beach chair

Transcription

beach chair

LE RETOUR
de la position assise
en orthopédie
M a r i e - j o s é e n a d e a u
Av r i l 2 0 1 3
La position assise en
ORTHOPÉDIE
Abandonnée par plusieurs neurochirurgiens à
cause des complications associées
Correspondance avec l’expérience en
neurochirurgie?
Chirurgies de l’épaule
‣ Moins complexes
‣ Moins longues?
objectifs
Décrire la physiologie de la position assise
Énumérer les complications potentielles et les
considérations anesthésiques
Établir une conduite anesthésique en fonction des
recommandations
Changements
hemodynamiques
Diminution du retour veineux, du débit cardiaque
et de la pression de perfusion cérébrale
Effet de la gravité
Effets des anesthésiques
Effets de la ventilation mécanique
Réflexe de Bezold-Jarish
orthopédie
Chaise de plage modifiée
Arthroscopy: The Journal of Arthroscopic and Related Surgery 4(4):256-259
Published by Raven Press, Ltd. © 1988 Arthroscopy Association of North America
Shoulder Arthroscopy with the Patient in the
Beach-Chair Position
M i c h a e l J. S k y h a r , M . D . , D a v i d W . A l t c h e k , M . D . , R u s s e l l F . W a r r e n , M . D . ,
T h o m a s L . W i c k i e w i c z , M . D . , a n d S t e p h e n J. O ' B r i e n , M . D .
Summary: We evaluated the use of the beach-chair, or sitting, position for
orthopédie
Chaise de plage modifiée
Est préférée de plusieurs orthopédistes
Facilite l’approche chirurgicale
Facilite l’orientation anatomique
Facilite la conversion en approche ouverte
Diminue le risque de trauma neurovasculaire
la petite histoire de
l’anesthésie pour la
chirurgie
orthopédique en
position assise
1 La catastrophe
Journal of Clinical Anesthesia (2005) 17, 463 – 469
PATIENT
ATCD
TENSION
ARTÉRIELLE
DIAGNOSTIC POST-OP
♀47
∅
TAS 80-90
Infarctus cérébral
État végétatif permanent
Case report
DTEI
DLP
TAS 95-100
Réaction à la douleur
♂57
Cerebral ischemia during shoulder surgery in the
upright
position:
a caseTAS
series
∅
♂53
80-90
Dysfonctions permanentes
Andrea Pohl MD (Clinical Associate)a,b,
TAS
70-100 a,b,*
David
Chairman)
♀54J. Cullen MD,∅MS (Professor,
(NIBP au MI)
a
Infarctus médullaire
Décès
Department of Anesthesiology and Pain Medicine, Elizabeth’s Medical Center, Boston, MA 02135, USA
Tufts University School of Medicine, Boston, MA 02111, USA
b
Received 19 May 2004; accepted 8 September 2004
08
PAGE 83
La discussion
2 Pressure
fusion
Defined
g position generally. Among circulatory physioloedging, that the underlying physiology is not as
ts, the controversy
between adopting an open
straightforward or as intuitive as many of
us were
APSF NEWSLETTER Winter 2007-2008
PAGE
82
sus a closed model of the cerebral circulation is just
taught. Adding an extra level of complexity through
6
t: a controversy. I am not advocating an uncritical
BP “adjustments” that fail to acknowledge or even
Letter to the Editor:
eptance of the closed model, along with its implitake into account the basic physiological principles
ons for hemodynamic
monitoring.
Butof
I amPosture,
advo1. Quelle
est la
physiologie
de
la circulation
The
Problems
Pressure,
and
Perfusion
will
only obscure,
notcérébrale?
clarify, the eventual
above
ing that the anesthesia and monitoring
way in an awake patient sitting
measured in the sameanswer.
the “open” model is that we now have to distinguish
To the Editor:
in a preoperative clinic?
carefully, when we talk about “pressure,” between
mmunities acknowledge
and
address,
on
its
merits,
In the Summer 2007 APSF Newsletter, Cullen and
true perfusion pressure and transmural pressure. The
2.
Comment
prendre
en
charge
ces
patients?
James Munis,
MD, PhD
Regarding the methodology
of BP measurement,
cite a dramatic case of cerebral infarction during
uments forKirby
and
against
both
models.
In
this
practice of raising transducers to head level or making
the practice of “compensating” for arm BP cuff readshoulder surgery in the beachchair position. This case
numerical adjustments to BP cuff readings in a closed
Chair,
Division
of
Neuroanesthesia
ings in the sitting position extends back to 1954 when
1 of “right”
4 apparent cerebral
and/or
spinalvery
cord well
main, wherewas
the
answer
may
be
circulation model actually “adjusts” for something
that advice was first published by Enderby, and it has
infarctions presented as a series by Pohl and Cullen in
Assistant
Professor
of
Anesthesiology,
Physiology,
and
very different from perfusion
pressure—it adjusts
for
been followed uncritically ever since. The refinement
2005, as
from medico-legalimportant
reviews by one of to allow
nterintuitive,
itgleaned
is especially
transmural
pressure.
of Enderby’s advice inBiomedical
neurosurgical cases,
where the
the 2 authors (DJC).
Engineering
arterial line has largely supplanted the BP cuff,
Why does this matter? Because only perfusion
ysiology to lead
discussion.
Mostthe
anesthesia
professionals would not argue
Mayo
Clinic
Medicine
applies the same assumption
but by a College
different ofpressure,
not transmural pressure, is associated with
against maintaining blood pressure (BP) within a reamethod. Raising an arterial line transducer to head
flow. And flow is what we are interested in. An artersonably
close range
of preoperative
values during
any make BP
Every day in
almost
every
anesthetic,
we
MN
level accomplishes byRochester,
physical means the
same thing
ial line measurement can be used to estimate perfuanesthetic, in the sitting position or otherwise; nor
as making a numerical “correction” to a BP cuff readsion pressure only if both inlet and outlet pressures on
would I. But
prescriptions
acceptable BP managef measurements
and
infer for
something
about whole
ing. Both adjustments make an intuitive assumption
either side of the organ of interest are measured, and
References
ment should acknowledge the lack of relevant human
the head is in a compromised position for perfuonly if both pressures are referenced to the same level. By
dy perfusion.
That
amake
time-tested
empiricthat
reladata, and
shouldisalso
reference to methodologic
1. Cullen
DJ, Kirby
Beach chair
position
may
decrease
conventional
definition,
“perfusion
pressure”
is a
sion when it is in its (normal)
upright position
relative RR.
issues in assessing cerebral perfusion pressure (CPP).
gradient,
not
a
single
point
measurement
at
pressure
to
the
heart.
Implicit
in
that
assumption,
but
rarely
cerebral perfusion: catastrophic outcomes have occurred.
nship for which
we have
much
experience
and
As such, I would
like to point
out several
potential
only one place in a circuit. Making inferences about
stated explicitly, is a correlative assumption: that the
areas of controversy or ambiguity that may arise from
APSF
Newsletter
perfusion based on a transmural pressure reading at
cerebral
fluid
path where a 2007;22(2):25,27.
ch data. I am
not, of course, suggesting that
wecirculation is an “open”
E
I
R
O
É
TH
DU
N
O
SIPH
1
2
4
Parenthèse
Les théories sur la physiologie de la
circulation cérébrale
Chute d’eau
Siphon
Parenthèse
La théorie de la CHUTE D’EAU
La circulation est en circuit ouvert
Le sang «chute» du côté veineux et n’aide pas
la circulation artérielle
Le sang artériel doit vaincre la gravité
Parenthèse
La théorie du SIPHON
La circulation cérébrale est en circuit fermé
La force gravitationnelle est la même du côté
artériel et veineux
Pperfusion = Partérielle - Pveineuse
Aucun travail contre la gravité
(le sang du côté veineux «siphonne» le sang artériel)
Parenthèse
La théorie du SIPHON
Toute la circulation doit être en série
Veines non collabées
Aucune obstruction artérielle
08
PAGE 83
APSF NEWSLETTER Spring 2009
La discussion
2 Pressure
fusion
Defined
Goal Should Be to Avoid Harm
® physiolog position generally. Among circulatory
edging, that the underlying physiology is not as
ts, the controversy
between
anPreceding
open
intracranial
pressure,
andwere
head position
“Headadopting
Up,” From
Page
straightforward orregional
as intuitive
as many
of
us
APSF NEWSLETTER
Winter
2007-2008
PAGE
82
Such
anlevel
analysis
dictates measuring
blood pres
taught.
Adding
an
extra
of
complexity
through
head-up, anesthetized patients, what should we do
at the level
ofFoundation
the most vulnerable tissue (i.e.
t: a controversy.6 I am not advocating
The Official Journal of the Anesthesia Patient
Safety
www.apsf.organ uncritical
BP
“adjustments”
that
fail
to
acknowledge
even well w
for contemporary blood pressure measurement and
pressure
brain), and maintaining bloodor
eptance of the closed
model,
along
with would
its impliseem
appropriate
that
our
into
account
the
physiological
principles
take
Circulation
84,122
Volume 24,management?
No. est
1, 1-24 la It
Spring 2009
the basic
patient’s
normal
range
of blood press
1.
Quelle
physiologie
de
la
circulation
cérébrale?
ons for hemodynamic
monitoring.
Butof
I err
amPosture,
advopractices should
on
the side of providing
excesThe Problems
Pressure,
and
Perfusion
observed
while
unanesthetized.
This managem
will
only obscure,
not
clarify,
the eventual
above
sive blood
to non-critical
tissues,
and adeing that the anesthesia
andpressure
monitoring
philosophy is consistent with our historic role a
SPECIAL
EDITORIAL
answer.
o
patient sitting
measured in the same way in an awakeo
the
Editor:
To
APSF
NEWSLETTER
Spring
2009 in ato
PAGE
3
quate
blood
pressure
critical
tissues. Suchde
an perfusion
vulnerable
homeostatic
defens
2.
Comment
évaluer
la
pression
preoperative
clinic?
carefully, whenpatient’s
we cérébrale
talk about last
“pressure,”
between
and
address,
on
its
merits,
In the Summer
2007
APSF
Newsletter,
Cullen
and
Cerebral
Perfusion:
Err
on
the
Side
of
Caution
true perfusion
pressure
and transmural
pressure. The
has during
merit not because
wemethodology
have
proven
thatMD, PhD
James
Munis,
avoiding
injury
during
anesthesia
and surgery.
Regarding the
of BP measurement,
cite a dramatic case approach
of cerebral infarction
uments forKirby
and
against
both
models.
In
this
practice
of
raising
transducers
to
head
level
or
making
en
fonction
de
la
mesure
de
tension
artérielle?
the practice of
for arm BP cuff readposition.watershed
This case
shoulder surgery in the beachchair
a modified
of“compensating”
cerebral
circulation
As controversy
continues
regardingmodel
the hemodynamic
management
of patients
in the
head-up
or beach to
chair
BP cuff readings in a closed
numerical
Chair,
of Neuroanesthesia
extendsDivision
back to 1954 when
ings in the sitting position
William
L.isadjustments
Lanier,
MD
1
of
4
apparent
cerebral
and/or
spinal
cord
was
main, whereinfarctions
the “right”
answer
may
very
well
be
model
actually
“adjusts”
circulation
position,
the
APSF
Newsletter
turns
to
Dr.
William
Lanier
for
editorial
perspective.
Dr.
Lanier
Editor-in-Chief
of for something
operant
inCullen
head-up
patients
orfirst
that
corebyprinciples
that advice was
published
Enderby, and it has
presented as ais
series
by Pohl and
in
Assistant
Professor
of
Anesthesiology,
Physiology,
and
APSF
NEWSLETTER
Spring
2009
Professor
of
Anesthesiology
very different from
perfusion pressure—it adjusts
for
Mayo
Clinic Proceedings
as well
a highly
regarded
neuroanesthesiologist
and neurophysiology
investigator.
been
followed
uncritically
ever since. Thebut
refinement
2005, as
from medico-legal
reviews
nterintuitive,
itgleaned
is especially
important
toasallow
have led
us bytoone
anof unimpeachable
conclusion,
transmural
pressure.
where the Mayo Clinic
Engineering
the an
other
patient
hadblood
simultaneous
EEG
changes
in appears
animals
tohead-up
betterposition
exploreduring
the issue
of monitoring site
“Head
Up,”
From
Page
1
This
debate
about
pressure
monitoring
and
instead
because
such
approach
moves
us
in
a cuff,
In
the
Summer
2007
issue
of
the
APSF
Newsletter,
that the
anesthesia
arterial line has largely supplanted the BP
Why
does this matter?
Because only perfusion
ysiology to lead
discussion.
Mostthe
anesthesia
professionals
would
not
argue
both
cerebral
hemispheres,
though
more
prominent
in
versus
cerebral
well-being
as
related
to siphon versus
Editor-in-Chief
management
in head-up
patientsClinic
isbut
unavoidable
Cullen These
and Kirby
reported
on 2 patients
in whom a applies
and surgery
is here tonot
stay,
even thoughpressure,
ideal blood
Mayo
of
Medicine
the same
assumption
by a College
different
pressure,
transmural
is associated with
parallel.
parallel
aspects
ofwithin
the circusome inmaintaining
management
direction
away
from
hypoperfusion
against
blood
pressure
(BP)
a
rearight. ofAngiography
revealed
that, because
waterfall
hemodynamic
models,in itthese
must be rememinadequate empirical
data involving
anes- of pressure
catastrophic, new-onset brain injury was discovered thebecause
monitoring
andismanagement
method.
Raising
an
arterial
line
transducer
to
head
flow.
And
flow
what
we
are
interested
in. An arterMayo
Clinic Proceedings
lation may
place
tissues
within
remote
watershed
thetized,
head-up
patients
who
are at
risk for
rare, con- patients
sonably
closeafter
range
of preoperative
values
during
any
surgery
in theanesthetic,
beach chair
(barbershop)
posiis controversial.
widespread
atherosclerosis,
the left
carotid
artery
bered
that measurements of well-being must take into
Every day in
almost
every
we
make
BP
Rochester,
MN
(whatever
the
cause).
This
approach
also
has
merit
level
by physical
meansdeficits.
the same thing
ial line measurement can be used to estimate perfufor
ischemic
injuryor
coincident
regions at risk
but accomplishes
debilitating,
neurologic
The
authorsposition
presented
views
on the with
effect
tion.
anesthetic,
in the
sitting
otherwise;
northat tributed
ANEST
nothing postoperative
to the circulation
of either cerebral One
account
the features
watershed
regions
of
brain, eyes, and
Rochester,
MN
of
thepressure
core
current
debate
as
making
a
numerical
“correction”
to
a
BP
cuff
readsion
onlyofif the
both
inlet and
outlet pressures on
global
cerebral
and
spinal
cord
blood
flow
remainVarious
forms
of
head-up
positioning
are
used
not
blood
pressure because
monitoring
andexperience
management
may hemisphere;
would
I.
But
prescriptions
for
acceptable
BP
managetells
usadjustments
that
small
reductions
however,
the right
carotid artery sup- aboutspinal
cord, using
techniquesthesuch
as microspheres,
f measurements
andIthadisinfer
something
about
whole
pressure
head-up
Both
make an intuitive
assumption blood
either
side ofmanagement
the organ in
of interest
are measured, and S A F E T
only
for neurosurgical
procedures
(e.g., posterior
on neurologic
injury
and provided
ing adequate.
not
so simple
toofmodel
thehuman
cere-a for- ing.
References
position
revolves
around
whetheror
themultidimensional
circulation
ment
shouldhave
acknowledge
the lack
relevant
plied
blood
for
both
hemispheres.
Clearly
these
collaser
Doppler
flowmetry,
radioReferences
fossa
craniectomy
and
cervical
laminectomies)
where
mula
for
correcting
hydrostatic
blood
pressure
graare system
referenced
same level. By
that the headare
is in astatistically
compromised position
for perfuiffunctions
both pressures
from
normal
blood
pressure
more
bral and
circulation
asaamake
waterfall
either,
because
a
abovelogic
theonly
heart
as
a siphon
orblood
astoa theflows,
dy perfusion.
That
is
time-tested
empiric
reladata,
should
also
reference
to
methodologic
and
lective
observations
of
Toole
and
Tucker
imaging
to
quantify
regional
and
thewhen
effectsit is
oninhemodynamics
have been
more
1. Cullen
DJ,
Kirby
RR.
Beach
chair
position
may
decrease
dients from
the site
ofthe
measurement
togradithe site of sion
conventional
definition,
“perfusion
pressure”
is a
its (normal)
upright
position
relative
analogy
dictates
that
hydrostatic
waterfall
regional
intracranial
pressure,
and
head
positioning.
waterfall
system.
Based
onKirby
the
available
evidence,
“Head
Up,”
From
Preceding
Page
1.
Cullen
DJ,
RR.
Beach
chair
position
may dec
C
issues
in assessing
cerebral
perfusion
pressure
(CPP).
Perkins
et al.pondered,
speak
to the
that thetofrom
plumbing
multiple-lead electrical recordings to assess electrical
produce
injury
intensely
but
alsofact
for(e.g.,
surgery
the thy- of
vulnerable brainlikely
tissues. Thisto
publication
generated long-term
gradient,
not
a
single
point
measurement
at
pressure
to
the
heart.
Implicit
in
that
assumption,
but
rarely
either
scenario
is
probably
an
oversimplification
in
ent
of
the
column
of
blood
in
vessels
meaningfully
cerebral
perfusion:
catastrophic
outcomes
have
occurred.
nship for which
we
have
much
experience
and
As such, I would
to point
several
potential
gland,brain
shoulder,
non-neurosurgical
cerebral
perfusion:
Catastrophic
outcomes have occu
Such
an analysis
dictates
measuring
blood
pressure
a series like
of letters
to the out
Newsletter,
either
supporting theroid
human
canand
beother
variable,
dependent
on anesthetized,
well-being.
Crude
assessments
of
well-being,
using
patients.
Theinferences about
only surgically
one placepositioned
in a circuit.
Making
stated
explicitly,
isdo
ain
correlative
assumption:
the
influences
the
relationship
between
the
pressure
at corischemia)
than
are
small
elevations
blood
pressure
sites
where
debate
about
blood
pressure
manage-that
ADVI
or challenging
the
need for
the
blood
pressure
head-up,
anesthetized
patients,
what
should
wepositioning,
areas
of controversy
or ambiguity
that
may
arise
from
changes
in head
and
conceptually
quite
transcranial
Doppler
sonography
of
conducting
vesAPSF
Newsletter
2007;22(2):25,27.
APSF
Newsletter
2007;22(2):25,27.
at the
level
of the
most
vulnerable
(i.e.,
siphon
concept
is very
appealing
when
speaking
of the reading
perfusion
based
on atissue
transmural
pressure
at
cerebral
circulation
is an “open”
fluid
the aortic
the remote regions
of the brain. that
ch data. I am
not,rootofandcourse,
suggesting
we
ment
has
been less common.
Placing
the path
patientwhere a
NEWSLETTER
E
I
R
O
É
H
T
Too High
DULikely Safer Than Too Low
N
O
H
SIP
1
4
2
1,6
1
2
8,9
10
1,4,5
08
PAGE 83
La discussion
2 Pressure
fusion
Defined
® physiolog position generally. Among circulatory
edging, that the underlying physiology is not as
ts, the controversy
us were
PAGE
82
6
t: a controversy. I am not advocating
The Official Journal of the Anesthesia Patient Safety Foundation
www.apsf.organ uncritical
eptance of the closed
model, along
with its impli-Circulationtake
into
account
the basic physiological
84,122
Volume 24, No. est
1, 1-24 la physiologie
Spring 2009 principles
1.
Quelle
de
la
circulation
cérébrale?
ons for hemodynamic
monitoring. Butof
I amPosture,
advoThe Problems
Pressure,
and
will only obscure,
not Perfusion
clarify, the eventual
above
ing that the anesthesia and monitoring
EDITORIAL
oSPECIAL
in the sameanswer.
way in an awakeo
patient sitting
measured
the Editor:
To
APSF
NEWSLETTER
Spring
2009
PAGE 3
2.
Comment
évaluer
la
pression
de
perfusion
in a preoperative
clinic?
carefully, when we cérébrale
talk about “pressure,” between
and
address,
on
its
merits,
In the Summer
2007
APSF
Newsletter,
Cullen
and
Cerebral Perfusion:
Err
onMunis,
theMD,
Side
Caution
true of
perfusion
pressure and transmural pressure. The
James
PhD
Regarding the methodology
of BP measurement,
Kirby cite a dramatic case of cerebral infarction during
uments forshoulder
and
against
both
models.
In
this
practice of raising transducers to head level or making
en
mesure
de
tension
practice of “compensating”
for
arm BP cuff read- artérielle?
surgery fonction
in the beachchair position. de
This casela the
As controversy continues
regarding the hemodynamic
management
of patients
in the
head-up
or beach to
chair
adjustments
BP cuff readings in a closed
numerical
Chair,
Division
of
Neuroanesthesia
ings in the sitting position extends back to 1954 when
1 of “right”
4 apparent cerebral
and/or
spinalvery
cord well
main, wherewas
the
answer
may
be
model
actually
“adjusts”
circulation
position,
the
APSF
Newsletter
turns
to
Dr.
William
Lanier
for
editorial
perspective.
Dr.
Lanier
is
Editor-in-Chief
of for something
that advice was first published by Enderby, and it has
infarctions presented as a series by Pohl and Cullen in
Assistant
Professor
of
Anesthesiology,
Physiology,
and
APSF
NEWSLETTER
Spring
2009
very different from
perfusion pressure—it adjusts
for
Mayo
Clinic Proceedings
as well
a highly
regarded
and neurophysiology
investigator.
been
followed
uncritically
ever since. The refinement
2005, as
from medico-legal
reviews by one
of toasallow
nterintuitive,
itgleaned
is especially
important
transmural
pressure.
where the
Engineering
the other
patient
hadblood
simultaneous
EEG changes
in appears
animals
tohead-up
betterposition
exploreduring
the issue
of monitoring site
“Head
Up,”
From
Page
1
This
debate
about
pressure
monitoring
and
In
the
Summer
2007
issue
of
the
APSF
Newsletter,
that the
anesthesia
Why
does this matter?
Because only perfusion
ysiology to lead
discussion.
Mostthe
anesthesia
professionals
would
not
argue
both
cerebral
hemispheres,
though
more
prominent
in
versus
cerebral
well-being
as
related
to siphon versus
management
in head-up
patientsClinic
isbut
unavoidable
Cullen These
and Kirby
reported
on 2 patients
in whom a applies
and surgery
is here tonot
stay,
even thoughpressure,
ideal blood
Mayo
of
Medicine
the same
assumption
by a College
different
pressure,
transmural
is associated with
parallel.
parallel
aspects
ofwithin
the circusome inmaintaining
against
blood
pressure
(BP)
a
rearight. ofAngiography
revealed
that, because
waterfall
hemodynamic
models,in itthese
must be rememinadequate empirical
data involving
anes- of pressure
catastrophic, new-onset brain injury was discovered thebecause
monitoring
andismanagement
method.
Raising
an
arterial
line
transducer
to
head
flow.
And
flow
what
we
are
interested
in. An arterlation may
place
tissues
within
remote
watershed
thetized,
head-up
patients
who
are at
risk for
rare, con- patients
sonably
closeafter
range
of preoperative
values
during
any
surgery
in theanesthetic,
beach chair
(barbershop)
posiis controversial.
widespread
atherosclerosis,
the left
carotid
artery
bered
that measurements of well-being must take into
Every day in
almost
every
we
make
BP
Rochester,
MN
level
by physical
meansdeficits.
the same thing
ial line measurement can be used to estimate perfufor
ischemic
injuryor
coincident
regions at risk
but accomplishes
debilitating,
neurologic
The
authorsposition
presented
views
on the with
effect
tion.
anesthetic,
in the
sitting
otherwise;
northat tributed
ANEST
nothing postoperative
to the circulation
of either cerebral One
account
the features
watershed
regions
of
brain, eyes, and
of
thepressure
core
current
debate
as
making
a
numerical
“correction”
to
a
BP
cuff
readsion
onlyofif the
both
inlet and
outlet pressures on
global
cerebral
and
spinal
cord
blood
flow
remainVarious
forms
of
head-up
positioning
are
used
not
blood
pressure monitoring
and management
may hemisphere; however, the right carotid artery supwould
I.
But
prescriptions
for
acceptable
BP
managecord, using techniques
such
as microspheres,
f measurements
andIthadisinfer
something
about
whole
aboutspinal
blood pressure
head-up
Both
adjustments procedures
make an intuitive
assumption
either side ofmanagement
the organ in
of the
interest
are measured, and S A F E T
only
for neurosurgical
(e.g., posterior
on neurologic
injury
and provided
ing adequate.
not
so simple
toofmodel
thehuman
cere-a for- ing.
References
position
revolves
around
whetheror
themultidimensional
circulation
ment
shouldhave
acknowledge
the lack
relevant
plied
blood
for
both
hemispheres.
Clearly
these
collaser
Doppler
flowmetry,
radiofossa
craniectomy
and
cervical
laminectomies)
where
mula
for
correcting
hydrostatic
blood
pressure
graare system
referenced
same level. By
that the head is in a compromised position for perfuiffunctions
both pressures
bral and
circulation
asaamake
waterfall
either,
because
a
abovelogic
theonly
heart
as
a siphon
orblood
astoa theflows,
dy perfusion.
That
is
time-tested
empiric
reladata,
should
also
reference
to
methodologic
and
lective
observations
of
Toole
and
Tucker
imaging
to
quantify
regional
and
thewhen
effectsit is
oninhemodynamics
have been
more
1. Cullen
DJ,
Kirby
RR.conventional
Beachand
chair
position
may decrease
dients from
the site
ofthe
measurement
togradithe site of sion
definition,
“perfusion
its (normal)
upright
position
relative
analogy
dictates
that
hydrostatic
waterfall
regional
intracranial
head
positioning.
waterfallpressure,
system. Based
on the
available
evidence, pressure” is a
“Head
Up,”
From
Preceding
Page
C
issues
in assessing
cerebral
perfusion
pressure
(CPP).
et al.pondered,
speak but
to the
fact
that thetoplumbing
multiple-lead electrical recordings to assess electrical
for surgery
the thy- of
vulnerable brain tissues. This publication generated Perkins
gradient,
a single point
at
pressure
to intensely
the
heart.
Implicit
inalso
that
assumption,
but rarely
either scenario
is probably
an not
oversimplification
in measurement
ent
of
the
column
of
blood
in
vessels
meaningfully
cerebral
perfusion:
catastrophic
outcomes
have
occurred.
nship for which
we
have
much
experience
and
As such, I would
to point
several
potential
gland,brain
shoulder,
non-neurosurgical
Such
an analysis
dictates
measuring
blood
pressure
a series like
of letters
to the out
Newsletter,
either
supporting theroid
human
canand
beother
variable,
dependent
on anesthetized,
well-being.
Crude assessments
of
well-being,
using
patients.
Theinferences about
only surgically
one placepositioned
in a circuit.
Making
stated
explicitly,
isdo
a correlative
assumption:
the
influences
the
relationship
the
pressure
at corsites
where
debate
about
blood
pressure
manage-that
ADVI
or challenging
the between
need for
the
blood
pressure
head-up,
anesthetized
patients,
what
should
wepositioning,
areas
of controversy
or ambiguity
that
may
arise
from
changes
in head
and
conceptually
quite
transcranial
Doppler
sonography
of
conducting
vesAPSF
Newsletter
2007;22(2):25,27.
at the
level
of the
most
vulnerable
(i.e.,
siphon
concept
is very
appealing
when
speaking
of the reading
perfusion
based
on atissue
transmural
pressure
at
cerebral
circulation
is an “open”
fluid
the aortic
the remote regions
of the brain. that
ch data. I am
not,rootofandcourse,
suggesting
we
ment
has
been less common.
Placing
the path
patientwhere a
NEWSLETTER
1
Too High Likely Safer Than Too Low
4
2
1,6
1
2
8,9
10
1,4,5
08
PAGE 83
®
NEWSLETTER
La
discussion
fusion Pressure
Defined
2
www.apsf.org
Volume 24, No. 1, 1-24
Spring 2009
Circulation 84,122
g position generally. Among circulatory physiolothe underlying physiology is not as
SPECIALedging,
EDITORIALthat
o
o
ts, the controversy
us were
PAGE
82
Cerebral
Perfusion:
Err
on
the
Side
of
Caution
6
controversy
continues
the hemodynamic management of patients in the head-up or beach chair
t: a controversy. I amAsnot
advocating
anregarding
uncritical
the APSF Newsletter turns to Dr. William Lanier for editorial perspective. Dr. Lanier is Editor-in-Chief of
Letter to position,
the Editor:
eptance of the closedMayo
model,
along with
itsasimpliClinic Proceedings
as well
a highly regardedtake
and the
neurophysiology
investigator.
into
account
basic physiological
principles
1.
Quelle
est
la
physiologie
de
la
circulation
cérébrale?
ons for hemodynamic
monitoring. Butof
I amPosture,
advoThe Problems
Pressure,
and
Perfusion
will and
onlyappears
obscure,
not
clarify,
the eventual
above
This debate about blood
pressure
monitoring
In the Summer 2007 issue of the APSF Newsletter,
that the
head-up
position
during anesthesia
management
in
head-up
patients
is
unavoidable
Cullen
and
Kirby
reported
on
2
patients
in
whom
a
and
surgery
is
here
to
stay,
even
though
ideal
blood
L’important:
ing that the anesthesia
and monitoring
because ofin
inadequate
involving
anes- sitting
answer.
catastrophic, new-onset brain injury was discovered measured
pressurethe
monitoring
and management
in these
the sameempirical
way in data
an awake
patient
“open” model
is that we now
have to distinguish
To the Editor:
thetized,
head-up
patients who are at risk for
rare, perfusion
after surgery in the beach chair (barbershop)
posipatients is controversial.
2.
Comment
évaluer
la
pression
de
cérébrale
in
a
preoperative
clinic?
carefully,
when
we
talk
about
“pressure,”
between
and
address,
on
its
merits,
conséquences
pour
les
patients
but debilitating,
postoperative
neurologic
deficits.
In the Summer
APSF
Newsletter,
Cullen
andthat
The2007
authors
presented
views on
the effect
tion.les
One of
theperfusion
core features
of the current
debate pressure. The
true
pressure
and
transmural
James
Munis,
Various
forms the
of head-up
positioning
are used
notMD, PhD
blood pressure
monitoring
management
Regarding
methodology
of BP
measurement,
cite a dramatic
case of
cerebral and
infarction
duringmay
about blood
pressure
management
in the head-up
uments forKirby
and
against
both
models.
In
this
practice
of raising
transducers
to head level or making
only
for
neurosurgical
procedures
(e.g.,
posterior
have
had
on
neurologic
injury
and
provided
a
foren
fonction
de
la
mesure
de
tension
artérielle?
the practice of “compensating” for arm BP cuff readshoulder surgery in the beachchair position. This case
position revolves around whether the circulation
adjustments
to
BP
cuff
readings in a closed
numerical
fossa craniectomy and cervical
laminectomies)
where of Neuroanesthesia
Chair,
Division
mula for correcting hydrostatic blood pressure gra- ings
in the sitting position extends back to 1954 when
above the heart functions as a siphon system or as a
1 of “right”
4 apparent cerebral
and/or
spinalvery
cord
main, wherewas
the
answer
may
be
the effects
on hemodynamics have been more
dients from the
site of measurement
to the site of well
model
actually
“adjusts”
circulation
waterfall system. Based on the available evidence, for something
that
advicepondered,
was first but
published
by Enderby,
and it has
infarctions presented
as a series
byThis
Pohl
and Cullen
in
intensely
also for
surgery
toProfessor
the thyvulnerable
brain
tissues.
publication
generated
Assistant
of Anesthesiology,
Physiology,
and
Les
deux
théories
sont
certainement
une
very different
from
perfusion
pressure—it
adjusts
for
either scenario
is probably
an oversimplification
in
been
uncritically
evernon-neurosurgical
since. The refinement
2005, as
from
medico-legal
reviews
bysupporting
one of to allow
roidfollowed
gland, shoulder,
and other
of letters
to the Newsletter,
either
nterintuitive,
itgleaned
isa series
especially
important
transmural
pressure.
anesthetized,
surgically
positioned patients. The
Enderby’s
adviceabout
inBiomedical
neurosurgical
where the
where debate
blood pressurecases,
managethe 2 authorsor(DJC).
challenging the need for the blood pressure cor- of sites
Engineering
siphon concept cérébrale
is very appealing when speaking of
sur-simplification
de
la
physiologie
ment
has
been
less
common.
Placing
the
patient
rections
suggested
by
Cullen
and
Kirby.
Notable
Why does this matter? Because only perfusion
ysiology to lead
discussion.
the physiology of unanesthetized healthy humans or
Mostthe
anesthesia
professionals
would
not
argue
supine the
or prone
physiologic
among those letters was that of Munis who argued applies
Mayo
Clinic
ofpressure,
Medicine
sameto avoid
assumption
butchallenges
by a College
different
not transmural
pressure,
giraffes;
however,
anesthetized
surgical
patientsis associated with
against maintaining
blood for
pressure
(BP)gradients
within a was
rea-not
imposed by a head-up position is not always an
that a correction
hydrostatic
method. Raising an arterial line transducer to head
flow.
And
flow
is
what
we
are
in. An arterplaced head up—often with the head positioninterested
devisonably
closeneeded
range
of preoperative
values
during
any make
option,
as the sitting position
for posterior fossa
cranbecause,
in anesthetic,
the head-up
position,
the
circulaEvery day in
almost
every
we
BP
Rochester,
MN
ating
considerably
from
neutral—may
introduce
level
accomplishes
physical
meansblood
the same
ial line measurement can be used to estimate perfuiotomy
is reported tobydiminish
operative
loss thing
above
the heart
functions
a siphon. Cucchiara
anesthetic, tion
in the
sitting
position
orasotherwise;
nor
more complex
physiology.
As we
will see
later,
these
as
making
a
numerical
“correction”
to
a
BP
cuff
readsion pressure
only
if both
inlet
and
outlet pressures on
and significantly improve postoperative cranial
took
another approach
and chidedBP
practitioners
to
would I. But
prescriptions
for
acceptable
managef measurements
and
infer
something
about
whole
head-position
variations,
independent
of
a
gravity
ing.
Both
adjustments
make
an
intuitive
assumption
either
side
of
the
organ
of
interest
are measured, and
With
cervical
spine
surgery
or
posnerve
function.
an arterial catheter in head-up patients and
References
ment shouldplace
acknowledge
the lack of relevant human
effect, have
a bearing on cerebral circulation. Further,
terior
fossa
intracranial
surgery,
converting
from
the
measure blood pressure at the level of the head to that
the head is in a compromised position for perfuonly if both pressures are referenced to the same level. By
the siphon
analogy
assumes
that vessels
will functionmay decrease
dy perfusion.
That
isalsoamake
time-tested
empiric reladata, and
should
reference to methodologic
1.may potentially
Cullen
DJ,pul-Kirby
RR.
Beach
chair
position
sitting
to prone
avoid the need for arithmetically corrected measure- sion
conventional
definition,
“perfusion
when
it is inposition
its (normal)
uprightworsen
position
relative
in
series,
when
in
fact
the
vessels
connecting
the pressure” is a
issues in assessing
cerebral
perfusion
pressure
(CPP).
gas exchange in patients having medically
ments altogether. This debate continues in the cur- to monary
gradient,
not
a
single
point
measurement
at
pressure
the
heart.
Implicit
in
that
assumption,
but
rarely
heart tocatastrophic
the most remote areasoutcomes
of the brain tissues
cerebral
have
occurred.
nship for which
we
have
much
experience
and
As such, I would
like ofto the
point
out several
potential
complicated
obesity, or may contribute
to the perfusion:
risk of
rent issue
Newsletter
with
letters from
only
place
a circuit.
Making
stated
explicitly, is a correlative assumption: that the
and spinal
cordone
have
someinelements
in series
andinferences about
postoperative visual impairment in rare instances.
Drummond
al. who argue
areas of controversy
or etambiguity
thatthat
mayclinical
arise managefrom
APSF
Newsletter
perfusion based on a transmural pressure reading at
cerebral
fluid
path where a 2007;22(2):25,27.
ch data. I am
not, of course,
suggesting
that
wecirculation is an “open”
1,6
1
1
2
4
2
2
7
3
1,4,5
3
Le consensus
®
NEWSLETTER
Atelier de
www.apsf.org
Anesthesia Patient Safety
APSF Workshop:
Cerebral Perfusion Experts
Foundation
Volume 24, No. 4, 45-68
Circulation 84,122
Winter 2009-2010
Share Views on Management of Head-Up Cases
by Lorri Lee, MD and Robert Caplan, MD
The APSF held their annual Board of Directors
Workshop in New Orleans, LA, on the topic of cerebral perfusion pressure (CPP) in the beach chair position. This conference followed a series of articles over
the last year in the APSF Newsletter describing several
cases of severe brain and spinal cord injury following
the use of deliberate hypotension in the beach chair
position for shoulder surgery. Dr. Robert K. Stoelting,
president of the APSF, opened the workshop by intro-
of deliberate hypotension. Dr. David Cullen, previous
chair in the Department of Anesthesiology at Tufts
Medical Center, reviewed his case series of 4 patients
who developed severe and permanent brain or spinal
cord infarcts after having anesthesia with deliberate
hypotension in the beach chair position. He reported
that he was aware of an additional 11 cases in which
patients suffered severe brain damage under similar
circumstances. Dr. Cullen believes that anesthesia care
providers need to maintain blood pressure at or near
baseline levels in the sitting position. He provided the
thus an ominous predictor of postoperative mortality.
Dr. Sessler described additional preliminary and
unadjusted data demonstrating that 20 or more minutes of a Triple Low was associated with prolonged
hospitalization and a 3-fold increase in mortality. The
team also found that mortality was no higher than
normal when patients were given a vasopressor
within 5 minutes of entering a Triple Low. Dr. Sessler
cautioned that these results are based on retrospective
data and preliminary analyses, and that prospective
Volume 24, No. 4, 45-68
Winter 2009-2010
Circulation 84,122
APSF Workshop: Cerebral Perfusion Experts
3
Le consensus
president of the APSF, opened the workshop by introducing the APSF’s position statement: “The APSF
believes that reports of global ischemic brain damage
following surgical procedures in the semi-sitting
(“beach chair”) position may reflect unrecognized
cerebral hypoperfusion. Patient safety may benefit
from a discussion of acceptable cerebral perfusion
pressures and methods to monitor the adequacy of
cerebral blood flow.” He noted the 4 goals of the
workshop were “to understand how experts currently
identify 1) the lower limit of acceptable blood pressure during anesthesia, 2) the effects of patient position on the lower limit of acceptable blood pressure,
3) patients who are appropriate candidates for deliberate hypotension and/or beach chair position, and 4)
how we can improve safety in the presence of deliberate hypotension and/or the beach chair position.”
following recommendations to avoid hypotension in
the sitting position: 1) titration of anesthetics to avoid
excessive depth of anesthesia; 2) minimizing sudden
changes in position; 3) administration of intravenous
fluids to offset the effects of NPO status and the sitting
position on venous return; 4) use of vaspressors to
maintain blood pressure, as needed; and 5) correction
of blood pressure for the difference in height between
the site of measurement and the brain (1 cm height =
0.77 mmHg or 1 mmHg = 1.25 cm height) .
study would be required to validate these findings.
The study was supported by Aspect Medical and
some coinvestigators are Aspect employees.
Dr John C. Drummond, anesthésiologiste
Atelier de
Représentation erronée de l’autorégulation
cérébrale dans certains ouvrages
Dr. Nigel E. Sharrock, staff anesthesiologist from
the Hospital for Special Surgery in New York,
reviewed his experience with the use of deliberate
hypotension in elderly patients undergoing
Valeur de la limite inférieure
de laSafety
perfusion
l’Anesthesia
Patient
cerébrale
Foundation
Cercle de Willis incomplet chez plus de 45% de
Dr. Daniel I. Sessler, chair of the Department of
Outcomes Research at the Cleveland Clinic presented
preliminary data from a retrospective study of 24,000
patients undergoing volatile anesthesia with
Bispectral Index (BIS) monitoring. Dr. Sessler’s group
examined combinations of mean arterial pressure ≤75
mmHg, BIS <45, and minimum alveolar concentration (MAC) <0.7 (each averaged over case duration).
Thirty-day mortality was similar in patients in whom
only a single average was low and in those with no
low averages. However, 30-day mortality was doubled when 2 were low averages, and tripled when all
3 were low. A Triple Low of MAP, MAC, and BIS is
la population
Dr. Robert C. Caplan, member of the APSF
Executive Committee and of the ASA Closed Claims
Group, and staff anesthesiologist at Virginia Mason
Hospital in Seattle, WA, moderated the workshop
which included a list of speakers nationally and internationally recognized for their expertise in neuroanesthesia, outcomes research, and research on the use
See “Workshop,” Page 47
Volume 24, No. 4, 45-68
Winter 2009-2010
Circulation 84,122
APSF Workshop: Cerebral Perfusion Experts
3
Le consensus
president of the APSF, opened the workshop by introducing the APSF’s position statement: “The APSF
believes that reports of global ischemic brain damage
following surgical procedures in the semi-sitting
(“beach chair”) position may reflect unrecognized
cerebral hypoperfusion. Patient safety may benefit
from a discussion of acceptable cerebral perfusion
pressures and methods to monitor the adequacy of
cerebral blood flow.” He noted the 4 goals of the
workshop were “to understand how experts currently
identify 1) the lower limit of acceptable blood pressure during anesthesia, 2) the effects of patient position on the lower limit of acceptable blood pressure,
3) patients who are appropriate candidates for deliberate hypotension and/or beach chair position, and 4)
how we can improve safety in the presence of deliberate hypotension and/or the beach chair position.”
Consensus:
following recommendations to avoid hypotension in
the sitting position: 1) titration of anesthetics to avoid
excessive depth of anesthesia; 2) minimizing sudden
changes in position; 3) administration of intravenous
fluids to offset the effects of NPO status and the sitting
position on venous return; 4) use of vaspressors to
maintain blood pressure, as needed; and 5) correction
of blood pressure for the difference in height between
the site of measurement and the brain (1 cm height =
0.77 mmHg or 1 mmHg = 1.25 cm height) .
study would be required to validate these findings.
The study was supported by Aspect Medical and
some coinvestigators are Aspect employees.
LA TENSION ARTÉRIELLE
EN POSITION ASSISE
Atelier de
Éviter l’hypotension contrôlée
Dr. Nigel E. Sharrock, staff anesthesiologist from
the Hospital for Special Surgery in New York,
reviewed his experience with the use of deliberate
hypotension in elderly patients undergoing
Corriger pour le gradient
hydrostatique
l’Anesthesia
Patient
Safety
Réduction maximale
de 30%
Foundation
Dr. Daniel I. Sessler, chair of the Department of
Outcomes Research at the Cleveland Clinic presented
preliminary data from a retrospective study of 24,000
patients undergoing volatile anesthesia with
Bispectral Index (BIS) monitoring. Dr. Sessler’s group
examined combinations of mean arterial pressure ≤75
mmHg, BIS <45, and minimum alveolar concentration (MAC) <0.7 (each averaged over case duration).
Thirty-day mortality was similar in patients in whom
only a single average was low and in those with no
low averages. However, 30-day mortality was doubled when 2 were low averages, and tripled when all
3 were low. A Triple Low of MAP, MAC, and BIS is
See “Workshop,” Page 47
Pas de consensus sur le monitoring, installer
NIBP au membre supérieur
Dr. Robert C. Caplan, member of the APSF
Executive Committee and of the ASA Closed Claims
Group, and staff anesthesiologist at Virginia Mason
Hospital in Seattle, WA, moderated the workshop
which included a list of speakers nationally and internationally recognized for their expertise in neuroanesthesia, outcomes research, and research on the use
4 Une idée émerge
Saturométrie
Cérébrale
4 Une idée émerge
Saturométrie cérébrale et position assise
Plusieurs désaturations enregistrées
Associées à des périodes d’hypotension
Peu de corrélation avec la SjO2
Effet sur le outcome non établi
up and 3 in LDP group); incomplete data collection (2 in istered to the BCP and LDP groups by the same
P group and 3 in LDP group); and procedure canceled providers (15 anesthesiologists).
Cerebral oximetry values may be affected by
re entering the operating room (1 in LDP group). As a
anesthesia, type of anesthetic administered, arteria
lt, data analysis was performed on 61 patients in the BCP dioxide concentrations, inspired oxygen content,
up and 63 patients in the LDP group. The BCP and LDP temic blood pressure management.14 –16 Therefo
ups were similar in terms of demographic characteristics. thetic management was carefully standardized in
re were no differences between groups in age, weight, in both cohorts. Patients received midazolam 2
ht, sex, preoperative hemoglobin values, preexisting before being transported to the operating room. Int
dical conditions, or ASA physical status (Table 1). Intraop- tive monitoring consisted of electrocardiograph
ive management data are presented in Table 2. The matic arterial blood pressure assessment using
placed on the nonoperative upper extremity, pul
ation of anesthesia was longer in the LDP group. A higher etry, capnography, bispectral index monitorin
Neuroscience in Anesthesiology and Perioperative Medicine
centage of patients in the LDP group received interscalene system; Aspect Medical Systems, Newton, MA), a
Section Editor: Gregory J. Crosby
ks (71.4%) compared
with the BCP
group (8.2%,
P " surement
of core temperature via an esophagea
Saturométrie
cérébrale
et position
assise
CME of intraoperative fentanyl was used Anesthesia was induced with propofol 2.0 to 2.5
01) and a lower dose
fentanyl 100 !g, lidocaine 50 mg, and rocuronium
he LDP group (PCerebral
" 0.0001).
Plusieurs
désaturations
Oxygen
Desaturationenregistrées
Events
Assessedofby
mg/kg.
Maintenance
anesthesia consisted of sev
Hemodynamic data are presented in Figures 1 and 2.
Near-Infrared
Spectroscopy
During
Shoulder
Arthroscopy
1% to
3% ind’hypotension
an oxygen/air
mixture (fraction of
Associées
souvent
à des
ANOVA statistics revealed
that whereas
HR and
MAPpériodes
oxygen [Fio2] Positions
of 50%). Sevoflurane concentratio
inLDP
theand
Beach
Chair after
and induction
Lateral Decubitus
reased in both the
BCP groups
adjusted
to maintain MAP within 20% of baseline va
deMD,*corrélation
avec
laMarymont,
SjO2MD,*
GlennPeu
S. Murphy,
Joseph W. Szokol, MD,*
Jesse H.
Steven B. Greenberg, MD,*
4 Une idée émerge
Michael J. Avram, PhD,† Jeffery S. Vender, MD,* Jessica Vaughn, BA,* and Margarita Nisman, BA*
Effet ANESTHESIA
sur le outcome
non établi
& ANALGESIA August 2010 • Volume 111 • Number 2
BACKGROUND: Patients undergoing shoulder surgery in the beach chair position (BCP) may be
at risk for adverse neurologic events due to cerebral ischemia. In this investigation, we sought
to determine the incidence of cerebral desaturation events (CDEs) during shoulder arthroscopy
in the BCP or lateral decubitus position (LDP).
METHODS: Data were collected on 124 patients undergoing elective shoulder arthroscopy in the
BCP (61 subjects) or LDP (63 subjects). Anesthetic management was standardized in all
patients. Regional cerebral tissue oxygen saturation (SctO2) was quantified using near-infrared
spectroscopy. Baseline heart rate, mean arterial blood pressure, arterial oxygen saturation, and
SctO2 were measured before patient positioning and then every 3 minutes for the duration of the
surgical procedure. SctO2 values below a critical threshold (!20% decrease from baseline or
absolute value "55% for !15 seconds) were defined as a CDE and treated using a
predetermined protocol. The number of CDEs and types of intervention used to treat low SctO2
values were recorded. The association between intraoperative CDEs and impaired postoperative
recovery was also assessed.
0.011) was observed in
to the
BCPbeach
and LDP
groups by the same
up and 3 in LDPthe
group);
incomplete
data collection
(2 in
groups
at any time.
The number
of istered
patients
in the
chair
compared end-tidal
with subjectss
providers
(15
anesthesiologists).
P group and 3 inposition
LDP group);
procedure
group and
increased
fromcanceled
57 at baseline to 59 at 6 minutes,
landmarkscerebral
(with the exd
Cerebral
oximetry
values
may
be
affected by
re entering the operating
room (1to
in 58
LDPatgroup).
As a after which it decreased
then decreased
45 minutes
admission) did not diff
anesthesia, type of anesthetic administered,
arterin
who had
To determine wheth
lt, data analysis was
performed
on
61
patients
in
the
BCP
progressively
over
time
to
49
at
1
hour
and
to
18
at
90
minutes,
Figure 5. Bispectral index (BIS) for the patients
in the
beach chair inspired oxygen content,
dioxide
concentrations,
nauseated
contributing
to the naus
whereas
the
number
of
patients
in
the
lateral
decubitus
up and 63 patients in theposition
LDP group.
BCP
and
LDP temic
group andThe
in the
lateral
decubitus
positionblood
group.pressure
The data position
management.14 –16 Therefo
globin concentration,
areofpresented
as mean
& SD.
There were
no differences
betweenand then
decreased
from
63characteristics.
at
baseline
to thetic
61
atmanagement
48 minutes
sia but diino
ups were similar group
in terms
demographic
was
carefully
standardized
the groups
at any
time.
number
of patients
in the
beach
end-tidal sevoflurane co
progressively
over
time
to The
54
atweight,
1 hour
andboth
to
40
at 90chair
minutes.
re were no differences
between
groups
in
age,
in
cohorts.
Patients
received univariate
midazolam 2
position group increased from 57 at baseline to 59 at 6 minutes,
cerebral desaturation
before
being
transported to the operating
room. Ini
then decreased values,
to 58 at preexisting
45 minutes after
which
it decreased
ht, sex, preoperative hemoglobin
included
who
had
not
had
regio
progressively over time to 49 at 1 hour and
to monitoring
18 at 90 minutes,
tive
consisted
of
electrocardiograph
dical conditions, or ASA physical
status (Table 1). Intraopnauseated as
and predict
patients
whereas the number of patients in the lateral
decubitus
position
matic
arterial
blood
pressure
assessment
usin
ive management data group
are presented
in 63
Table
2. The
decreased from
at baseline
to 61 at 48 minutes and then
sia but did become nau
operative
placed
on90
the
nonoperative upper extremity,
pul
progressively
time
to 54 A
at higher
1 hour and
to 40 at
minutes.
univariate analyses as
ation of anesthesia was longer
in theover
LDP
group.
capnography, bispectral index
monitorin
Neuroscience in Anesthesiology and Perioperative etry,
Medicine
ration.
Thm
included
in
the
initial
centage of patients
in
the
LDP
group
received
interscalene
Saturométrie
cérébrale
pour
la
chirurgie
en
position
system; Aspect Medical Systems, Newton, MA), a
Section Editor: Gregory J. Crosby
as predictors
of nause
logistic
reg
ks (71.4%) compared with the BCP group (8.2%, P " surement of core temperature
via an esophagea
assise
operative position,
and
occurrence
CME of intraoperative fentanyl was used Anesthesia was induced with propofol
01) and a lower dose
2.0 to 2.5
ration. The only variab
fentanyl 100 !g, lidocaine 50 mg, and2.639
rocuronium
he LDP group (PCerebral
" 0.0001). Oxygen Desaturation Events
[0
Assessed
by
logistic regression%
mod
consisted of sev
Hemodynamic data
are presented
in Figures 1 and enregistrés
2. mg/kg. Maintenance of anesthesia
ratio
test
occurrence
of cerebral
Épisodes
peropératoires
Near-Infrared Spectroscopy During
Shoulder
Arthroscopy
1%
to
3%
in
an
oxygen/air
mixture
(fraction
of
ANOVA statistics revealed that whereas HR and MAP
2.639 % [0 sensitivity
! no desatur
oxygen [Fio2]Positions
of 50%). Sevoflurane concentratio
inLDP
theand
Beach
Chair after
and induction
Lateral Decubitus
ratio test statistic ! 1
reased in both the
BCP groups
4 Une idée émerge
adjusted to maintain MAP within 20%specificity
of baseline va
of the logis
Associé parfois avec hypotension
sensitivity
Glenn S. Murphy, MD,* Joseph W. Szokol, MD,* Jesse H. Marymont, MD,* Steven B. Greenberg,
MD,*
Michael J. Avram, PhD,† Jeffery S. Vender, MD,* Jessica Vaughn, BA,* and Margarita Nisman,specificity
BA*
was 56.0%.
ANESTHESIA & ANALGESIA August 2010 • Volume 111 • Number 2
Corrélation
très faible avec SjO2
DISCUSS
BACKGROUND: Patients undergoing shoulder surgery in the beach chair position (BCP) may be
at risk for adverse neurologic events due to cerebral ischemia. In this investigation, we sought
in the BCP or lateral decubitus position (LDP).
METHODS: Data were collected on 124 patients undergoing elective shoulder arthroscopy in the
Figure
6.subjects)
Regional
cerebral
tissue Anesthetic
oxygen saturation
BCP (61
or LDP
(63 subjects).
management (Sct
was Ostandardized
O2 in all
2) for the
patients. Regional
tissue
oxygen
saturation group
(SctO2) was
quantified
usinglateral
near-infrared
patients
in thecerebral
beach
chair
position
and
in the
spectroscopy. Baseline heart rate, mean arterial blood pressure, arterial oxygen saturation, and
decubitus
positionbefore
group.
The
data are
presented
as mean
SD. of the
SctO2 were measured
patient
positioning
and then
every 3 minutes
for the &
duration
The
solid
horizontal
the threshold
time during
the
O2
surgical
procedure.
SctO2 line
valuesindicates
below a critical
(!20% which
decrease
fromSct
baseline
or
absolute
value
"55%
for
!15
seconds)
were
defined
as
a
CDE
and
treated
using
a
values in the patients of the beach chair position group differed from
predetermined protocol. The number of CDEs and types of intervention used to treat low SctO2
their
baseline
SctOThe
(3–between
0 minutes,
overallCDEs
P "and
0.05)
whereas
2 values
values
were recorded.
association
intraoperative
impaired
postoperative
recovery
washorizontal
also assessed.
the
dotted
line indicates the time during which the SctO
DISCUSSION
Patientssho
un
Patients undergoing
Figure 6. Regional cerebral tissue oxygen saturation (Sct ) forrisk
thefor cerebral
hypoxia
risk for
cer
patients in the beach chair position group and in the lateral
technology, which pro
technology
decubitus position group. The data are presented as mean & between
SD.
oxygen supply
between o
The solid horizontal line indicates the time during which the Sct
of Othe
2 brain, has not b
changes inofScto
th
the
2 inbra
0.011) was observed in
to the
BCP
and toLDP
by the same
history group); incomplete
4 (6.6%)
("17.5%
4.8%) groups 0.364
up and 3Drinking
in LDP
data collection
(28 (12.7%)
in
the groups at any
time.
The number
of istered
patients
in"6.1%
the
beach
chair
compared end-tidal
with subjectss
providers
(15
anesthesiologists).
CI
#
confidence
interval;
MI
#
myocardial
infarction;
COPD
#
chronic
obstructive
pulmonary
disease;
CVA
#
cerebrovascular
accident;
TIA
#
transient
ischemic
P groupattack.
and 3 inposition
LDP group);
procedure
group and
increased
fromcanceled
57 at baseline to 59 at 6 minutes,
landmarkscerebral
(with the exd
Cerebral
oximetry
values
may
be
affected by
Data arethe
mean operating
!
SD, median
(range),
or number
of patients
re entering
room
(1to
in
LDP(%).
group).
As a after which it decreased
then
decreased
58
at
45
minutes
admission)
did
not diff
n # 60.
anesthesia, type of anesthetic administered,
arterin
who
had
To determine wheth
lt, data analysis
was
performed
on
61
patients
in
the
BCP
progressively
over
time
to
49
at
1
hour
and
to
18
at
90
minutes,
n # 52.
Figure 5. Bispectral index (BIS) for the patients
in the
beach chair inspired oxygen content,
dioxide
concentrations,
nauseated
contributing
to the naus
whereas
the
number
of
patients
in
the
lateral
decubitus
up and 63 patients in theposition
LDP group.
BCP
and
LDP temic
group andThe
in the
lateral
decubitus
positionblood
group.pressure
The data position
management.14 –16 Therefo
globin concentration,
areofVariables
presented
as mean
& SD.
There were
no differences
betweenand then
group
decreased
from
63characteristics.
at
baseline
to thetic
61
atmanagement
48 minutes
sia but diino
2. Perioperative
ups wereTable
similar
in terms
demographic
was
carefully
standardized
the groups
at any
time.
number
of Lateral
patients
in the
beach
end-tidal Psevoflurane
co
Beach
chair
group
group
(95% CI)
value
progressively
over
time
to The
54
atweight,
1 hour
and
to
40
atDifference
90chair
minutes.
re were no differences
between
groups
in
age,
in
both
cohorts.
Patients
received
midazolam
2
univariate
position group increased from
57 at baseline
to 59 at 6 minutes,
cerebral desaturation
No. of patients
61
63
—
—
before
being
transported
the operating
room. Ini
then decreased values,
to 58 5 at
45 minutes45after
which
it"63.2%
decreased
ht, sex,Interscalene
preoperative
hemoglobin
preexisting
block
(8.2%)
(71.4%)
("74.6% to to
"48.5%)
$0.0001
included
who
had
not
had
regio
Intraoperative
progressively over time to 49 at 1 hour and
to monitoring
18 at 90 minutes,
tive
consisted
of
electrocardiograph
dical conditions,
or ASA physical
status (Table !1).31IntraopTotal time (min)
! 46 decubitus
"18.0
("32 to 4) nauseated0.011
and predict
patients
as
whereas the number of117patients
in the 135
lateral
position
matic
arterial
blood
pressure
assessment
usin
!
g)
200
(50–500)
100
(0–325)
50
(25–100)
$0.0001
Dose
fentanyl
(
ive management
data
are
presented
in
Table
2.
The
group
decreased
from
63
at
baseline
to
61
at
48
minutes
and
then
sia
but
did
become
nau
Dose rocuronium (mg)
50 (30–140)
50 placed
(30–155) on the nonoperative
0 (0–10)
0.054
operative
upper extremity,
pul
progressively
over
time
to
54
at
1
hour
and
to
40
at
90
minutes.
Crystalloid (L) was longer in the LDP group.
1.11 ! 0.39
! 0.38
"0.09 ("0.23 to 0.05)
univariate0.201
analyses as
ation of anesthesia
A higher1.20etry,
bispectral
index
monitorin
Final OR temperature
(°C)
! 0.6
36.1
! 0.6 capnography,
"0.1 ("0.4 to
0.1)
0.224
Neuroscience
in Anesthesiology35.9
and
Perioperative
Medicine
ration.
Thm
included
in
the
initial
centage of
patients
the LDP
received
interscalene
Times
toSaturométrie
recoveryin
landmarks
(min) group
cérébrale
pour
la
chirurgie
en
position
system; Aspect 0Medical
Systems, Newton,
MA), a
Open eyes Section Editor: Gregory J. Crosby
8 (1–25)
8 (2–16)
("1 to 1)
0.896
as
predictors
of
nause
logistic
reg
ks (71.4%)
compared
with the BCP group8 (1–26)
(8.2%, P " 8 surement
of core
temperature via 0.088
an esophagea
Squeeze
hands
(2–22)
1 (0–3)
assise
operative 0.576
position,
and
extubation
10 (2–36)
9 (0–24)
0 ("1 to 2)
occurrence
CME of intraoperative fentanyl
01) and aTracheal
lower
dose
was
used
Anesthesia
was
induced
with
propofol
2.0
to
2.5
Arrive PACU
17 (5–35)
13 (5–28)
3 (1–5)
$0.001
ration. The
only variab
fentanyl 100 !g, lidocaine 50 mg, and2.639
rocuronium
PACU
he LDP group
(PCerebral
" 0.0001). Oxygen Desaturation Events
[0
Assessed
by
logistic regression%
mod
Aldrete scores
Maintenance
of anesthesia consisted
of sev
Hemodynamic
are presented
in Figures
2. 8 mg/kg.
Arrival data
8 (2–10)1 and enregistrés
(2–10)
"1 ("1 to 0)
$0.001
ratio
test
occurrence
of
cerebral
Épisodes
peropératoires
During
Shoulder
Arthroscopy
30 min Near-Infrared Spectroscopy
9 (7–10)
9 1%
(2–10)to
0 ("1
to 0)
0.050
3%
in
an
oxygen/air
mixture
(fraction
of
ANOVA statistics
revealed that whereas HR
and MAP10 (8–10)
2.639 % [00.475
! no desatur
60 min
9 (8–10)
0 (0–0)
sensitivity
oxygen
[Fio2]Positions
of
50%). Sevoflurane0.494
concentratio
inLDP
theand
Beach
Chair after
and
Lateral10Decubitus
90 min the
10 (8–10)
(8–10)
0 (0–1)
ratio test statistic ! 1
reased in both
BCP
groups
induction
Discharge
9 (8–10)
10 (9–10)
"1 ("1 to 0)
0.378
a
b
4 Une idée émerge
a
a
b
c
d
e
adjusted to maintain MAP within 20%specificity
of baseline va
sensitivity
of the logis
Nausea
24 (39.3%)
(8.1%)
Glenn S. Murphy, MD,* Joseph W. Szokol,
MD,* Jesse H.5Marymont,
MD,* 31.3%
Steven(17.1%–45.1%)
B. Greenberg,
MD,* $0.0001
Nausea severity
(1–3
scale)
1.5
(1–3)
1
(1–2)
0
(0–1)
0.970
Michael J. Avram, PhD,† Jeffery S. Vender, MD,* Jessica Vaughn, BA,* and Margarita Nisman,specificity
BA*
was 56.0%.
Associé parfois avec hypotension
f
g
a
h
i
Vomiting
13 (21.3%)
1 (1.6%)a
19.7% (9.8%–31.8%)
$0.001
j
k
Vomiting severity (1–3 scale)
1 (1–2)
1
—
a
• Volume
111
2
Pain medication
52 (85.3%)
33inAugust
(52.4%)
32.9%
(17.0%–47.3%)
BACKGROUND: Patients undergoing
shoulder surgery
the beach 2010
chair position
(BCP)
may
be • Number0.0001
l
m
Pain medication dose (mg
1.5
(0.5–4)
1 (0.5–4.0)
0 (0–0.5)
0.374
at hydromorphone)
risk for adverse neurologic
events
due to cerebral ischemia.
In this investigation,
we sought
PACU discharge (min)
in the BCP or lateral decubitus
Criteria met
80 position
(35–193)(LDP).
83.5 (39–145)a
"1 ("13 to 10)
0.830
sho
a
METHODS: Data were collected
124 patients undergoing
elective
shoulder arthroscopy
the Patients undergoing
Actual discharge
93 on
(45–298)
94 (55–181)
2 ("10 toin12)
0.765
Figure
6.
Regional
cerebral
tissue
oxygen
saturation
(Sct
O
)
for
the
BCP (61 subjects) or LDP (63 subjects). Anesthetic management was standardized
O2 in all risk for cerebral hypoxia
2
CI # confidence interval; OR patients
# patients.
operating Regional
room;
PACU
# postanesthesia
care
unit.
cerebral
tissue
oxygen
saturation
(SctO2) was
quantified
usinglateral
near-infrared
in the
beach
chair
position
group
and
in the
Data are mean ! SD, median (range),
or number
of patients
spectroscopy.
Baseline
heart(%).
rate, mean arterial blood pressure, arterial oxygen saturation, and technology, which pro
decubitus
position
The
data
presented
as1, mean
a
d
h
j
l
m SD.
Sct
weree n
measured
positioning
then
every
duration
of the
n # 62, b n # 58, c n # 57,
n O#2 18,
# 27, f nbefore
#group.
9, g patient
n # 4,
n#
24, i are
nand
# 5,
n#
13,3k minutes
n#
nfor
#the
52,&
n # 33.
The
solid
horizontal
the threshold
time during
the
O2
surgical
procedure.
SctO2 line
valuesindicates
below a critical
(!20% which
decrease
fromSct
baseline
or between oxygen supply
absolute
"55% for of
!15
seconds) chair
were defined
as group
a CDE differed
and treated
using a of Othe brain, has not b
values
in value
the
patients
the
position
from
Scto
of anesthesia, intraoperative
HR
andprotocol.
MAP values
didbeach
are presented
in
Figure
2
predetermined
The number
ofnot
CDEs and types
ofdata
intervention
used to treat
low
SctO26 and2Table 3. Scto2
their
baseline
Sct
O
values
(3–
0
minutes,
overall
P
"
0.05)
whereas
differ between groups. values
No differences
groups
values before
(75.5
4.0 vspostoperative
75.9 ! 3.9) changes
and after (baseline:
2 association
were recorded.between
The
between intraoperative
CDEs
and!
impaired
in Scto2 in th
recovery
washorizontal
alsosevoflurane
assessed.
the
line concenindicates the
during
which
O
were noted in Spo (Fig.
80.4time
! 5.0
vs 81.1
! the
5.1) Sct
induction
of anesthesia were
end-tidal
3),dotted
ANESTHESIA & ANALGESIA
Corrélation
très faible avec SjO2
DISCUSS
DISCUSSION
Figure 6. Regional cerebral tissue oxygen saturation (Sct ) for the
patients in the beach chair position group and in the lateral
decubitus position group. The data are presented as mean & SD.
The solid horizontal line indicates the time during which the Sct
Patients un
risk for cer
technology
between o
of the bra
FIN
ÉPISODE 1
de la petite histoire
de la position assise
en orthopédie
L’OXYMÉTRIE CÉRÉBRALE monitore
l’oxygénation d’une RÉGION du cerveau
Corrélation de l’OXYMÉTRIE CÉRÉBRALE
avec le outcome clinique est encore sous étude
ATTENTION
Ne pas utiliser l’OXYMÉTRIE CÉRÉBRALE
comme outil pour tolérer une hypotension en
position assise
Interpréter la valeur à la lumière de la clinique
Conduite lors de
désaturation
Vérifier la position de la tête, éliminer toute
source d’obstruction au flot sanguin
Normaliser la pCO2
Optimiser la tension artérielle
Augmenter la FiO2
Chirurgie
orthopédique
en position assise
LE MANAGEMENT
ANESTHÉSIQUE?
Les complications
décrites
Ischémie cérébrale
Quadriplégie
Perte de vision et ophtalmoplégie
Embolie gazeuse
Pneumothorax, pneumomédiastin
Neuropathies périphériques
Anesth Analg 2003; 96: 899-902.
Spine 2006; 31: 1056-9.
Br J Anaesth 1999; 82: 117-28.
Anesthesiology 1998; 89: 805-6.
Br J Anaesth 2000; 85: 925-7.
Chest 1992; 101: 1265-7.
Les complications
décrites
‣
Syndrome de Tapia (Récurrent Laryngé + Hypoglosse)
‣
Nerf Hypoglosse
‣
Petit nerf occipital et Grand nerf auriculaire
Anesth Analg 2003; 96: 899-902
J Bone Joint Surg Am 1992; 74: 137-9
J Shoulder Elbow Surg 2008; 17: e28-30
Arthroscopy 2005; 21: 631e1-e3
Complications
potentielles
Macroglossie
Occlusion de la veine jugulaire
Ischémie aux membres inférieurs
Compression du nerf sciatique
J Neurosurg 1989; 71: 618-9.
Br J Anaesth 1999; 82: 117-28.
Management
Positionnement
Bonne pré-hydratation
Montée graduelle
Bas support ?
Vérification du positionnement
‣ Fréquentes
‣ À tout changement de position
Arthroscopy 2010: 26: 729-33.
Anesth Analg 1983; 62: 648-53.
Management
Tête
Fixation?
Points de pression au visage
Conserver position neutre
Bras
Support sous le coude non opéré
Jambes
Flexion légère des genoux
Flexion de la hanche de ≺ 90 degrés
Cerebral
Management
PERIOPERATIVE MEDICINE
Maintenance
les options:
Générale vs régionale
Halogénés vs propofol
Fig. 2. Jugular venous oxygen saturation after moving to the Fig. 6. Regional cer
Fig. 5. The incidences of hypotension (mean arterial pressure
beach
chair position
in patients under sevoflurane-nitrous
Can
Anesth
58: 986-92
56: 872-9 plotted
of Jless
than2011;
50 mmHg),
jugular venous oxygen Anesthesiology
desaturation 2012:spectroscopy
oxide Elbow
or propofol-remifentanil
anesthesia. Values are tion
Fig.from
3. Individual
J (less
Shoulder
Surg
in press
726 pairs ao
than 50%),
and2013;
cerebral
oxygen desaturation (more than
means ! SD *P # 0.05 versus baseline. †P # 0.05 versus surgery
saturation
patie
underinsevoflu
20% decrease from baseline) after moving to the beach chair
propofol-remifentanil anesthesia group (all the time). The tanil
propofol-remifentan
anesthesia. P/R
position in patients under sevoflurane-nitrous oxide or propo-
Management
Maintenance
les options:
Générale vs régionale
Halogénés vs propofol
Oxymétrie cérébrale ?
Can J Anesth 2011; 58: 986-92
J Shoulder Elbow Surg 2013; in press
Anesthesiology 2012: 56: 872-9
En résumé
La POSITION ASSISE est appréciée de
plusieurs orthopédistes
Est associée à des changements
hémodynamiques significatifs
Des complications sont à redouter
Ischémie cérébrale
En résumé
L’ISCHÉMIE CÉRÉBRALE est rare, mais
dévastatrice
Survient chez des patients jeunes en bonne
santé
Mécanisme causal imprécis,
l’hypoperfusion cérébrale est l’hypothèse
principale
En résumé
Recommandations de l’APSF:
Éviter l’hypotension contrôlée
Corriger la valeur de TA pour la position
Réduction maximale de la TA de 30%
Si NIBP, l’installer au membre supérieur
En résumé
Conseils supplémentaires:
Installation graduelle du patient
Vérifications fréquentes du positionnement
Consensus HEJ
‣
‣
‣
‣
‣
‣
‣
‣
‣
‣
Évaluation préopératoire
Canule au méat auditif
Bas élastiques compressifs
Montée graduelle
Descendre au besoin
Maximum 70 degrés
Tête en position neutre
Bras non opéré supporté
Champs opératoires dégagés
Vérification au moins 1x/heure

beach chair

Transcription

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