ANESTHESIA

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:

1. The technique should anesthetize

not only the operative field but also all the
areas involved in the surgery (e.g., site of
tourniquet placement, sites where skin or
bone grafts are to be taken)
 Several factors have to be taken
into consideration:

2. The adequacy of the duration of

the sensory block with the expected
duration of postoperative pain
3. The physical condition of the
patient
 Several factors have to be taken
into consideration:

4. The local conditions at the site of

puncture
5. The suitability of the position
required for performing the block
according to the lesions and/or the
physical condition of the child
 Several factors have to be taken
into consideration:

6. The similar importance of

anesthetic and surgical techniques (under
normal conditions, central blocks have to
be avoided for minor surgery)
7. The experience of the
anesthesiologist
 General Anesthesia
 General anesthesia remains the most widely
used anesthetic technique because of its
popularity with patients, surgeons, and
anesthesiologists
 Anesthesiologist must consider:
1. the recovery characteristics of the
anesthetics
2. the management of postoperative pain
and nausea/vomiting when making the
anesthesia plan.
 General Anesthesia
 BENZODIAZEPINES
 OPIOIDS
 MUSCLE RELAXANT (non-depolarizing)
 LIDOCAINE
 BARBITURATES
 MUSCLE RELAXANT (depolarizing) –
intubating dose
 General Anesthesia
 INGALED ANESTHETICS
1. HALOTHANE
2. ISOFLURANE
3. ENFLURANE
4. DESFLURANE
5. SEVOFLURANE
6. METHOXYFLURANE
 RATIONALE FOR THE USE OF
EPIDURAL AND SPINAL
ANESTHESIA
1. Metabolic and endocrine alterations
2. Blood loss
3. Thromboembolic complications
4. Cardiopulmonary complications
 Continuous epidural analgesia
for postoperative pain relief
 ANATOMY
Bony structures
Ligaments
Epidural space – located between
the ligamentum flavum and the
dura mater
Subdural space
Subarachnoid space
 PATIENT EVALUATION AND
PREPARATION FOR EPIDURAL
AND SPINAL ANESTHESIA
 Physical examination of the back and
history of back problems
 Coagulation profile
 Explanation of technique and perceived
advantages
 Description of the forms of sedation
available
 Tailor preoperative medication to level of
anxiety and need for analgesia
CONTRAINDICATIONS FOR
EPIDURAL AND SPINAL
ANESTHESIA
ABSOLUTE CONTRAINDICATIONS
1. Patient refusal
2. Infection at the puncture site
3. Uncorrected hypovolemia
4. Severe coagulation abnormalities
5. Anatomic abnormalities
CONTRAINDICATIONS FOR
EPIDURAL AND SPINAL
ANESTHESIA
RELATIVE CONTRAINDICATIONS
2. Bacteremia
3. Preexisting neurologic disorders
(multiple sclerosis)
4. Minidose heparin
 TECHNICAL ASPECTS
LANDMARK:

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.

Padding over bony prominence, chest roll to protect

neurovascular bundle in the axilla, and proper alignment
of cervical spine
FLEXED LATERAL
DECUBITUS POSITION. The
point of flexion lies beneath the
dependent iliac crest to
minimize interference with the
dependent lung and diaphragm.
 FLEXED LATERAL
DECUBITUS POSITION
The LAWN CHAIR
POSITION with flexion of
the hips, minimal knee
flexion, and trunk section
level.
LAWN CHAIR
POSITION
Brachial plexus in relation to
surrounding structures. (A) arm at
side: 1. Brachial plexus. 2. Clavicle, 3.
Coracoid process, and 4. Head of
humerus. (B) arm at right angle. (C)
arm hyperextended by shoulder brace,
depresses scapula, streching brachial
plexux beneath coracoid process and
around humeral head.
Flexing, then raising of the legs
for the lithotomy position
Holding the leg and stirrups for
final positioning
Final lithotomy position showing
the leg placement
Lithotomy position with less hip
flexion for endoscopic
procedures e.g. TURP
 Lithotomy with hip
flexion slightly greater
than 90 degrees
Legs do not touch
support poles
Straps use instead of stirrups
Risk to fingers when
the lower portion of
the operating table
is lowered
The lateral position showing upper arm
rest in position; axillary roll, which
support the chest to free the axilla and 1
type of leg positioning
 The lateral
decubitus
position for
thoracotomy,
showing
more
headward
position of
the arms to
facilitate
surgical
exposure
Movement
of the
patient
from the
supine to
lateral
position
Movement
of the
patient
from the
supine to
lateral
position
Movement
of the
patient
from the
supine to
lateral
position
Movement
of the
patient
from the
supine to
lateral
position
 The lateral oblique position ( three-
quarters prone). The axillary roll is
placed under the chest, and the lower
shoulder is brought forward to the edge
of the bed or just slightly over the edge
 Femoral neck
fracture can be
managed in the
supine position on
the fracture table
For midfemoral fracture, the patient is placed
on the fracture table in the lateral position,
with the legs spaced and positioned to allow
xray at an angle in several planes
 Lateral view of upright
shoulder position. The
endotracheal tube and head are
secured to prevent movement
and accidental extubation
 Arrangement for surgery in the sitting position.
The scrub nurse is to the right of the surgeon to
place the instruments into the surgeon’s right
hand. The entire left side of the patient is available
for the anesthesiologist’s care
 The patient is in semisitting position with the
knees flexed slightly. The headrest support is
fastened to the upper part of the table so that
the head can be lowered without changing the
relationship of the pinion head holder to the
torso. Arms must be supported and buttocks
padded.
The head can slip while in the horseshoe
headrest, and pressure may develop in
the eye owing to the weight of the head
GOOD DAY !!!