Position: Trendelenburg, arms tucked
Time: 2-4 hours (long)
Blood Loss: High (200 – 500 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: Yes

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

High Blood Loss (general considerations): Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.

[/if 126]

Trendelenburg Position (general considerations): Take precautions for upper airway obstruction or stridor. Avoid excessive fluid administration. OG tube is a good consideration to empty the contents of the stomach. Regurgitation of stomach contents can ulcerate the airway and/or damage the eyes. Consider throat packs and/or eye lubrication to further protect the patient. Brachial nerve injury is also a strong possibility. Be very careful with head and shoulder brace positioning. Peroneal nerve injury is a strong possibility if the patient is also in the lithotomy position. Make sure pressure points are padded. If there’s peroneal nerve damage, it will manifest as foot drop. Increased IOP. Take precaution with patients that have glaucoma. Conjunctival swelling will sometimes be irritating to the patient post-operatively. Keep reminding the patient not to rub their eyes. Increased ICP. Cerebral perfusion pressure = MAP-ICP. Make sure you keep the MAP up.

Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.