VIII. Positioning
A. Patients with heavy beards may be difficult
to tape ET tubes to. Obtain the patient's
permission for shaving before induction.
B. In the period of time between induction and
positioning, the depth of anesthesia is likely
to become very light. This is especially true
if lines are placed after induction rather than
before. Subsequent movement of the patient or
application of head pins is likely to elicit
bucking and/or hypertension. A large dose of
vecuronium at induction will carry through this
period of time. Even this amount of vecuronium
will wear off in time for EMG monitoring.
1. An option for preventing this response is
deepening the anesthesia with a bolus of
thiopental. Sometimes the surgeon is
moving so fast that this is your only
choice. Fentanyl takes at least 3 minutes
to take effect; volatile anesthetics are
also slow. A dose of around 200mg to 300mg
is usually adequate.
2. Another method for preventing the blood
pressure change with head pin placement is
to infiltrate the scalp under the pins
with local anesthetic as discussed
earlier. Use a 20 gauge needle. It is very
easy to stick the surgeon with the needle.
Insert the needle all the way to the
skull, then inject while withdrawing.
Allow a full minute for the anesthetic to
work prior to applying the head pins. Some
institutions use lidocaine and others use
bupivicaine. If the patient is very light,
he may react violently to just the pain of
the needle.
3. Moving the patient can cause movement of
the endotracheal tube. This stimulation
may result in either bucking or hypertension.
4. Treating the hypertension resulting from
head pin placement with thiopental can wipe
out neurophysiologic monitoring. For spine
cases, especially those involving unstable
spines and spinal stenosis, this can be a
problem. It has necessitated wake-up tests
prior to the start of surgery. Suspicion
is cast on the intubations as causing a C-
spine injury.
C. Before trying to move the patient, make sure
that the hand in which the A-line was started
is not taped down.
D. Location of lesion and patient position.
E. Prone Positioning
1. The patient is induced on the gurney and
then rolled onto the OR table. Arrange the
draw sheet on the OR table prior to
rolling so that the sheet may be used for
arm tucking in the final position.
a. The arms are tucked at the sides for
C-spine and occipital surgery. The
arms are forward in a swimming postion
for lumbar surgery.
2. Place EKG pads on the back so that they
will be on the up side after the flip.
Lines often end up underneath the patient
after the flip.
3. If a prone pillow is used instead of pins
or a horseshoe, place the prone pillow on
the face prior to the roll with the ET
tube protruding through it. Also place any
electrodes on the face for twitch
monitoring at this time.
4. If they are not working on the posterior
C-Spine, place the tape all the way around
the head
a. Use the tongue depressor trick for
handling the tape.
b. Consider Tegaderm to make the tape
waterproof.
5. Arrange all lines to come over the top of
the head prior to the flip, especially the
EKG lines.
6. Put the patient on 100% O2 prior to the
flip when going to the prone position in
case the ET tube comes out with the turn.
a. When making the turn, place one arm
well under the face down to the neck
and the other arm over the top of the
head and to the neck. Move this as a
unit.
b. The surgeon controls the turn if the
patient has an unstable C-Spine or if
the head pins are on before the flip.
7. Check eyes, ears, penis, breasts after the
turn.
a. The foley may get kinked or dragged
down into the penile urethra and
function only partially, making it
appear that the patient is
hypovolemic. Suspect this if mannitol
has little or no effect on the urine
output. Also consider this if only a
small amount of dilute urine comes
out.
8. Anchor the ET tube to the head pin holder
9. Place lines is arm closest to the OR table
( as the patient lies on the OR table).
Arrange all lines to come over the top of
the head prior to the flip, especially the
EKG. Those lines in the arm closest to the
OR table can dangle between the OR table
and the gurney prior to the flip.
10. Place twitch monitor pads on the face
prior to the flip.
F. Lateral position
1. drag up the table - put pt on his side -
place the Axillary roll - pillow between
the knees.
G. Lawn chair position
H. Sagita position
1. Basically a lateral position with the down
arm off the end of the table rather than
coming toward the anesthesiologist.
2. The down arn is off the end of the table
resting on the head pins. Supplement with
an armboard and eggcrate.
I. Suboccipital craniectomy
1. Lateral position with Ax roll, knee
pillow, taped to table.
2. Check the stretch on the brachial plexus.
Moving the shoulder foward takes the
tension off the brachial plexus.
3. Two fingers should fit between the
mandible and the clavicle.
J. Sitting Position
1. Transducer at ear level
2. air emboli and CV instability
a. Maintain the CVP (?colloid or Neo)
3. don't flex bed after head pins are in
4. Don't attach the ET tube to an IV pole
5. Doppler: at RSB in 3rd-4th ICS but really
end up putting it where it will work
6. Inject through the central line when you
test as injecting peripherally may not
work. The noise can be a result of
turbulence as well as air.
7. Checks for correct positioning
8. Times during surgery most likely to result
in emboli
a. posterior neck muscles dissected
b. bone excised
c. vascular tumor bed entered
K. If the patient appears to be hypertensive after
he has been moved from one table to another,
glance at the transducer any make sure it has
not fallen to the floor.
Maintenance