CARDINAL SANTOS MEDICAL CENTER

Department of Anesthesiology and Pain Medicine

Section of Neuroanesthesiology
Prepared by: Eduardo A. Barrenechea II, MD

Learning Outcome:
Anesthesiologists will be able to describe the physiologic and anatomic implications of placing
an anesthetized patient in the prone position, and they will be able to identify the risks and
benefits of such a position during neurosurgery. Likewise, they will be able to contribute to the
decision-making process in determining the best position for a patient who is about to undergo
a neurosurgical procedure, while mitigating the risks and maximizing the benefits of the said
position.

Learning Objectives:
1. To be able to describe the physiologic and anatomic implications of the prone position
in an anesthetized patient
2. To be able to enumerate the risks associated with placing a patient in the prone position
3. To be able to enumerate the advantages of placing a patient in the prone position
during neurosurgery, compared to the sitting position
4. To be able to define the indications for placing a patient for neurosurgery in the prone
position
5. To be able to identify the common complications associated with placing a patient in the
prone position and how to initially manage these said complications

Post-Lecture Questions:
1. In an anesthetized patient in the classic prone position, which of the following should you
ensure as you place the patient in his final optimal position prior to initiation of surgery?
A. A pillow is placed on the anterior thorax to address the pressure points
B. The ventral abdominal wall should be free from compression
C. The legs should be below the level of the heart to ensure venous drainage
D. The optimal head level is always below the level of the heart

2. The classic prone position entails all of the following EXCEPT:

A. Head resting on a C-shaped pad/gel with the eyes and ears snuggly compressed
against the gel to ensure no movement
B. Arms tucked closely to the torso to prevent movement and padded accordingly
C. Legs are bent at the knees for a more physiologic position
D. Chest rolls are placed parallel to the torso

3. In a 45 year old male patient who underwent posterior fossa surgery for 12 hours in the
prone position, post-operative blindness was noted in the Neurosurgical intensive care
unit. Patient was noted to have no light perception during a focused neurologic exam.
Which of the following contributed to this condition?
 A. Frequent hypertensive spikes during the surgery particularly during extensive
surgical manipulation
B. The presence of conjunctival edema from hypervolemia
C. Estimated blood loss of 300 cc (when the allowable blood loss was 1400 cc)
D. Male sex of the patient

4. A morbidly obese patient is currently undergoing elective suboccipital craniectomy with

excision of cerebellar glioma in the prone position. Intraoperatively, the surgeon notes
that hemostasis is difficult with some of the cerebral sinuses distended. As the
neuroanesthesiologist in charge, which of the following maneuvers will help?
A. Placing the patient in the Trendelenburg position to remove the blood from the
surgical field
B. Hyperventilating the patient to induce vasoconstriction
C. Adjusting the pillows to free up the abdomen
D. Permissive hypotension

5. In positioning the transducer for the invasive arterial blood pressure monitor (A-line), at
what level should you place it, relative to the patient, to get the most accurate
measurement intraoperatively:
A. At the level of the right atrium
B. At the level of the Circle of Willis
C. At the level of the needle insertion site
D. At a fixed level three feet from the ground