True or False/ write in
How often should you assess and reassess patient positioning?
q 15min
Which positioning technique should be used to prevent Ulnar Nerve Palsy? (select all that apply)
A. supinated or neutral hand position
B. Avoid flexing arm more than 90 degrees
C. avoid compression against the posterior and lateral aspect of the humerus
D. Avoid extreme wrist dorsiflextion
A and B!
Incorrect:
C. avoid compression against the posterior and lateral aspect of the humerus (this is radial nerve)
D. Avoid extreme wrist dorsiflextion (this is median nerve)
Your patient wakes up from surgery with decreased use of their Right arm. The CRNA knows this to be a brachial plexus injury. Which of the following is most likely the cause of injury?
A. shoulder braces placed over the acromioclavicular joint
B. Shoulder abduction > 90 degrees
C. An axillary block placed under US guidance
D. head rotation toward the abducted arm
Correct: B. Shoulder abduction > 90 degrees
Shoulder abduction should be maintained < 90 degrees
THIS WAS TRICKY
A. shoulder braces placed over the acromioclavicular joint (although this can cause a compression injury, correct placement is over the acromioclavicular joint)
C. an axillary block placed under US guidance (an axillary block can cause BP injury, however US guidance has greatly reduced the incidence)
D. head rotation toward the abducted arm (head rotation AWAY from the abducted arm should be avoided)
Match the type stirrups with their possible complication
1. Allen (rest under calf) a. compartment syndrome and DVT
2. Suspension (candy cane) b. increased flexion at hip
1. Allen (rest under calf) = a
2. Suspension (candy cane = b
What is the most common peripheral neuropathy caused by surgery? (HINT: often characterized as a claw hand)
A. Ulnar
B. Radial
C. median
D. Axillary
A. Ulnar nerve nueropathy R
Risk factors: M>F, length of sx, older, body habitus, CV surgery, DM, vitamin deficiency, alcoholism, CA, cigarette smoking, asymptomatic compression of cubital tunnel (degenerative arthritis, occupational trauma)
True or false: when a peripheral nerve injury occurs the CRNA should perform and document a directed physical exam to determine the extent of the sensory or motor deficit and seek a neurological consult.
True!
an EMG can be performed to determine the exact location of a motor injury
-> motor deficit take 4-6wk to recover
-> sensory deficit usually transient
Who is involved in the positioning of the patient? (Select all that apply)
A. OR nursing staff
B. The patient
C. Surgical team
D. Anesthesia personnel
A, B, C, and D
the patient (ideally the are positioned awake)
What is the most frequently damaged nerve of the lower extremity? (HINT: most often caused by compression of the lateral thigh from lithotomy)
A. Sciatic
B. Femoral
C. Common peroneal
D. Obturator
C. Common Peroneal Nerve
May be mistaken for sciatic nerve injury: LOOK FOR FOOT DROP
Match the AANA Standard
A. 8 1. preop interview
B. 2 2. Documentation
C. 5 3. patient positioing
D. 9 4. monitoring
A. 8 = 3
B. 2 = 1
C. 5 = 2
D. 9= 4
What are the two major sites of ulnar nerve damage?
A. Carpel and epicondyle tunnel
B. Cubital and humeral tunnel
C. Cubital and Condylar tunnel
D. Anticubital fossa and Epicondyle tunnel
C. Cubital and Condylar tunnel
1.Condylar groove
• External compression against the posterior aspect of the medial
epicondyle of the elbow
• Less adipose padding M than F
2.Cubital tunnel
• Compression of the nerve distal to the condylar groove
• More likely the cubital tunnel is more developed
• M > F
• Worse with elbow flexed > 110 degrees
True or False: Women are more likely to experience ulnar nerve injuries
False!
Men have less adipose tissue and are therefore more likely to have external compression
In which positions does the CRNA know more perfusion is going to the dependent lung and greater ventilation going to the non-dependent lung causing a V/Q mismatch in the ASLEEP patient? (Select all that apply)
A. Supine
B. Prone
C. Sitting
D. Lateral Decubitus
Sorry it was just one hehe
D. Lateral decubitus (V/Q asleep< paralyzed < open chest)
no V/Q mismatch is seen while the patient is awake due to increased ventilation related to the stretch of the diaphragm
As a rule of thumb, you do not want any joints extended or flexed passed ____ degrees
A. 30
B. 60
C. 90
D. 50
C. 90
Shoulder shouldn't be abducted more than 90 to prevent brachial plexus injury
Elbow should not be bent more than 90 to prevent an ulnar nerve injury
ankle should not be extended more than 90 in prone position
Match the nerve injury with the signs and symptom
I couldn't get it to format here so this is the link to the matching
https://www.flexiquiz.com/SC/N/fce7187c-7614-4b34-ba2c-141e39eb2e9f
What is the second most commonly injured peripheral nerve? (HINT: characterized by sensory and motor deficits in the arm)
A. Axillary
B. Median
C. Brachial Plexus
D. Radial
C. Brachial plexus
Non-cardiac surgery: Painless motor deficits in the upper & middle nerve roots (median & radial nerves)
Cardiac surgery: Sensory deficits in the lower nerve root (ulnar)
What is the most frequent positioning complication when the surgical access site is above the head?
Venous Air Embolism
ie. craniotomy and central line placment
Maintain venous pressure > 0 at the wound
Which positioning is associated with retinal ischemia (select all that apply)
A. Reverse trendelenburg
B. Prone
C. Lithotomy
D. sitting
B and D
Incorrect:
A. Reverse trendelenburg (associated with VAE)
C. Lithotomy (associated with compartment syndrome, alopecia, and digit amputation)
This is a common injury with prone positioning that is confirmed with Fluorescein.
A. ischemic optic neuropathy
B. ischemia d/t prolonged tourniquet time
C. Cubital tunnel entrapment
D. Corneal abrasion
D. Corneal abrasion
Usually on 16% permanency
Characterized by burning, pain, and photophobia.
Requires an ophthalmology consult. Often treated with eye drops
Sort the following position based on how they will affect FRC, ICP/IOP and CO/Preload (*Note some position have minimal effect on a system and therefore are not listed)
↑ FRC ↑IOP/ICP ↑ CO/ Preload ↓ FRC ↓ICP/IOP ↓CO/ Preload
Supine, Trendelenburg, Reverse Trendelenburg, Lithotomy, Prone, Lateral Decubitus, Sitting
↑ FRC: reverse Trendelenburg, Sitting
↑IOP/ICP: Trendelenburg, Prone
↑ CO/ Preload: Lithotomy
↓ FRC: Supine, Trendelenburg, Lithotomy, Prone, Lateral Decubitus
↓ICP/IOP: reverse Trendelenburg, Sitting
↓CO/ Preload: Trendelenburg, reverse Trendelenburg, Prone, Sitting
What nerve is commonly injured d/t compression by NIBP cuff, IV placement, or arm slipping off the table? (HINT: you will see a wrist drop)
A. Radial nerve
B. Ulnar nerve
C. Axillary nerve
D. Median nerve
A. Radial Nerve
External compression as it traverses the spiral groove of the humerus in the lower third of the arm
The CRNA is asked to position the patient in reverse trendelenburg. The patient has an a-line.
True or False: The CRNA should leave the transducer at the phlebostatic axis
False: it should be moved to the circle of Willis since the pt will experience decreased cerebral perfusion pressure and blood flow
*Note this should also be done with sitting position
Air embolism can result from which positions? (Select all that apply)
A. Trendelenburg
B. Reverse Trendelenburg
C. sitting
D. Prone
B, C, and D
A. trendelenburg = associated with alopecia
When positioning a patient in lithotomy, the CRNA knows the correct technique is:
A. abduct the legs and raise them to place them into the stirrups at the same time
B. bring the legs to midline and raise them to place them in the stirrups one at at time
C. abduct the legs and raise them to place them into the stirrups one at a time
D. bring the legs to midline and raise them to place them in the stirrups at the same time
D. bring the legs to midline and raise them to place them in the stirrups at the same time
When taking the patient out of lithotomy the procedure is reversed
Not a matching I just didn't have enough slots:
Choose the Risk factors that increase risk of perioperative ulnar neuropathy:
A. cardiac sx
B. extreme body habitus
C. male
D. outpatient surgery
E. female
F. Prolonged hospital stay
G. youth
H. regional anesthesia
A, B, C, and F
Your patient with HTC, DM, CAD, and tobacco use presents for spinal surgery, which requires them in the prone position. Which of the following are possible complications from the prone position?
A. Ischemic optic neuropathy
B. Negative pressure pulmonary edema
C. Facial and scleral edema
D. All of the above
D. all of the above!!
A. Ischemic optic neuropathy (pt history put them at higher risk for this)
B. Negative pressure pulmonary edema (Compression of the abdomen and thoracic cage ↓ total lung compliance & increases the work of breathing with spontaneous ventilation)
C. Facial and scleral edema (Extreme head rotation may obstruct the jugular veins & vertebral arteries leading to ↓ cerebral venous drainage ↓ cerebral blood flow)