The Hemodynamic Management of 5177 Neurosurgical and Orthopedic Patients Who Underwent Surgery in the Sitting or “Beach Chair” Position Without Incidence of Adverse Neurologic Events

Pin-on, Pathomporn; Schroeder, Darrell R.; Munis, James R.

doi:10.1213/ane.0b013e31828446bb

Cited by 22 publications

(12 citation statements)

References 25 publications

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“…The intraoperative mean arterial pressure (MAP) of that population was maintained at approximately 75mmHg or greater. 23 However, the interpretation of this value is problematic because cerebral autoregulation is attenuated (CBF becomes more dependent on systemic blood pressure) with a wide range of MAP at the lower limit of autoregulation 24 during anesthesia in the beach chair position. Until the lower limit of autoregulation can be routinely monitored, blood pressure control alone cannot be assumed sufficient to protect patients from neurological injury during anesthesia in the beach chair position.…”

Section: Discussionmentioning

confidence: 99%

Influence of Ventilation Strategies and Anesthetic Techniques on Regional Cerebral Oximetry in the Beach Chair Position

et al. 2015

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Background Beach chair positioning during general anesthesia is associated with cerebral oxygen desaturation. Changes in cerebral oxygenation resulting from the interaction of inspired oxygen fraction, end-tidal carbon dioxide and anesthetic choice have not been fully evaluated in anesthetized patients in the beach chair position. Methods This was a prospective interventional within-group study of patients undergoing shoulder surgery in the beach chair position that incorporated a randomized comparison between two anesthetics. Fifty-six patients were randomized to receive desflurane or total intravenous anesthesia with propofol. Following induction of anesthesia and positioning, inspired oxygen fraction (Fio2) and minute ventilation were sequentially adjusted for all patients. Regional cerebral oxygenation (rSO2) was the primary outcome and was recorded at each of five set points. Results While maintaining Fio2 at 0.3 and end tidal carbon dioxide (PETCO2) at 30mmHg there was a decrease in rSO2 from 68%, SD 12 to 61%, SD 12 (p<0.001) following beach chair positioning. The combined interventions of increasing Fio2 to 1.0 and increasing Petco2 to 45mmHg resulted in a 14% point improvement in rSO2 to 75%, SD 12 (p <0.001) for patients anesthetized in the beach chair position. There was no significant interaction effect of the anesthetic at the study intervention points. Conclusions Increasing Fio2 and Petco2 resulted in a significant increase in rSO2 that overcomes desaturation in patients anesthetized in the beach chair position and that appears independent of anesthetic choice.

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Section: Discussionmentioning

confidence: 99%

Influence of Ventilation Strategies and Anesthetic Techniques on Regional Cerebral Oximetry in the Beach Chair Position

et al. 2015

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“…Arterial hypotension is commonly reported in procedures performed in this surgical setting, which has been reported to produce ABP decreases of 20% in an extensive study including 5177 patients undergoing neurosurgery and orthopaedic surgeries. 50% of these patients experienced severe hypotension defined as an ABP decrease ≥ 40% relative to pre-operative values [43]. In another study including 4169 shoulder surgery procedures, 47% of patients presented hypotension defined as an ABP < 66 mm Hg or a decrease > 30% from pre-anaesthesia values.…”

Section: Discussionmentioning

confidence: 99%

Cerebrovascular assessment of patients undergoing shoulder surgery in beach chair position using a multiparameter transcranial Doppler approach

Cardim

Robba

Matta

et al. 2018

J Clin Monit Comput

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Although the beach-chair position (BCP) is widely used during shoulder surgery, it has been reported to associate with a reduction in cerebral blood flow, oxygenation, and risk of brain ischaemia. We assessed cerebral haemodynamics using a multiparameter transcranial Doppler-derived approach in patients undergoing shoulder surgery. 23 anaesthetised patients (propofol (2 mg/kg)) without history of neurologic pathology undergoing elective shoulder surgery were included. Arterial blood pressure (ABP, monitored with a finger-cuff plethysmograph calibrated at the auditory meatus level) and cerebral blood flow velocity (FV, monitored in the middle cerebral artery) were recorded in supine and in BCP. All subjects underwent interscalene block ipsilateral to the side of FV measurement. We evaluated non-invasive intracranial pressure (nICP) and cerebral perfusion pressure (nCPP) calculated with a black-box mathematical model; critical closing pressure (CrCP); diastolic closing margin (DCM—pressure reserve available to avoid diastolic flow cessation); cerebral autoregulation index (Mxa); pulsatility index (PI). Significant changes occured for DCM [mean decrease of 6.43 mm Hg (p = 0.01)] and PI [mean increase of 0.11 (p = 0.05)]. ABP, FV, nICP, nCPP and CrCP showed a decreasing trend. Cerebral autoregulation was dysfunctional (Mxa > 0.3) and PI deviated from normal ranges (PI > 0.8) in both phases. ABP and nCPP values were low (< 60 mm Hg) in both phases. Changes between phases did not result in CrCP reaching diastolic ABP, therefore DCM did not reach critical values (≤ 0 mm Hg). BCP resulted in significant cerebral haemodynamic changes. If left untreated, reduction in cerebral blood flow may result in brain ischaemia and post-operative neurologic deficit.

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“…29,30 In a retrospective analysis from a single institution there were no strokes in 5177 patients undergoing either orthopedic or neurological surgery in the BCP. 31 Researchers have speculated that hemodynamic changes associated with head elevation and anesthesia may result in inadvertent cerebral hypotension when anesthesiologists fail to consider the gravitational effects of head elevation on cerebral perfusion. 12,13 That is, when blood flows vertically, blood pressure decreases proportionally to the weight of the column of blood.…”

Section: Discussionmentioning

confidence: 99%

Shoulder Surgery in the Beach Chair Position Is Associated with Diminished Cerebral Autoregulation but No Differences in Postoperative Cognition or Brain Injury Biomarker Levels Compared with Supine Positioning

Laflam¹,

Joshi

Brady

et al. 2015

Anesthesia &Amp; Analgesia

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Background Although controversial, failing to consider the gravitational effects of head elevation on cerebral perfusion is speculated to increase susceptibility to rare, but devastating, neurologic complications after shoulder surgery in the beach chair position (BCP). We hypothesized that patients in the BCP have diminished cerebral blood flow autoregulation than those who undergo surgery in the lateral decubitus position (LDP). A secondary aim was to examine whether there is a relationship between patient positioning during surgery and postoperative cognition or serum brain injury biomarker levels. Methods Patients undergoing shoulder surgery in the BCP (n=109) or LDP (n=109) had mean arterial blood pressure (MAP) and regional cerebral oxygen saturation (rScO2) monitored with near-infrared spectroscopy. A continuous, moving Pearson’s correlation coefficient was calculated between MAP and rScO2, generating the variable cerebral oximetry index (COx). When MAP is in the autoregulated range, COx approaches zero because there is no correlation between cerebral blood flow and arterial blood pressure. In contrast, when MAP is below the limit of autoregulation, COx is higher because there is a direct relationship between lower arterial blood pressure and lower cerebral blood flow. Thus, diminished autoregulation would be manifest as higher COx. Psychometric testing was performed before surgery and then 7–10 days and 4–6 weeks after surgery. A composite cognitive outcome was determined as the Z-score. Serum S100β, neuron-specific enolase, and glial fibrillary acidic protein were measured at baseline, after surgery, and on postoperative day 1. Results After adjusting for age and history of hypertension, COx (p=0.035) was higher and rScO2 lower (p<0.0001) in the BCP group than in the LDP group. After adjusting for baseline composite cognitive outcome, there was no difference in Z-score 7 to 10 day (p=0.530) or 4 to 6 weeks (p=0.202) after surgery between the BCP and the LDP groups. There was no difference in serum biomarker levels between the 2 position groups Conclusions Compared with patients in the LDP, patients undergoing shoulder surgery in the BCP are more likely to have higher COx indicating diminished cerebral autoregulation and lower rScO2. There were no differences in the composite cognitive outcome between the BCP and LDP groups after surgery after accounting for baseline Z-score.

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The Hemodynamic Management of 5177 Neurosurgical and Orthopedic Patients Who Underwent Surgery in the Sitting or “Beach Chair” Position Without Incidence of Adverse Neurologic Events

Cited by 22 publications

References 25 publications

Influence of Ventilation Strategies and Anesthetic Techniques on Regional Cerebral Oximetry in the Beach Chair Position

Influence of Ventilation Strategies and Anesthetic Techniques on Regional Cerebral Oximetry in the Beach Chair Position

Cerebrovascular assessment of patients undergoing shoulder surgery in beach chair position using a multiparameter transcranial Doppler approach

Shoulder Surgery in the Beach Chair Position Is Associated with Diminished Cerebral Autoregulation but No Differences in Postoperative Cognition or Brain Injury Biomarker Levels Compared with Supine Positioning

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