed between legs.  Head is flexed at neck and then rotated to look toward the floor (120⁰ from vertical & laterally flexed 20⁰ ).
  32. 32. SEMILATERAL POSITION  Named after the neurosurgeon who popularized its use for microvascular decompression of 5th cranial nerve.  Used for petrosal, retromastoid & U/L frontotemporal approaches.  Achieved by lateral tilting of table 100 to 200 combined with a generous shoulder roll.  Extreme head rotation should be avoided (to prevent compression of contralateral jugular vein by the chin).  Excessive traction on shoulder should be avoided.
  33. 33. INTRODUCTION  Also known as ‘ventral decubitus position’.  Used for spinal cord, occipital lobe, craniosynostosis & posterior fossa procedures.  Physiological changes:-  If legs are in plane with torso → haemodynamic reserve is well maintained.  Pulmonary function is superior to supine or lateral decubitus positions if the patient is properly positioned with no abdominal pressure.
  34. 34. 1 • When general anaesthesia is planned, all intravenous accesses are obtained & trolley is kept parallel and adjacent to operating table. 2 • Trachea is first intubated on the stretcher. 3 • ETT is well secured to prevent dislodgement and loosening of tape due to drainage of saliva when prone. • Antisialogogue (glycopyrrolate) and adhesive (benzoin) may reduce loosening of tape. POSITIONING
  35. 35. 4 • With the help of entire operating room staff, patient is turned prone onto the surgical table. 5 • Neck is kept in line with spine during proning & arms of the patient kept alongside the body. 6 • If cervical spine is stable, anaesthetist manage head & coordinate turn; if unstable  neurosurgeon. POSITIONING
  36. 36. 7 • Disconnecting BP cuffs, arterial and venous lines present on outside arm that rotates furthest is recommended to avoid dislodgment. 8 • Pulse oximetry can usually be maintained if applied to the inside arm. 9 • Full monitoring should be reinstituted as rapidly as possible. POSITIONING
  37. 37. POSITIONING 10 • ET tube position and adequate ventilation immediately reassessed after the move. 11 • Legs should be padded and flexed slightly at the knees and hips. 12 • Head may be supported facedown with its weight borne by the bony structures or turned to the side.
  38. 38. ARMS POSITION  Both arms may be kept along the patient’s sides and tucked in neutral position or placed in the “stick-em up” position.  In ‘stick-em up’ position, arms should not be abducted > 90⁰ & elbows should not be extended > 90⁰ (90-90 position) to prevent excessive stretching of brachial plexus, especially in patients with head turned.  Elbow should be anterior to the shoulder to prevent wrapping of brachial plexus around head of humerus.  Extra padding under the elbow may be needed to prevent compression of ulnar nerve.
  39. 39. Prone position with Wilson frame
  40. 40. HEAD POSITION  Head may be turned laterally, if neck mobility is adequate.  Patients with cervical arthritis or cerebrovascular disease → lateral rotation of neck may ↓carotid or vertebral arterial blood flow or jugular venous drainage.  Head is kept in neutral position (most common) using → a) Surgical pillow, b) Horseshoe headrest or c) Mayfield head pins.  Disadvantage with pillows → face is not always visible making eye checks more difficult.  Mirror systems are available to facilitate intermittent visual confirmation that eyes are not compressed.
  41. 41.  Horseshoe headrest supports only forehead and malar regions and allows excellent access to the airway.  Mayfield rigid pins firmly hold the head in one position without any direct pressure on face & allow access to the airway. HEAD POSITION Mirror system for prone position Prone position with horseshoe adapter
  42. 42. TAKE CARE OF ABDOMEN & THORAX  Aim of posterior spinal surgery - ↓venous pressure to minimize bleeding and facilitate surgical exposure.  External pressure on abdomen → ↑intra-abdominal and intra-thoracic pressures.  ↑Abdominal pressure → ↑venous pressure of valveless abdominal & spine vessels (including epidural veins) and causes compression of IVC →↓VR, cardiac output.  External pressure on abdomen pushes diaphragm cephalad → ↓FRC & pulmonary compliance; ↑PIP.  Firm rolls or bolsters placed along each side from clavicle to iliac crest to support the torso → ↓abdominal, thoracic pressures.
  43. 43. PRESSURE POINTS
  44. 44. PRECAUTIONS  Use of wire-reinforced ET tube to avoid kinking and obstruction as it exits patient’s mouth during prone position.  Dependent eye must be frequently checked for external compression.  Abdomen should hang relatively free and move with respiration.  Breasts should be placed medial to gel bolsters.  Lower portion of each roll or bolster must be placed under its respective iliac crest to prevent pressure injury to genitalia and femoral vasculature.
  45. 45.  Prevention of patient movement when head is held in rigid pins → skidding out of pins can result in scalp lacerations/cervical spine injury.  Horseshoe and pin headrests attach to adjustable articulating supports → any slippage or failure of this bracketing device may lead to complications due to sudden dropping of head.  Face must be periodically checked to ensure → weight is borne only by bony structures, airway is uncompromised and no pressure on the eyes. PRECAUTIONS
  46. 46.  Modification of prone position.  Used for cervical spine & posterior fossa procedures.  Neck flexion, reverse Trendelenburg, arms tucked alongside to trunk & elevation of legs → this orientation brings surgical field to a horizontal position.  Complication – 1) necrosis of chin & 2) obstruction of cerebral venous outflow. THE CONCORDE POSITION
  47. 47. 1. Postoperative vision loss (POVL) – Retinal ischemia Ischemic optic neuropathy (ION) (more common) COMPLICATIONS Blindness Cause - Orbital compression causing central retinal vessel occlusion. Precaution - must be intermittently confirmed (every 15 min) & after any surgery-related head or neck movement that eyes are not impinged Cause – ↓BP, ↓hematocrit, lengthy surgical procedures, ↑i.v. fluid administration, poor collateralization or absence of autoregulation of vasculature of optic nerve head, small and anatomically “crowded” optic nerve head, impaired cerebral venous drainage, ↑IOP.
  48. 48. 2. Macroglossia –  Flexion of neck frequently required to facilitate surgical access → ↓AP dimension of hypopharynx → compression ischemia of tongue base, soft palate, posterior wall of pharynx occur in presence of foreign bodies (ETT, esophageal stethoscope, oral airway).  Edema accumulates after reperfusion of ischemic tissue → Macroglossia → post-extubation airway obstruction.  Swollen tongue may protrude between and trap by teeth during prolonged prone procedure.  Rolled gauze bite block may be used instead of oral airway. COMPLICATIONS
  49. 49. INTRODUCTION  Used for posterior cervical spine and posterior fossa surgeries.  Infrequently used.  Advantages –  Excellent surgical exposure  Drier field  ↓Perioperative blood loss  Superior access to the airway  ↓Facial swelling  Improves ventilation  Can see face during cranial nerve stimulation
  50. 50. PHYSIOLOGY  Cardiovascular system:- ↓ VR, Stroke volume, Cardiac output, Cardiac index  MAP – unchanged  ↑ SVR, PVR  Respiratory system:-  FRC, VC improves  V/P mistmatch (hypoperfusion of upper lung)  Other systems:-  ↓RBF, CBF
  51. 51. POSITIONING  More commonly patient positioned in modified recumbent position.  Head may be fixed in Mayfield head pins.  Head holder should be attached to back portion of the table, rather than to the thigh or leg portions → makes lowering of head and closed chest massage if necessary, easier.  Arms must be supported (due to gravitational pull) to the point of slight elevation of shoulders to avoid traction on shoulder muscles and neurovascular structures.
  52. 52.  Legs should be kept as high as possible (usually with pillows under knees) to promote venous return.  Knees are slightly flexed for balance and to reduce stretching of sciatic nerve.  Feet are supported and padded.  Elastic stockings and active leg compression devices also help to maintain venous return. POSITIONING
  53. 53. Patient is typically semi- recumbent rather than sitting. A – The head-holder support is correctly positioned so that the head can be lowered without the necessity to first detach the head holder. B – This configuration with the support attached to the thigh portion of the table, should be avoided.
  54. 54. PRESSURE POINTS
  55. 55. CARE OF HEAD & NECK  Excessive cervical flexion may occur with head fixed in pins –  Impede both arterial and venous blood flow → hypoperfusion or venous congestion of brain.  Impede normal respiratory excursion.  Obstruct ETT and place significant pressure on tongue → leading to macroglossia.
  56. 56.  Careful vigilance of BP.  MAP should be corrected to head level → zeroing arterial pressure transducer at interaural plane/skull base (CPP maintenance become easier).  If manual BP cuff is used → correction (a column of water 32 cm high exerts a pressure of 25 mmHg) for hydrostatic difference between arm and operative field should be applied.  Excessive flexion of knees towards chest should be avoided → prevent abdominal compression,lower extremity ischemia and sciatic nerve injury. PRECAUTIONS
  57. 57.  Maintaining at least 2 fingers’ distance between mandible and sternum is recommended.  Patients should not be positioned at the extreme of their range of motion.  Extra caution with neck flexion is advised if TEE is used for air embolism monitoring (as esophageal probe lies between flexed spine and airway with ETT → compression of laryngeal structures and tongue).  Screening contrast echocardiography to investigate the patency of the inter-atrial septum is performed before considering sitting position. PRECAUTIONS
  58. 58. COMPLICATIONS 1. Cardiovascular instability 2. Venous air embolism 3. Paradoxical air embolism 4. Pneumocephalus 5. Macroglossia 6. Quadriplegia
  59. 59. ANY QUESTIONS??
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Different positioning in neurosurgical procedures with the aim to provide best surgical acess and decrease patient related risk.

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