on 05-Sep-2017 (Tue)

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

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

Safety strap? Two needed for obese patient's

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

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

After ulnar, brachial plexus is 2nd most common injury

Two fixation points, vertebrae, fascia of axilla

Two moveable points, clavicle and humeru

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

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

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

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

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.

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

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

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

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

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

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

Pressure Alopecia First week: Swelling Edema Crusting Ulceration

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

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

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

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

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

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

• 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

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

• 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

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

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

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

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

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

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

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

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 )

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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

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

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

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

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

• 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

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

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

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

• 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

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

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

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.

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.

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 !

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.')

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

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

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

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

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

• 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

Anesthetic Considerations
AVOID HYPOTENSION! • Aggressively treat hypotension

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hyperabduction syndrome

Anterior scalene

Costoclavicular

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

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

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

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

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

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

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

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

• 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

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

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.

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.

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

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

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

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

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

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

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

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

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.’

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

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

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

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

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

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

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

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

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

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

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

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?

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