Академический Документы
Профессиональный Документы
Культура Документы
AND
POSITIONING
by:
JOVEN A. OCCEÑA, MD.
Anesthesia Chief Resident
DAVAO REGIONAL HOSPITAL
ANESTHESIA
OBJECTIVES
CONSIDERATIONS:
1. Quality
2. Safety
3. Efficiency
4. Cost of drugs
5. Equipment
Anesthetic should:
1. have a rapid and smooth onset
of action
2. produce intraoperative
amnesia and analgesia
3. good surgical conditions with a
short recovery period
4. no side effects.
Standard intraoperative
monitoring equipment
includes:
A. precordial stethoscope
B. electrocardiogram (ECG)
C. blood pressure cuff
D. pulse oximeter
E. capnograph
Several factors have to be taken
into consideration:
VERTEBRAL SPINAL
PROCESSES (MIDLINE)
ILIAC CREST
( A LINE DRAWN BETWEEN
THE CRESTS CROSSES L4)
EPIDURAL ANESTHESIA
17 or 18 gauge tuohy needle (curved
Huber point)
Loss of resistance technique
Catheter placement
Test dose = 3-4cc local anesthetic +
1:200,000 epinephrine
SPINAL ANESTHESIA
Midline approach
Paramedian or lateral approach
The Taylor approach
Continuous spinal anesthesia
PHYSIOLOGIC EFFECTS OF
SPINAL AND EPIDURAL
ANESTHESIA
A. Spinal anesthesia
1. Sympathetic nervous system
blockade
2. Cardiovascular system
a) Bradycardia
b) Venodilation
c) Decreased blood pressure
PHYSIOLOGIC EFFECTS OF
SPINAL AND EPIDURAL
ANESTHESIA
A. Spinal anesthesia
3. Respiratory system
4. Renal system
5. Gastrointestinal system
PHYSIOLOGIC EFFECTS OF SPINAL
AND EPIDURAL ANESTHESIA
B. Epidural anesthesia
1. Hemodynamic effects
a. Level of anesthesia (above T5)
b. Systemic absorption of local anesthetic
c. Inclusion of epinephrine (B1 and B2 effects)
d. Intravascular fluid volume
e. Cardiovascualr status of the patient
2. Effects on regional blood flow
PHARMACOLOGIC
CONSIDERATIONS
B. Spinal anesthesia
1. Selection of a specific local anesthetic
A. Hyperbaric lidocaine
B. Hyperbaric tetracaine
C. Isobaric bupivacaine
PHARMACOLOGIC
CONSIDERATIONS
B. Spinal anesthesia
2. Factors that influence distribution of
local anesthetics in the CSF
A. Baricity of the local anesthetic
solution
B. Shape of the spinal canal
C. Position of the patient
D. Vasoconstrictors
B. Epidural anesthesia
1. The quality of epidural anesthesia is
determined by several factors:
A. Local anesthetic selected
B. Mass of the drug injected
C. Addition of epinephrine
D. Site but not speed of injection or
patient position
E. Patients >40 yrs of age
F. Pregnancy
COMPLICATIONS OF SPINAL
AND EPIDURAL ANESTHESIA
SPINAL
1. Hypotension
2. Postdural puncture headache
i. Postural component
ii. Frontal or occipital
iii. Tinnitus
iv. Diplopia
v. Young females
vi. Use of large gauge needle
COMPLICATIONS OF SPINAL
AND EPIDURAL ANESTHESIA
SPINAL
3. Extensive spread of spinal anesthesia
i. Agitation
ii. Hypotension
iii. Nausea
iv. Absent intercostal muscle function
v. Inadequate air movement to generate
an audible voice
4. Backache
5. Major neurologic injury or infection
COMPLICATIONS OF SPINAL
AND EPIDURAL ANESTHESIA
EPIDURAL
1. Toxicity due to local anesthetics
i. Site of injection
ii. Total dose
iii.Vasoconstrictor
iv.Pharmacologic profile of
local anesthetic
COMPLICATIONS OF SPINAL
AND EPIDURAL ANESTHESIA
EPIDURAL
2. Technique related complications:
1) Hypotension
2) Accidental Subdural or
subarachnoid injection
3) Dural puncture and postdural
headache
4) Neural damage
5) Catheter complications
POSITIONING
THE SURGICAL
PATIENTS
OBJECTIVES
PROPER LITHOTOMY
POSITION: minimal
external rotation of legs,
thighs minimally flexed
toward abdomen,
symmetrical position of legs.
Protective paddings not
shown.
CLASSIC PRONE POSITION with
arms extended next to head (A), or
alongside torso (B). Chest roll placed
below clavicle and pillow under iliac
crest to along abdomen to hang free.
The table is flexed to a variable degree
depending on the lumbar lordosis and
the needs of the surgeon. With flexion, a
subgluteal anchor is needed to prevent
caudal slippage of the patient.
CLASSIC PRONE
POSITION
The ANDREWS FRAME,
which supports the chest and
buttocks, with the knees
padded. The knees are never
flexed more than 90 degrees
on the thighs.
ANDREWS FRAME
Methods of avoiding excessive turning
of the head in the prone position, A, B,
and C are acceptable. Extreme rotation
of the neck (D) may be dangerous in
patients with cervical spine disease or
cerebrovascular disease. The eyes
themselves must be free from pressure,
since pressure on the globe may reduce
flow in the retinal vessels enough to
produce permanent retinal blindness.
NEUROSURGICAL SITTING
POSITION. The legs are slightly flexed
and raised to the level of the heart. The
feet are padded to maintained a
dorsiflexed position. The sciatic nerve
is protected by gluteal padding. The
framed of the head holder is clamped
to the back section of the table so that
the patient head’s head can be lowered
in case of air embolism.
NEUROSURGICAL
SITTING POSITION
The RIGHT LATERAL
DECUBITUS POSITION. (Above)
inadequate padding and improper
head position. (Below) Padding
over bony prominence, chest roll to
protect neurovascular bundle in
the axilla, and proper alignment of
cervical spine. The lower leg is
flexed to stabilized the patient.
inadequate padding and improper
head position.