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on 05-Sep-2017 (Tue)

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A first step is recognition of risk related events to vulnerable patient populations

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You should be checking a patients position at least every 15 minutes, arms fall off bed, heads fall off pillow

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Safety strap? Two needed for obese patient's

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Pt too heavy for bed, each bed has a limit, some beds won’t move if pt is too heavy, find out the bed’s tolerance

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Recommendations for Positioning of the Brachial Plexus •Limit arm abduction to 90 degrees or less •Axillary role placed for lateral position to minimize compression of humeral head into axilla •In prone position with arms above head, maintain abduction and anterior flexion of the arm to 90 degrees or less

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After ulnar, brachial plexus is 2nd most common injury

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Two fixation points, vertebrae, fascia of axilla

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Two moveable points, clavicle and humeru

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Nerve stretch from head turn opposite and arm abducted more than 90 degrees

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Ulnar Neuropathy Anatomical Considerations Tubercle of the coronoid process is 1.5 times larger in men and boys Males are also more likely to have a thicker cubital tunnel retinaculum Females have a much thicker layer of subcutaneous fat between the skin and the ulnar nerve at the cubital tunnel and medial aspect of the coronoid process

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Ulnar Nerve Damage Manifestations: ◦ Inability to abduct or oppose the fifth finger, diminish sensation over both surfaces of the fourth and fifth finger with resultant atrophy ◦ Claw Hand

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A Simple, Quick, and Easy Test an Axillary Block To quickly assess the block, perform the “push-pull-pinch-pinch” test. This test can be done in less than a minute. It can identify “missed” nerves allowing time to formulate an alternative plan of anesthesia (i.e. supplementation or general anesthesia).

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Ask the patient to extend or “push” their forearm against light resistance. This tests the radial nerve.

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Ask the patient to flex or “pull” the arm towards the nose against light resistance. This will test th e musculocutaneous nerve

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A Simple, Quick, and Easy Test an Axillary Block To quickly assess the block, perform the “push-pull-pinch-pinch” test. This test can be done in less than a minute. It can identify “missed” nerves allowing time to formulate an alternative plan of anesthesia (i.e. supplementation or general anesthesia). Ask the patient to extend or “push” their forearm against light resistance. This tests the radial nerve. Ask the patient to flex or “pull” the arm towards the nose against light resistance. This will test th e musculocutaneous nerve.

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Pinch the hypothenar aspect of the hand (i.e. small finger). This will test the ulnar nerve.

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Pinch the thenar aspect of the hand (i.e. on the palmar surface of the hand). This will test the median nerve.

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Radial Nerve Damage ◦ Manifested by: ◦ Wrist drop ◦ Inability to extend the metocarpals ◦ Weakness of abduction of the thumb

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Ulnar Nerve Injury Etiology ◦ Complex Most common peripheral nerve injury ◦ 0.5% incidence in general population ◦ 35% incidence in cardiac surgical patient ◦ Why: ◦ Runs very superficial at the elbow ◦ Little tissue or fat to protect the nerve from external compression

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Postural hypotension: Frequent complication of supine or head elevated position Treatment of choice includes: Fluids Vasopressors Avoid head up position until patient is CV stable

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Prolonged compression of the hair follicles can occur causes ischemic changes to the blood vessels. Hypothermia and hypotension enhance the process Hair regrowth is usually complete within twelve weeks Generally occurs between the 3 rd and 28 th postoperative day Permanent hair loss can occur

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Pressure Alopecia First week: Swelling Edema Crusting Ulceration

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Permanent hair loss can occur Occipito-parietal pain and tenderness within 24 hours postop

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Anti-Alopecia Recommendations • Reposition head every 30 minutes reduced the incidence of alopecia from 14% to 1% in a prospective study in cardiac surgical patients. • Remember that when you lift the head forward, your ETT is pushed forward and if the patient is light, they will gag, it can also change the position of your LMA, always consider listening with your stethoscope after a position change

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Contoured Supine Position Commonly referred to as the ‘lawn chair’ position offers the patient an anatomically feasible position because of reduced lumbar sacral strain

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So you have a nerve injury, now what? •Neurological consult •Nerve conduction and electromyographic studies •Nerve injuries sometimes take 18-21 days to manifest •Testing promptly can indicate whether the injury is old or new, acute or chronic •Recovery is slow •Deficits may be irreversible

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Early neurology consultation EMG Determine level of lesion Sensory deficits are usually transient If longer than 5 days, refer to neurology for follow up No reliable treatment for peripheral nerve injury except supportive care Physical therapy is useful to prevent: Muscle atrophy Joint contractures Surgical decompression is used only when neuroma formation hampers recovery

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Gather what you think you'll need, you get points for being independent and thoughtful • Blankets • Tape • Foam • Head pillow, Gummy pillow • Arm boards • Blue or green towels. • Prep for tape

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• Arms straps • Axillary roll • Eye lube • Skin prep • Special arm holders • Pillows to elevate legs • To name but a few • No one remembers everything, write stuff down, have a flight plan

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Initial Assessment •Comorbidities, diabetes, neuropathy, stroke, arthritis •Previous nerve injuries, stroke, trauma, surgery •Previous surgeries, wounds, chest tubes, vac dressings •ROM limitations/Any broken bones or dislocations

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• Steroid skin/Super thin and friable • Anti coagulated, you can get a hematoma from just lying there • Labs, are they on Tpn, how is their nutrition • What nerve groups do I have to be worried about with the positioning •Pacemaker/AICD/, can I go prone? How long will the surgery be? •Accessed or nonaccessed Chemotherapy port •Old with no subcutaneous fat, skin tear waiting to happen

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How would you attempt to decrease Peak • pressures during mechanical ventilation in the • paralyzed anesthetized patient? • Hint: deepen anesthetic, muscle relaxation, • decrease Vt and increase Rate, change I:E ratio • from 1:2 to 1:1.5. • Consider Pressure Control ventilation due to its • decelerating waveform

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The supine or dorsal recumbent position should place the patients cervical, thoracic and lumbar vertebrae in a straight line. horizontal

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Even More Supine Influence of gravity is minimal Intravascular pressures from head to foot vary little from mean pressures at the level of the heart

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Cardiovascular Changes from Standing to Supine • Changing from the erect to the supine position: • Venous pooled lower extremity blood is returned to the heart • Increase in preload stimulates atrial stretch receptors

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More Cardiovascular Stuff • Myocardial contractility increases to disperse venous blood • CO and BP transiently increase • Baroreceptors respond to increased BP, decrease sympathetic output and heart rate slows and vasodilation occurs

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More Cardiovascular Stuff • Numbers to remember • 0.5 – 1.0 liters of blood can pool in the lower extremities in the upright position • Cardiac output is reduced by 20% in the upright position • SPU and discharge considerations • Translation, are they tanked enough to leave

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Supine Respiratory Concerns • Abdominal viscera gravitates towards the dorsal body wall and moves the dorsal parts of the diaphragm cephalad • Decreases FRC by approximately 0.5 liters

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Complications of Supine Position ▪Pressure alopecia ▪Backache (paraspinal musculature and the normal lordotic curve are lost under anesthesia) ▪Pressure ulcers at bony prominences due to ischemia (heels, sacrum) ▪Ulnar nerve injury ▪Brachial plexus injury (stretch, abduction >90 0 )

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Soft Tissue and Skeletal Injuries Back Pain Frequently occurs secondary to anesthesia and surgical positioning 20% of the patient population Etiology: Relaxation of the paraspinous muscles Flattening of the lumbar lordosis Application of tension to posterior ligament/muscles Prevention: Lumbar support Lithotomy: Bring 2 legs together simultaneously

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Supine Arm Positioning Classic teaching: Palm up or supination is preferred over palms down or pronation: Relieves pressure on the ulnar nerve as it passes through the humeral notch at the elbow Pressure on the brachial artery is also decreased in this position

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Lithotomy Patient supine with arms on the abdomen or abducted on armboards. Both legs are flexed at the hip and knee and simultaneously elevated to expose the perineum

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Cardiopulmonary Changes with Lithotomy • CV: • Increases the central blood volume • Autotransfusion from elevating the legs above the trunk. • Leg volume estimated 100 – 250 ml per leg • Hypovolemia may not be recognized in a patient in the lithotomy position • Respiratory: • FRC is not significantly changed • Lithotomy with Trendelenburg does further reduce FRC • Raising the legs causes a slight decrease in TV and an 18% decrease in vital capacity

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Cardiopulmonary Changes with Lithotomy • Severe hypotension can occur if volume replacement has been inadequate or compensatory mechanisms are abolished by general or regional anesthesia • Bring legs midline from stirrups or leg holders and place on bed simultaneously • ANESTHESIA IMPLICATION • Always check blood pressure after legs are down and BEFORE moving patient to PACU or SPU

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Lithotomy Complications • Flexion of hips > 90 degrees • Kinks or compresses the femoral neurovascular structures under the tight inguinal ligament with subsequent arterial or venous occlusion and nerve palsy • Raising one leg at a time can lead to hip dislocation and back pain postoperatively • Extreme flexion of the knee • Obstructs the popliteal vein and impedes venous outflow from the extremity • Duration • Lower extremity neuropathy • Limit duration of lithotomy to < 2 hours

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Exaggerated Lithotomy • Combines the worst features of lithotomy and trendelenburg into one position • Head down tilt adds the weight of the abdominal viscera and that produced by the flexed thighs • Net effect: • A greater ventilation perfusion mismatch

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Lithotomy Position Boots Boot stirrups evenly distribute the load between the heels and the calves. Molded foot pieces decrease the risk of compartment syndrome

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Lithotomy Position Vulnerable Body Sites • Popliteal space • Peroneal nerve • Lateral aspect of the leg • Legs • Knees • Feet and hips

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Ischemia, edema and the possibility of rhabdomyolysis occurs from the increased pressure in the fascial compartment

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Injury to the common peroneal nerve. This is the MOST COMMOM nerve injury to the lower extremities accounting for 78% of all lower extremity motor neuropathies caused by compression of the nerve between the lateral head of the fibula and “candy cane” bar stirrups

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Duration of surgery greater than 2 hours is a predictor of increased incidence of lower extremity neuropathy

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Reverse Trendelenburg Tilt Test
• The cardiovascular response to head up tilt of 75 degrees for three minutes can be a useful indicator of the magnitude of acute blood loss • If sustained tilt causes an increase in HR of more than 25 bpm, but does not produce hypotension or syncope: • The blood volume deficit is 9 - 14 mL/kg • If syncope occurs on tilting: • The deficit is likely to be as much as 20 mL/kg

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Reverse Trendelenburg Cardiovascular Changes When the lower extremities are lower than the level of the heart, blood pools in the distensible dependent vessels, causing a reduction in effect of circulating blood volume, cardiac output, and systemic perfusion

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Trendeleburg Cardiovascular Changes • Pressure in the cerebral veins increases in proportion to the gradient upward to the heart • Some c/o pounding headache • Contraindicated in the presence of intracranial pathology • Baroreceptors activated • Results in rapid vasodilation, reduced CO, and decreased organ perfusion

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AUTONOMIC FUNCTION • Aortic arch and carotid sinus house barorecetors that are part of the bodies homeostatic mechanism to maintain blood pressure within a narrow range. Increased firing of the receptors when stretched from an increase in blood pressure is part of a negative feed back loop. • The increased firing from the baroreceptors enhances the parasympathetic nervous system lowering blood pressure and slowing the heart rate

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Bottom Line, anesthesia ablates or reduces the bodies ability (feedback systems to respond to hemodynamic changes, we are now the part of the external feedback loop for hemodynamic control.

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Trendelenburg Respiratory Changes • Trendelenburg shifts the weight of the visceral mass onto the diaphragm • Result = impeded caudad excursions, prevention of lung base expansion • Movement of the mediastinum toward the head moves the carina closer to the ETT • Can result in preferential ventilation of one lung • Tube can move into the right main bronchus

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Trendelenburg Position Complications • Swelling • Face • Larynx • Conjunctiva • Increase incidence of postoperative upper airway complications • Leak Test for Extubation, suction before you deflate cuff

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Lowering the head will increase the pressure in the • cerebral veins which may lead to vascular head ache, congestion of nasal mucosa and conjunctiva in
• healthy individuals. This may lead to edema in the
• larynx as well. The sclera is the window to the
• vocal cords

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Normal excursion of the diaphragm in head down position is impeded and increase the work of breathing

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In the paralyzed mechanically ventilated patient, higher peak pressures will be required for adequate ventilation

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• Head lowering in patients with intra-cranial lesions will exacerbate the condition raising CPP and ICP
• Maintenance of CPP reduces mortality in severe head injury.

CPP should be maintained above 70-80mmHg
• Systemic hypotension is associated with poor prognosis

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Solution to swelling • Return them to supine and place them in high fowlers • If they can hemodynamically tolerate it and if the procedure will allow the post surgical position • Reverse Trendelenburg in a pince if you can’t bend them

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Sitting Position • The weight of the body becomes unequally distributed over certain areas • Flexion of the thighs and some elevation tends to prevent untoward changes in blood pressure: • TEDS or inflation stockings

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Sitting position • Rarely if ever see true sitting • Torso at 90 degrees • Modification of Sitting Position • Lounging or beach chair position • Torso at 45 degrees

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• CV: • CO decreases as the patient is elevated • Venous pooling • Intrathoracic blood volume decreases 300 – 500 ml • Intracranial perfusion • Hypotension is NOT tolerated because MAP decreases 2mm Hg for each inch the head is above the level of the heart

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Pulmonary: • Caudal shifting of the abdominal contents causes less interference with diaphragmatic movement. • Allows for greater expansion of the dependent lung regions

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Beachchair Considerations • Developed in 1980’s for arthroscopic shoulder surgery • 30 – 90 o above horizontal plane • Upright ‘beachchair’ position • Decreases in • CVP • MAP • CO • PaO2 • Increase in • Total peripheral resistance

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Urban poets in the c Abbasid period easily rivalled the obscenity of the Umayyad poets, with new refinements and adding a new dimension by introducing homosexual themes.

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Sexual invective before the time of Jarir and al-Farazdaq is not very common, however. 32 The rise of sexual invective in poetry coincides with poetry becom- ing a form of public amusement. We could almost say that sexual invective came into being with Islam and the founding of urban centres such as Basra and Kufa, where the flytings found a wide audience.

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Jarir was, in fact, blamed for repeating himself. Abu cUbayda (d. 210/825), when asked who was the better poet, Jarir or al-Farazdaq, replied with a rhetorical counter-question: Hasn't Jarlr said about al-Farazdaq anything except three things: (the matter of) al-Zubayr (the case of) Jicthin, and the (fact that he calls him the descendant of a) qayn, 'blacksmith'? But al-Farazdaq says about him a hundred different things !

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a woman called Umm Jacd more or less raped the well-known pre-Islamic poet Aws b. I:Iajar, it is told, making some obscene verses into the bargain, and when Aws fled she followed him, exclaiming in rajaz verse: atfubu Awsan la uridu ghayrah I nayaktuhUfa-shaqqa ba:r,ri ayrah ('I want Aws and no-one else. I fucked him and my clit split his prick.')

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Sitting Position Venous Air Embolism Air may enter the venous system because of the negative pressure that exists between the right atrium and the veins in the operative site Incidence: 8% for cervical foraminotomy 41 – 45% for posterior fossa surgery Complications: Range in relation to the quantity of air entrained and the rapidity with which it is entrained

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Sitting Position Venous Air Embolism • Air entering the right side of the heart limits gas exchange in the lungs as it displaces blood in the pulmonary vasculature • Monitoring: • TEE • Doppler (millwheel murmur) • CVP • Precordial stethoscope • Treatment protocols • Capnography

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Sitting Position Venous Air Embolism • TEE is the most sensitive monitor for VAE detection • Can detect volume as small as 0.05 ml/kg • -Fireflys for PFO • Precordial doppler • Detects air via ‘mill wheel’ murmur sound • Placed over the 3 rd to 6 th intercostal space to the right of the sternum

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Supine position • BP measured in the arm and BP perfusing the brain are essentially the same

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Beachchair position • BP is less in the brain than at the heart or arm • BP difference will be equal to the hydrostatic pressure gradient between the heart/arm and the brain

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• BP at the heart/arm = 120/80 • (MAP 92mmHg) • Height of the external auditory meatus (base of brain) is now 20 cm above the level of the heart • Difference in BP at the heart compared to the brain is 15 mmHg • BP at the base of the brain is 105/65 • BP’s on the ankle, strokes, not a good thing

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Anesthetic Considerations
AVOID HYPOTENSION! • Aggressively treat hypotension

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Sitting Position Quadriplegia
Occurs after hyperflexion of the neck • Maintain two fingerbreadths between the mandible and chest • Greatest spinal cord stretch at C4 – C5 fulcrum • Stretching of the spinal cord • Due to decreased arterial blood flow by feeding vessels • Decreases caliber of the spinal cord vessels • Compromises midcervical vasculature • Some recommend monitoring of evoked potentials • SSEP’s

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Prone Position ◦ The patient is anesthetized in the supine position and rolled into the prone position face down for surgery on the body’s dorsal side ◦ Turning must be done smoothly with assistance available

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The arms are rotated to the padded arm boards, bringing them through their normal range of motion to rest beside the patient’s head on boards or brought down to the side of the body

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Prone Position Cardiac Changes CV: ◦ CO can be decreased ◦ Pooling of blood in the extremities is theorized to decrease venous return ◦ Goal: ◦ Prevent pressure on the abdomen which: ◦ Impedes venous return ◦ Increases venous pressure ◦ Interferes with ventilation by impingement on diaphragmatic excursion

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Prone Position Pulmonary Changes • Limited rib cage expansion, abdominal compression, diaphragmatic excursion may lead to V/Q mismatching

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Ventilation Perfusion (Q) • In respiratory physiology, the ventilation/perfusion ratio (or V/Q ratio) is a measurement used to assess the efficiency and adequacy of the matching of two variables. It is defined as: the ratio of the amount of air reaching the alveoli to the amount of blood reaching the alveoli. • "V" – ventilation – the air that reaches the alveoli • "Q" – perfusion – the blood that reaches the alveoli

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Shunt • Perfusion of lung units without ventilation • Unoxygenated blood enters the systemic circulation • V/Q = 0 • Pneumonia • Pulmonary Contusion • Positioning

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Dead space • Ventilation of lung units without perfusion • Gas enters and leaves lung units without contacting blood • Wasted ventilation • V/Q is infinite • Pulmonary Embolism • Positioning

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The head is padded on a small pillow with foam head rest, keeping the neck in alignment with the spinal column. • Protect • Eyes • Ears • Pressure on the jugular veins to prevent increased ICP and cervical venous distention

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Prone Position Complications The eyes and ears are at risk in the prone position even when the head is turned to one side. The eyes should be lubricated?? and covered. If intraocular pressure exceeds retinal artery pressure, blindness occurs The eyes should be checked after positioning and frequently during surgery to assure that no malpositioning of the head occurs

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Prone Position Complications • INTRA OPERATIVE BLINDNESS • Most common catastrophic problem occurring in anesthesiology in the last 5 to 10 years • Most notable in spine and cardiac surgery • Incidence • 1 in 61,000 to 1 in 125,000 • Depends on endpoint chosen • Small visual field loss versus total blindness

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Prone Position Complications Neck • Anesthesia impairs neck muscle spasm that protects the skeleton against motion that would be painful in the alert patient • Lateral rotation of the head and neck in the anesthetized patient may result in: • Neck pain • Limited range of motion • Decreased cerebral circulation and perfusion pressure

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Don’t forget the face and other small bits of wisdom • Extended periods prone can cause skin tears • Face Prep • Make sure the tube is anchored • Lube the eyes • Circumfrential taping, how to do it

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Prone Position Thoracic Outlet Syndrome • Assess • Have patient clasp hands behind the occiput during preanesthesia patient assessment • If the patient describes dyesthesias • Keep arms alongside the trunk in the prone position

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Closure of outlet occurs secondary to: ◦ Upward movement of the first rib ◦ Presence of a cervical rib ◦ Shifting of the clavicle.

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[unknown IMAGE 1679247150348]
#has-images #hyperabduction
Hyperabduction syndrome

Anterior scalene

Costoclavicular

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Complications (Thoracic Outlet Syndrome) Thoracic Outlet Syndrome or TOS: ◦ Disorder of the upper extremities ◦ Nerve involvement ◦ Pain ◦ Numbness ◦ Tingling ◦ Weakness ◦ Swelling ◦ Circulation changes ◦ Arterial involvement ◦ Tired, achy arm ◦ Venous involvement ◦ Enlarged veins of arm and chest

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Prone Position Modifications Jacknife Position Modification of the prone position Also referred to as the ‘Kraske’ position Utilized for proctology procedures Arms and legs must be: ◦ Protected ◦ Supported ◦ Padded

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Prone Position Modifications
Knee Chest Position ◦ Appears extreme but physiologically satisfactory for some orthopedic procedures (laminectomy) ◦ Enhances access to intravertebral spaces, reduces pressure on the vena cava, lumbar and epidural veins resulting in less blood loss

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Lateral Position Patient is anesthetized in the supine position and turned lateral utilizing coordinated help The head must be properly supported to align with the spinal column The torso is stabilized and supported with braces or other devices that prevent movement or changes in position during the procedure

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Cardiopulmonary Changes • CV: • Minimal changes • Flexion of the trunk and the kidney rest may significantly affect venous return, CO, and blood pressure • Vena caval obstruction • Dependent head positioning can lead to venous congestion

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VENOUS AIR EMBOLISM -Venous air embolism may be manifested as cardiac dysrhythmias, arterial oxygen desaturation, drop in End Tidal C02, pulmonary hypertension or frank cardiac arrest. -Actions to take if you suspect an air embolism is to ask the surgeons to flood the field with saline and to apply bone wax to boney edges

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Cardiopulmonary Changes • Pulmonary: • In the anesthetized individual the dependent lung is better perfused • Nondependent lung is better ventilated • Tidal volumes of 15 ml/kg and inspired oxygen of 0.5 is suggested to compensate for V/Q mismatching

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Pads or pillows are placed between the legs and the feet A special pad ‘bean bag’ is available to stabilize the patient after transfer to lateral position The peroneal nerve leaves the posterior aspect of the knee and wraps laterally around the head of the fibula is particularly vulnerable to injury in the lateral position ◦ Adequate padding to the lateral aspects of the knees is mandatory

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• Put BP cuff and Aline if in the dependent arm if Possible • If you think there is a vascular problem, do a BP in both arms, use the one that’s higher

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Non dependent arm is “air planed” or supported with pillows and not allowed to be abducted greater than 90 degrees. • Place pillow between knees with dependent leg flexed. Pressure points include acromion process, iliac crest, greater trochanter, peroneal nerve and lateral maleolus

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Lateral Position Complications • Eye and ear injuries. Make sure that downside ear and eye are “free” from pressure. Use a donut roll for the ear. • Use of the Opti-guard or eye guard is considered useful in lateral positions. Neck flexion needs to be avoided. Position neck midline with supporting towels.

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Kidney Position Stabilize the patient to prevent movement and shifts caudad on the table so that the kidney rest may not relocate itself into the downside flank. Ventilation issues again may occur due to dependent lung compromise and V-Q mismatching.

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Ocular Injury :
Excessive ocular pressure on the globe =: ◦ Thrombosis of the retinal artery ◦ Retinal ischemia ◦ Irreversible blindness ◦ When intraocular pressure exceeds retinal artery pressure PERMANENT BLINDNESS occurs

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Ocular Injury When IOP (intraocular pressure) exceeds RAP (retinal artery pressure) blindness occurs ◦ Hypoperfusion of the eye occurs

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Ocular Injury Ischemic Optic Neuropathy (ION) ◦ Cause ◦ Visual pathways reach from their origins in the retinal ganglion cells to the primary visual cortex in the occipital lobes. ◦ Infarction of the anterior or posterior parts of the optic nerve

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Ocular InjuryANTERIOR Ischemic Optic Neuropathy (ION) Pathophysiology: ◦ Infarction at watershed areas between the zones of distribution of the short posterior ciliary arteries. ◦ Individual variation in blood supply can affect the severity of damage ◦ Severe injury can cause complete and irreversible blindness

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Ocular InjuryPOSTERIOR Ischemic Optic Neuropathy (ION) Pathophysiology ◦ Vascular insufficiency to the optic nerve ◦ Subtly different than AION ◦ Blood supply in PION occurs from smaller vessels that may easily be compressed by fluid buildup in that area ◦ In the prone position ◦ Blood supply into posterior optic nerve inadequate ◦ Hypotension and low oxygen carrying capacity can lead to blindness ◦ Facial swelling increases intrasheath pressure ◦ Large volumes of IV fluids causes additional edema

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POSTERIOR Ischemic Optic Neuropathy (ION)
Risk Factors
Obesity
Prone Position ◦ IOP in prone position increases 100% over a 6 hour period of time
Anemia
History of hypertension
Smoker
Large crystalloid infusion
Diabetes Long surgery
Pre-existing visual impairment
Trendelenberg position
Anatomical variation of the blood supply to the optic head

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ION Etiology TRIAD ◦ Blood loss ◦ Decreased oxygen carrying capacity ◦ Predonor therapy ◦ Decreased hematocrit ◦ Anemia ◦ Hemodilution and predonation anemia ◦ Hypotension patients ◦ Hypotension may not be tolerated even for brief periods of time particularly in hypertensive patients

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ION Etiology ◦ Additional considerations ◦ Increased perioperative glucose levels ◦ Associated with poor neurologic outcome ◦ Hypoxic or ischemic tissue is unable to metabolize sugar through normal pathways and the size of infarcted areas is increased ◦ Maintain ‘tight’ glycemic control perioperatively

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ION Anesthesia Periop Care Issues Preanesthesia assessment ◦ Assess for history of vascular disease or diabetes ◦ Assess for history of previous visual problems Positioning ◦ Pad patient well ◦ No abdominal compression ◦ Protect eyes Staging procedure Notation on anesthesia record at regular intervals ‘Patient’s head checked, eyes – pressure etc.’

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Leak Test • Patients with possible airway burns, prone, trendelenburg, traumatic intubations and victims of allergic reactions may have edema of the trachea. Extubation of these patients without first verifying that swelling no longer exist is critical for save extubation of these patient. The “cuff-leak” test is intended to help predict the occurrence of glottic edema and/or stridor after extubation. The two methods that are frequently used are as follows: • 1) Totally deflate the cuff, and then completely occlude the endotracheal tube. The presence of a leak around the tube during spontaneous breathing indicates that

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Think about when you do things Remove your NG or place it when they are paralyzed Give some Propofol/Sux to create a good condition Suction when they are paralyzed Suction before you remove the ETT Common sense stuff

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Leak Test Continued • Tracheal tissue is not encroaching on the endotracheal tube (a positive test) and • Therefore swelling is nonexistent or reduced. • The second method is similar, but the leak is assessed during positive pressure ventilation. • A negative test (no leak) indicates a high potential for postextubation obstruction

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ION Anesthesia Periop Care Issues Invasive monitoring of blood pressure to particularly for long cases associated with increased levels of blood loss Minimize hemodilution ◦ Colloids versus crystalloids may be better option Maintain urine output at 1 ml/kg/hour Timely blood replacement Tight blood glucose control ◦ < 150 mg/dl

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ON Anesthesia PACU Issues ◦ Assess patient carefully in PACU ◦ May be hours until POVL is appreciated in the postanesthesia recovery area

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Functional Residual Capacity (FRC) is the volume of air present in the lungs, specifically the parenchyma tissues, at the end of passive expiration. At FRC, the elastic recoil forces of the lungs and chest wall are equal but opposite and there is no exertion by the diaphragm or other respiratory muscles

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Traditional Concerns with Position Changes and Anesthesia and Functional Residual Capacity • In the supine position, probably because of conformational changes in the abdomen and diaphragm, FRC is decreased relative to the erect position by approximately 20% • An additional decrease of approximately 20% occurs with anesthesia or paralysis, resulting from a small and inconsistent shift of the diaphragm • Shape change is proposed rationale for additional 20% decrease in FRC • Newer studies dispute a significant shift in the diaphragm

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Did you say endotracheal tube? • ETT Placement • Wherever the nose goes, there goes the tube in relation to the carina • Extension = cephalad movement • Tube pulls away from carina • Flexion = caudad movement • Tube pushed into carina and right main • Lateral rotation • Tube pulls away from carina • Listen to all your patients for practice

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Bottom Line When in doubt with tube listen, right main stem, extubation Listen while bagging manually, you need the turbulance to hear the lungs Always remember DOPE D-ET Tube displaced, mask, Lma and/or reintubate O-ET Tube Obstructed, suction or bite block P-Pneumothorax, needle or chest tube E-Equipment issue or failure

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Vulnerable Situations • Excessive, sustained pressure on areas of the body (equipment and position) • Moisture: • Perspiration • Incontinence • Prepping fluids • Irrigating fluids • Girth

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When is the positioning initiated? •Often done while awake •Supine •Prone MAC •Ask, are you comfortable? •If you ask the pt to position themselves, you are given a baseline of comfort that you cannot provide

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Often done while asleep • Most patients don’t enjoy being naked in front of strangers, sedate them and be respectful, don’t become immune to the normal social graces of society, the ether drape is also there to provide a barrier so the patient can’t see that you can see • Lithotomy • Lateral decubitus, remember side down is the direction you chart • Foley • Central Venous Line, need it for induction • Vasopressors • Volume • Swan • Aline • Do they need it for induction?

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Flashcard 1679310064908

Tags
#1 #ccmc #jrs #positioning
Question
[...] is the art of moving and securing the human anatomy in place, allowing the best exposure of the surgical site and the least compromise in both physiological functions and mechanical stresses in joints and other body parts
Answer
Positioning


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Positioning is the art of moving and securing the human anatomy in place, allowing the best exposure of the surgical site and the least compromise in both physiological functions and mechanical

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Flashcard 1679312948492

Tags
#ccmc #jrs #positioning
Question
Positioning allows the best exposure of [...] site and the least compromise in both physiological functions and mechanical stresses in joints and other body parts
Answer
surgical


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Positioning allows the best exposure of surgical site and the least compromise in both physiological functions and mechanical stresses in joints and other body parts

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Flashcard 1679318191372

Tags
#1 #ccmc #jrs #positioning
Question
Potential for [eye part] abrasion is always present when mask ventilating patients.
Answer
corneal


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Potential for corneal abrasion is always present when mask ventilating patients.

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Flashcard 1679320026380

Tags
#1 #ccmc #jrs #positioning
Question
To prevent corneal abrasion, keep hanging [...] away from the patients face when hand ventilating
Answer
badges


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Keep hanging badges away from the patients face when hand ventilating

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Flashcard 1679322385676

Tags
#1 #ccmc #jrs #positioning
Question
Keep hanging badges away from the patients [body part] when hand ventilating
Answer
face


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Keep hanging badges away from the patients face when hand ventilating

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Flashcard 1679326317836

Tags
#1 #ccmc #jrs #positioning
Question
To treat Corneal Abrasions, use [...] Numbing and Antibiotics or consult eye/optho
Answer
Topical


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Treatment of Corneal Abrasions • Patch • Topical Numbing • Topical Antibiotics • Fluorscein Eye Stain/Wood Lamp • Sew there eyes shut • Optho Consult

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Flashcard 1679328677132

Tags
#1 #ccmc #jrs #positioning
Question
Apart from topical abx and numbing, [...] and [...] Eye Stain/Wood Lamp will be another option for Corneal Abrasions treatment
Answer
Patch and Fluorscein


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Treatment of Corneal Abrasions • Patch • Topical Numbing • Topical Antibiotics • Fluorscein Eye Stain/Wood Lamp • Sew there eyes shut • Optho Consult

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If you are worried about someone poking themselves in the eye with a sat probe, put it on there toe or finger

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Flashcard 1679332609292

Tags
#1 #ccmc #jrs #positioning
Question
If you are worried about someone poking themselves in the eye with a sat probe, put it on there [...] or finger
Answer
toe


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If you are worried about someone poking themselves in the eye with a sat probe, put it on there toe or finger

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Flashcard 1679335755020

Tags
#1 #ccmc #jrs #positioning
Question
Aortocaval Syndrome is when [...] of baby and uterus decreases blood return hence hypotension
Answer
Pressure


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Aortocaval Syndrome • Pressure of baby and uterus decreases blood return hence hypotension • Put a wedge under mom’s right hip

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Flashcard 1679338114316

Tags
#1 #ccmc #jrs #positioning
Question
Aortocaval Syndrome: Pressure of baby and [...] decreases blood return hence hypotension •
Answer
uterus


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Aortocaval Syndrome • Pressure of baby and uterus decreases blood return hence hypotension • Put a wedge under mom’s right hip

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Flashcard 1679344667916

Tags
#1 #ccmc #jrs #positioning
Question
w/ Aortocaval Syndrome, Pressure of baby and uterus decreases [...] hence hypotension
Answer
blood return


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Aortocaval Syndrome • Pressure of baby and uterus decreases blood return hence hypotension • Put a wedge under mom’s right hip

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Flashcard 1679349386508

Tags
#1 #ccmc #jrs #positioning
Question
Aortocaval Syndrome starts
Answer
at 18-24 weeks


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Aortocaval Syndrome starts at 18-24 weeks

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Flashcard 1679363017996

Tags
#1 #ccmc #jrs #positioning
Question
Sunderland Classification system divides nerve injuries into [...] categories
Answer
five


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Sunderland Classification system divides nerve injuries into five categories

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Flashcard 1679365377292

Tags
#1 #ccmc #jrs #positioning
Question
First-degree injury is A reversible local conduction block at the [...] of the injury.
Answer
site


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First-degree injury is A reversible local conduction block at the site of the injury. This injury does not require surgical intervention and usually will recover within a matter hours to a few weeks

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Flashcard 1679372193036

Tags
#1 #ccmc #jrs #positioning
Question
A second-degree injury is a loss of continuity of the [...]
If 2nd degree is confirmed through pre-operative nerve testing, surgical intervention is usually not required
Answer
axons or electrical wires within the nerve


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A second-degree injury is a loss of continuity of the axons or electrical wires within the nerve. If 2nd degree is confirmed through pre-operative nerve testing, surgical intervention is usually not required

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Flashcard 1679374028044

Tags
#1 #ccmc #jrs #positioning
Question
If 2nd degree is confirmed through pre-operative nerve testing, [surgical/no surgical intervention] ​​​​​​​ is needed?
Answer
Surgical intervention


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A second-degree injury is a loss of continuity of the axons or electrical wires within the nerve. If 2nd degree is confirmed through pre-operative nerve testing, surgical intervention is usually not required

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