Shoulder Surgery In Beach Chair Position Research Articles

Effect of Beach-Chair Position on Cerebral Blood Flow in Patients Undergoing Shoulder Surgery—A Preliminary Observational Study

Abstract Background Hypotension and cerebral hypoperfusion, commonly encountered in beach-chair position under general anesthesia, carry the risk of neurologic complications. There is a paucity of data on monitoring cerebral perfusion. Our objective was to compare the mean arterial pressure (MAP) and middle cerebral artery velocity (Vmca) in the supine and beach-chair position and estimate its correlation during hypotension. Materials and Methods Twenty ASA class I and II patients undergoing elective shoulder surgery in beach-chair position were included in the study. MAP was measured invasively with the pressure transducer leveled to the phlebostatic axis. Vmca was measured with a 2 MHz transcranial Doppler (TCD) probe through the temporal window. Both MAP and Vmca were measured at baseline after anesthetic induction in the supine position (BL), on assuming the beach-chair position (AP), at steady-state hemodynamics in beach-chair position (P1), whenever there was a drop in MAP > 20% (P2), and on the restoration of MAP (P3). Results A mean decrease in MAP and Vmca by 24.76% and 27.96%, respectively, from supine to beach-chair position with a significant linear correlation between MAP and Vmca along with a Pearsons' coefficient of 0.77 was seen. A change in MAP of 1 mm of Hg resulted in a change in Vmca by 0.53 cm/sec (p < 0.05). Conclusion A significant decrease in MAP and Vmca was observed in the beach-chair position. TCD could be used as a point-of-care noninvasive technique to reliably assess cerebral perfusion.

Prophylactic measures to prevent cerebral oxygen desaturation events in elective beach-chair position shoulder surgeries: a systematic review and meta-analysis.

BackgroundProphylaxis for cerebral desaturation events (CDEs) during anesthesia in the beach chair position (BCP) for shoulder surgeries has not been evaluated. We systematically analyzed the effectiveness of various prophylactic measures used in this clinical setting.MethodsWe performed a meta-analysis (PROSPERO; no. CRD42020167285) of trials reporting CDEs and regional cerebral oxygen saturation (rSO2) and jugular venous oxygen saturation (SjvO2) values in anesthetized patients undergoing shoulder surgery in BCP. Considering the type of prophylactic measures used (pharmacological or non-pharmacological), a subgroup analysis was planned. Outcomes included (1) rSO2 and SjvO2 data with and without prophylactic measures for CDEs, recorded for different time intervals, and (2) the number of patients experiencing CDEs and hypotension. ResultsTwelve studies (786 patients) were included in the analysis. We observed lower absolute rSO2 values for early and all-time periods for vasoactive agent prophylaxis. The lowest achieved rSO2 values were also lower for vasoactive agent prophylaxis. Risk of CDEs was higher with vasoactive agent prophylaxis. Subgroup analysis identified targeted mild hypercarbia as effective in preserving cerebral oxygenation. Similarly, targeted mild hypercarbia prevented the fall in rSO2 with position change. Meta-regressions revealed statistically significant highest estimates for vasoactive agent prophylaxis in contrast to targeted mild hypercarbia. Likelihood of not developing CDEs was higher for targeted mild hypercarbia. In contrast to rSO2, most prophylactic methods reduced hypotensive episodes. ConclusionsTargeted mild hypercarbia can reduce BCP-related CDEs. Evidence does not favor prophylactic use of vasoactive agents for the prevention of cerebral desaturations irrespective of whether their use interferes with cerebral oximetry readings.

Paraplegia by Acute Cervical Disc Herniation after Shoulder Arthroscopic Surgery in Beach-Chair Position

Paraplegia after non-cervical spine surgery under general anesthesia is a rare devastating postoperative complication [1]. A patient with shoulder pain was scheduled for shoulder arthroscopy due to rotator cuff repair. Arthroscopic shoulder surgery was performed with the patient in the beach-chair. Postoperatively, patients complained the weakness of both lower leg and marked numbness and tingling in the both arms. MRI showed a herniated intervertebral disc between C6 and C7 with spinal cord compression. Despite urgent discectomy, the patient remained dysesthesia of both upper extremities for 6 months. The purpose of this report is to introduce our case with a paraplegia observed after arthroscopic shoulder surgery in beach-chair position because of acute cervical herniation.

Effect of therapeutic hypercapnia on balance between cerebral O2 supply and demand in patients undergoing arthroscopic shoulder surgery in beach chair position

Objective To evaluate the effect of therapeutic hypercapnia on the balance between cerebral O2 supply and demand in the patients undergoing arthroscopic shoulder surgery in the beach chair position(BCP). Methods Forty-eight patients of both sexes, aged 21-64 yr, weighing 45-80 kg, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, scheduled for elective arthroscopic shoulder surgery in the beach chair position, were divided into 2 groups(n=24 each)using a random number table: control group(group C, end-tidal pressure of carbon dioxide 35-40 mmHg)and therapeutic hypercapnia group(group H, end-tidal pressure of carbon dioxide 45-50 mmHg). The regional cerebral oxygen saturation(rSO2)was recorded after induction and before BCP, immediately after BCP, at 3, 6, 9, 12, 15, 18, 21, 24, 27 and 30 min after BCP and at the end of surgery(T0-12). The occurrence of cerebral desaturation events, extubation time, duration of stay in postanesthesia care unit, development of nausea and vomiting and requirement for vasoactive drugs were recorded during surgery. Results Compared with the baseline at T0, the rSO2 was significantly decreased at T1-12 in group C and at T2-6 in group H(P 0.05). Conclusion Therapeutic hypercapnia can improve the balance between cerebral O2 supply and demand in the patients undergoing arthroscopic shoulder surgery in the BCP. Key words: Hypercapnia; Posture; Brain; Shoulder joint; Oxygen consumption

Vasopressin ameliorates hypotension induced by beach chair positioning in a dose-dependent manner in patients undergoing arthroscopic shoulder surgery under general anesthesia.

BackgroundThe beach chair position (BCP) is associated with hypotension that may lead to cerebral ischemia. Arginine vasopressin (AVP), a potent vasoconstrictor, has been shown to prevent hypotension in BCP. It also improves cerebral oxygenation in different animal models. The present study examined the effect of escalating doses of AVP on systemic hemodynamics and cerebral oxygenation during surgery in BCP under general anesthesia.MethodsSixty patients undergoing arthroscopic shoulder surgery in BCP under general anesthesia were randomly allocated to receive either saline (control, n = 15) or three different doses of AVP (0.025, 0.05, or 0.075 U/kg; n = 15 each) 2 minutes before BCP. Mean arterial pressure (MAP), heart rate (HR), regional cerebral oxygen saturation (SctO2), and jugular venous oxygen saturation (SjvO2) were measured after induction of anesthesia and before (presitting in supine position) and after BCP.ResultsAVP per se given before BCP increased MAP, and decreased SjvO2, SctO2, and HR in all patients (P < 0.05 for all). BCP decreased MAP, the magnitude of which and hence the incidence of hypotension was decreased by AVP in a dose-dependent manner. While in BCP, every dose of AVP reduced the HR and SctO2. Accordingly, it increased the incidence of cerebral desaturation (> 20% SctO2 decrease from the baseline value) with no differences in SjvO2 and the incidence of SjvO2 < 50% or SjvO2 < 40% among the groups.ConclusionsAVP ameliorates hypotension associated with BCP in a dose-dependent manner in patients undergoing shoulder surgery under general anesthesia. However, AVP may have negative effects on SctO2 before and after BCP and on SjvO2 before BCP.

Under General Anesthesia Arginine Vasopressin Prevents Hypotension but Impairs Cerebral Oxygenation During Arthroscopic Shoulder Surgery in the Beach Chair Position

Patients undergoing surgery in the beach chair position (BCP) are at a risk of cerebral ischemia. We evaluated the effect of arginine vasopressin (AVP) on hemodynamics and cerebral oxygenation during surgery in the BCP. Thirty patients undergoing shoulder surgery in BCP under propofol-remifentanil anesthesia were randomly allocated either to receive IV AVP 0.07 U/kg (AVP group, N = 15) or an equal volume of saline (control group, N = 15) 2 minutes before taking BCP. Mean arterial blood pressure (MAP), heart rate (HR), jugular venous bulb oxygen saturation (SjvO2), and regional cerebral tissue oxygen saturation (SctO2) were measured after induction of anesthesia and before (presitting in supine position) and after patients took BCP. AVP itself given before the positioning increased MAP and decreased SjvO2 and SctO2 (P < 0.0001), with HR unaffected. Although MAP was decreased by BCP in both groups, it was higher in the AVP group (P < 0.0001). While in BCP, HR remained unaltered in the control and decreased in the AVP group. SjvO2 in BCP did not differ between the groups. SctO2 was decreased by BCP in both groups, which was more pronounced in the AVP group until the end of study. The incidence of hypotension (13% vs 67%; P = 0.003) was less frequent, and that of cerebral desaturation (>20% SctO2 decrease from presitting value) (80% vs 13%; P = 0.0003) was higher in the AVP group. The incidence of jugular desaturation (SjvO2 <50%) was comparable between the groups. A prophylactic bolus administration of AVP prevents hypotension associated with BCP in patients undergoing shoulder surgery under general anesthesia. However, it was associated with regional cerebral but not jugular venous oxygen desaturation on upright positioning.

Influence of Beach Chair Position on Cerebral Oxygen Saturation

Although beach chair position (BCP) is frequently used for shoulder surgery, a potentially detrimental influence on cerebral oxygenation is discussed. Therefore, the present study investigated changes in regional cerebral oxygen saturation (rSO2/StO2) during BCP comparing 2 different devices for near-infrared spectroscopy measurement. Data were collected in 35 patients undergoing shoulder surgery in BCP and compared with a control group of 35 awake volunteers. The rSO2/StO2 was assessed using INVOS and FORE-SIGHT monitors. Mean arterial blood pressure (MAP), peripheral oxygen saturation (SpO2), PeCO2, FiO2, end-tidal sevoflurane concentration, and rSO2/StO2 were measured before positioning, during BCP, and in supine position after surgery. A decrease in rSO2/StO2 could be observed after BCP (INVOS: 76.1% supine vs. 66.7% BCP, P<0.001; FORE-SIGHT: 78.6% supine, 66.1% BCP, P<0.001), which was reversible in supine position. This decrease correlated with MAP during BCP, while in supine position no correlation was detected. In control group BCP did not influence rSO2/StO2. Changes detected with INVOS or FORE-SIGHT cerebral oximeter did not differ. BCP is associated with a decrease in rSO2/StO2 of 10% in anesthetized patients, which is reversible after repositioning. No changes occurred in supine position under general anesthesia as well as in awake subjects in BCP. This underlines the assumption that vasodilation by anesthetics in combination with BCP evoke a drop in rSO2/StO2. A strict hemodynamic management may be necessary to prevent desaturation events. Despite different technology used by the devices, the results of INVOS and FORE-SIGHT cerebral oximeters are comparable.

Retracted: Haemodynamics and cerebral oxygenation during arthroscopic shoulder surgery in beach chair position under general anaesthesia

Patients undergoing surgery in beach chair position (BCP) are at risk of cerebral ischaemia. We determined the prevalence and risk factors of jugular venous bulb oxygen desaturation (SjvO(2) < 50%) in BCP. It was also examined whether regional cerebral tissue oxygen saturation (SctO(2) ) measured by near-infrared spectroscopy and SjvO(2) are interchangeable for assessment of cerebral oxygenation. Fifty-six consecutive patients undergoing arthroscopic shoulder surgery in BCP were studied. Anaesthesia was intravenous with propofol and remifentanil (P/R) or inhalational with sevoflurane and 50% nitrous oxide (S/N) depending on provider choice. Mean arterial pressure (MAP), heart rate (HR), SjvO(2) , and SctO(2) were measured before (baseline; post-induction in supine position) and after the patients assumed BCP. Bland-Altman analysis was performed to measure the agreement between SctO(2) and SjvO(2) . SjvO(2) , SctO(2) , MAP, and HR decreased significantly when patients were raised into BCP. Jugular desaturation occurred in 41% of patients (56% with P/R vs. 21% with S/N anaesthesia, P = 0.0077). Risk factors for the desaturation included P/R anaesthesia [adjusted odds ratio (aOR) 4.76, 95% confidence interval (CI) 1.34-16.95, P = 0.016] and MAP < 50 mmHg (aOR 3.85, 95% CI 1.21-12.25, P = 0.023). Bland-Altman analysis showed a mean difference of -8.9% with 95% limit of agreement between -40.0% and 23.0%. The percentage error [1.96 standard deviation/mean of the reference method] was 48.5%. The incidence of jugular desaturation in BCP was 41%, and P/R anaesthesia and hypotension were associated with its occurrence while undergoing surgery under general anaesthesia. SctO(2) may not replace SjvO(2) for the determination of cerebral oxygenation.

Cerebral Oxygen Saturation Measured by Near-infrared Spectroscopy and Jugular Venous Bulb Oxygen Saturation during Arthroscopic Shoulder Surgery in Beach Chair Position under Sevoflurane-Nitrous Oxide or Propofol-Remifentanil Anesthesia

We examined the effects of different anesthetics on cerebral oxygenation and systemic hemodynamics in patients undergoing surgery in beach chair position (BCP). Jugular venous bulb oxygen saturation (SjvO2) and regional cerebral tissue oxygen saturation (SctO2) were determined while patients were placed from the supine to BCP. Whether SctO2 and SjvO2 are interchangeable in assessing the cerebral oxygenation was also examined. Forty patients undergoing shoulder surgery in BCP were randomly assigned to receive sevoflurane-nitrous oxide (S/N) or propofol-remifentanil (P/R) anesthesia. Four patients taking angiotensin II receptor antagonists were excluded post hoc. Mean arterial pressure and heart rate, as well as SjvO2 and SctO2, were measured before (postinduction baseline in supine position) and after BCP. Mean arterial pressure decreased by BCP in both groups. It was, however, significantly higher in S/N (n = 19) than in P/R group (n = 17) at 7 to 8 min after the positioning. SjvO2 also significantly decreased after BCP in both groups, the magnitude of which was lower in S/N than in P/R group (11 ± 10% vs. 23 ± 9%, P = 0.0006). The incidences of SjvO2 <50% and mean arterial pressure less than 50 mmHg were lower in S/N group, but SctO2and the incidence of cerebral desaturation (more than 20% decrease from baseline) did not significantly differ between the groups. SctO2 and SjvO2 were only weakly correlated (β = 0.218, r2 = 0.133). Bland-Altman analysis showed a mean difference of -7.2% with 95% limit of agreement between -38.2% and 23.8%. The margin of safety against impaired cerebral oxygenation is greater and SjvO2 is more preserved with S/N than with P/R anesthesia. SctO2 may not be reliable in detecting a low SjvO2 during the surgery in BCP.

Isolated unilateral hypoglossal nerve palsy after shoulder surgery in beach-chair position

Arthroscopy for the treatment of shoulder pathology has been widely accepted. The complications associated with this minimally invasive technique have been reported by many investigators.1,11,12,14,15,17 Among the complications, major nerve and cutaneous nerve injuries around the arthroscopic portal are frequently observed.11,12,15 On the other hand, neurologic injuries resulting in neurapraxia have been reported infrequently.9,12,15 To the best of our knowledge, the only report involving unilateral hypoglossal neurapraxia after arthroscopic surgery or combined open surgery of the shoulder was by Mullins et al.