Intraoperative Prevention of Injury
Intraoperative Prevention of Injury
Should be closed and taped shut to prevent drying. Taping the eyes shut will also prevent the eye from being scratched when performing routine anesthesia care around the face. When working around the eye with an anesthesia mask or during intubation, care must be taken to avoid contact with the patient's eyes. Scratches to the eye or drying can lead corneal abrasions. A corneal abrasion is a very uncomfortable and avoidable complication. Avoid placing pressure on the eye. Prolonged pressure can lead to the catastrophic complication of blindness. Pressure to the eyes must be avoided when the patient is positioned prone.
The facial nerves are close to the surface of the skin and can be easily damaged by pressure from hands, anesthesia mask, and straps. This may result in damage or paralysis to a portion of the face.
Ensure that there is not excessive pressure on any one area of the body. Ensure that pressure points are padded. Too much pressure will lead to a decrease in blood flow and may cause pressure sores. This is especially important over bony areas and areas with cartilage. Bony areas that deserve special attention include heels, ankles, elbows, hips, lower back (sacrum), and knees. Cartilaginous areas that deserve attention include the nose and ears. If the patient is positioned in a lateral decubitus position check the down ear.
Lips, Teeth, and Tongue
Are vulnerable to injury when performing laryngoscopy and during the insertion of an oral airway. When performing a preoperative assessment, check for loose teeth. This will help avoid the accidental removal of a loose tooth when performing laryngoscopy, intubation, and/or placement of an oral airway. Laryngoscopy and insertion of an oral airway must be gentle and not forced. Ensure that the tongue is not caught between the oral airway and the endotracheal tube.
Should be positioned at the patient's side. The patient's arms should be less than 90 degrees, if positioned on an arm board. If greater than 90 degrees, trauma to the brachial plexus, a large nerve which supplies the upper extremities, may occur due to stretching.
If a single arm or both arms are positioned above the head of the patient, damage may occur to the brachial plexus and axillary nerve. The damage caused may result in the patient not being able to raise their arm, as well as decreased skin sensation over the outer aspect of the upper arm.
If the patient's head must be turned to one side for surgical reasons, it is important not to position the opposite arm out to the side. This will cause stretching of the brachial plexus. The opposite arm should be placed at the side of the patient, padded padded at the elbow, and secured so it does not fall off the edge of the operating room table.
The radial nerve should be protected. The radial nerve can be compressed against the outer aspect of the humerus. Avoid pressure at this site, as noted in the above illustration. Damage to the radial nerve will result in wrist drop.
The elbow should be well padded. Pressure may damage the ulnar nerve. This may result in hand weakness, numbness and tingling, and pain. It is important to ensure that the elbow is not hanging off the side of the bed. Pressure to the ulnar nerve can result in nerve damage. When the arms are at the side or positioned out to the side, the hands should be palm up (supinated) to decrease the risk of ulnar nerve compression (Figure3.7).
The sciatic nerve can be damaged by a tourniquet or by an improperly placed intramuscular injection. Trauma to the sciatic nerve will result in paralysis of muscle and absence of sensation below the knee. The legs should be positioned at the same time with external rotation and the knees slightly flexed. The common peroneal nerve can be damaged in the lithotomy position (legs up) if the outside of the knee is against a firm object, such as a brace or leg holder. This area should be padded. The proximal portion of the knee contains the saphenous nerve and should be padded if against a brace.
If used for a surgical procedure, a tourniquet should not be inflated for more than120 minutes (2 hours). Ischemic nerve damage can occur when a tourniquet is left elevated for more than 2 hours. The anesthesia provider should notify the surgeon every 30 minutes concerning the amount of time that has passed since the tourniquet was inflated. Tourniquets should be applied with a thin layer of padding. The tourniquet pressure should be set at two times the systolic blood pressure for lower limbs and 70-90 mmHg greater than the patients' systolic blood pressure for upper limbs. If excessive pressure is applied, trauma can occur to skin and nerves. If you do not have an air tourniquet and need to use a bandage for a tourniquet, it is important to use as wide a tourniquet as possible. The bandage should not have much elasticity. Elastic, rubber type bandages or an Eschmark may result in damage to nerves due to excessive pressure. The use of bandage type tourniquets should be discouraged. It is impossible to know the amount of pressure being applied to the tissue below it. There are two key points to remember when using tourniquets:
- Tourniquet application should not be longer than 120 minutes.
- Elastic, rubber type bandages should be avoided.