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PATIENT POSITIONING AND ANAESTHETIC CONSIDERATIONS
- 1. PATIENT POSITIONING AND ANAESHTHETIC CONSIDERATION
- 2. Physiological changes related to change in body positioning •Gravitational effects •Redistribution of blood •Changes in pulmonary mechanics
- 3. VARIOUS POSITIONS • HORIZONTAL ● TRENDENLENUERG • LAWNCHAIR ● REVERSE TRENDELENBURG •FROG LEG SUPINE •PARK BENCH LATERAL •STANDARD ● HIGH •LOW ● EXAGGERATED LITHOTOMY •BEACH CHAIR SITTING •FULL PRONE ● PRONE KNEELING •PRONE JACK KNIFE PRONE
- 4. SUPINE
- 5. ASSOCIATED ARM POSITION • Abduction of arm is limited to <90 degrees to minimize the likelihood of brachial plexus injury. • When adducted they are usually alongside of body with a drawsheet that passes under the body. • The elbows and any protruding objects such as iv line are padded.
- 6. CARDIOVASCULAR CONCERNS Upright to Supine position venous return preload stroke volume Cardiac output Blood pressure ↑ ↓ ↑ ↑ ↑ ↓ ↓ ↓ ↑
- 7. Baroreceptors in aorta via vagus nerve Medulla oblongata Efferent Parasympathetic activity HR SV Contractility Little change in BP noted Baroreceptors in carotid sinus via Glossopharyngeal nerve ↓ ↓ ↓ ↓ ↓ ↓ ↓ ↓
- 8. PULMONARY CONCERNS Supine position FRC due to cephalad displacement of diaphragm Under GA spontaneously breathing patients tidal volumes functional residual capacity closing volumes V/Q mismatching due to increased atelectasis and a reduced minute ventilation. Using positive-pressure ventilation with muscle relaxation may counter some of the ventilation-perfusion mismatch by ensuring adequate minute ventilation and limiting atelectasis by use of positive end expiratory pressure ↓ ↓ * ↓ ↓ ↓ ↑ ↑ ↓
- 9. SUPINE CONCERNS • Circulation and pressure points Most common nerve injuries • Brachial plexus • Radial and Ulnar • Peroneal and Tibial • Bony prominences
- 10. SUPINE VARIATIONS • LAWN CHAIR POSITION Advantages • Better tolerated by awake patients or under monitor anaesthesia care • Venous drainage from lower extremity is enhanced • Abdominal wall tension is reduced
- 11. FROG LEG POSITION Allow easy excess to • perineum • Medial thigh • Genitilia • Rectum
- 12. TRENDELENBURG POSITION • Increased CVP , ICP , IOP • Prolonged head down swelling of face ,conjunctiva ,larynx and tongue post operative upper airway obstruction • Decreased FRC and pulmonary compliances ↓ ↓ Typically used for lower abdominal surgeries • Colorectal • Gynecological • Genitourinary procedures • Central venous cathether placement
- 13. REVERSE TREDELENBURG POSITION • Upper abdominal surgery • Hypotension due to decreased venous return therefore more frequently arterial monitoring is essential • Reduced perfusion pressure of brain • Shoulder braces should be avoided
- 14. COMPLICATIONS •Backache : mc •Tissue ischemia •Peripheral nerve injury •Pressure alopecia
- 15. LITHOTOMY • Gynecologic • Rectal • Urologic surgeries • Hips are flexed 80 to 100 degrees from trunk and legs are abducted 30 to 45 degrees from midline.
- 17. Various types of stirrups Knee cradles Allen stirrups Candy cane
- 18. COMPLICATIONS Lithotomy • Preload • CO, cerebral venous & ICP • displace the diaphragm cephald • Reduced lung compliance • Reduced tidal volume • Lower extremity compartment syndrome ↑ ↑
- 19. LATERAL DECUBITUS • Thorax • Retroperitoneal structures • Hip Patients head must be kept in neutral position to prevent excessive lateral rotation of the neck and stretch injuries to brachial plexus The dependent ear should be checked to avoid folding and undue pressure Eyes are securely taped before repositioning, dependent eye are checked for external compression Watch for compression of dependent axillary structures Vascular compression and venous engorgement in dependent arm Pulmonary compromise in mechanically ventilated patient
- 20. FLEXED LATERAL DECUBITUS POSITION • When a kidney rest is used it must be properly placed under the dependent iliac crest to prevent inadvertent compression of IVC.
- 21. PARK BENCH POSITION • occipital lobes • Lat post fossa • Post parietal • Aneurysms of vertebral and basilar arteries
- 22. PRONE POSITION • Posterior fossa of skull • Posterior spine • Buttocks • Perirectal area • Posterior lower extremities ARMS- either on side and tucked or above head on armboard • Extra padding under elbow • Arm should not abducted greater than 90 degree LEGS – padded and flexed slightly flexed at knees and hip elastic stocking and active compression devices are needed to minimize pooling of blood, especially with any flexion of body
- 23. pulmonary function is superior than other position if there is no abdominal pressure and the patient is properly positioned When general anaesthesia is planned , the patient is intubated on the stretcher , and all intravascular asceses is obtained as needed The ET is well secured to prevent dislodgment With the coordination of entire operation room staff the patient ,the patient is turned prone Because abdominal wall is easily displaced ,external pressure may ↑intra abdominal pressure → push diaphragm cephalad → ↓FRC & pulmonary compliance and ↑ peak airway pressure Abdominal pressure may impend VR through compression of IVC
- 24. MIRROR SYSTEM HORSESHOE HEAD REST MAYFIELD HEAD PINS
- 25. COMPLICATIONS • Accidental extubation • Obstructions of ETT bloody secretions/sputum plugs • Facial ,airway edema- prolonged head low position, increased crystalloid infusion • Visual loss • Neck injury • Accentuation of pre existing diseases
- 26. JACK KNIFE POSITION • Anal surgeries • Pilonidal sinus excision Places patient prone with head and feet at a lower level
- 27. KNEE CHEST POSITION • Sigmoidoscopies or lumbar laminectomies severe hypotension
- 28. SITTING POSITION • Post cervical spine • Posterior fossa Main advantages Excellent surgical exposure Decreased blood Superior access to airway reduced facial swelling Pulmonary mechanics preserved
- 29. complications • Venous air emboli • Hypotension • Brainstem manipulations resulting hemodynamic changes • Risk of airway obstruction • Macroglossia • Pneumocephalus • Quadriplegia
- 30. BEACH CHAIR POSITION • Shoulder surgeries including arthroscopies • Associated with Neurological neurapraxia, Hypotensive bradycardia
- 34. THANK YOU