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01-07-2019 | Original Article

Cerebral Oxygenation in the Sitting Position Is Not Compromised During Spontaneous or Positive-Pressure Ventilation

Authors: Jacques T. YaDeau, MD, PhD, Richard L. Kahn, MD, Yi Lin, MD, PhD, Enrique A. Goytizolo, MD, Michael A. Gordon, MD, Yuliya Gadulov, MD, Sean Garvin, MD, Kara Fields, MS, Amanda Goon, BA, Isabel Armendi, BSc, David M. Dines, MD, Edward V. Craig, MD, MPH

Published in: HSS Journal ® | Issue 2/2019

Abstract

Background

General anesthesia with neuromuscular blockade may facilitate total shoulder arthroplasty but appears to increase risk of cerebral oxygen desaturation. Cerebral desaturation is undesirable and is a proxy for risk of stroke.

Purposes/Questions

This study tested the hypothesis that cerebral oxygen desaturation occurs frequently during general anesthesia with neuromuscular blockade and positive-pressure ventilation but does not occur with spontaneous ventilation. Correlations were sought among cerebral oxygen saturation, blood pressure, and cardiac index.

Methods

We designed a prospective, observational, cohort study to measure cerebral oxygenation in 25 patients during general anesthesia, both with and without positive-pressure ventilation. Patients undergoing elective shoulder arthroplasty in the sitting position received an arterial catheter, near-infrared spectroscopic measurement of cerebral oxygenation, and non-invasive cardiac output measurement. Moderate hypotension was allowed. Blood pressure was supported as needed with ephedrine or low-dose epinephrine (but avoiding phenylephrine). Hypercapnia (45 to 55 mmHg) was targeted during positive-pressure ventilation.

Results

No cerebral oxygen desaturations occurred, regardless of ventilation mode. Under positive-pressure ventilation, the median (interquartile range: Q1, Q3) cerebral oxygenation was 110% of baseline (104, 113), the mean arterial pressure was 62% of baseline (59, 69), and the cardiac index was 82% of baseline (71, 104). Cerebral oxygenation did not correlate with blood pressure or cardiac index but had moderate correlation with end-tidal carbon dioxide. No strokes occurred.

Conclusions

There were no signs of inadequate brain perfusion during general anesthesia using paralytic agents. Positive-pressure ventilation with moderate hypotension in the sitting position does not endanger patients, in the context of moderate hypercapnia and hemodynamic support using ephedrine or epinephrine.

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Aguirre J, Borgeat A, Trachsel T, Cobo Del Prado I, De Andres J, Buhler P. Cerebral oxygenation in patients undergoing shoulder surgery in beach chair position: comparing general to regional anesthesia and the impact on neurobehavioral outcome. Rev Esp Anestesiol Reanim. 2014;61(2):64–72.CrossRefPubMed

Bijker JB, Persoon S, Peelen LM, et al. Intraoperative hypotension and perioperative ischemic stroke after general surgery. Anesthesiology. 2012;116(3):658–664.CrossRefPubMed

Cote R, Battista RN, Wolfson C, Boucher J, Adam J, Hachinski V. The Canadian Neurological Scale: validation and reliability assessment. Neurology. 1989;39(5): 638–643.CrossRefPubMed

Drummond JC. Stroke and intraoperative hypotension: to sleep, perchance to stroke—ay, there’s the rub. Anesth Analg. 2016;123(4):814–815CrossRefPubMed

Friedman DJ, Parnes NZ, Zimmer Z, Higgins LD, Warner JP. Prevalence of cerebrovascular events during shoulder surgery and association with patient position. Orthopedics. 2009;32:256.CrossRef

Gillespie R, Shishani Y, Streit J, et al. The safety of controlled hypotension for shoulder arthroscopy in the beach-chair position. J Bone Joint Surg Am. 2012;94:1284–1290.CrossRefPubMed

Koh JL, Levin SD, Chehab EL, Murphy GS. Cerebral oxygenation in the beach chair position: a prospective study on the effect of general anesthesia compared with regional anesthesia and sedation. J Shoulder Elbow Surg. 2013;22(10):1325–1331.CrossRefPubMed

Laflam A, Joshi B, Brady K, Yenokyan G, Brown C, Everett A, et al. 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: The Anesthesia Patient Safety Foundation Beach Chair Study. Anesth Analg. 2015;120(1):176–185.CrossRefPubMedPubMedCentral

Lee JH, Min KT, Chun YM, Kim EJ, Choi SH. Effects of beach-chair position and induced hypotension on cerebral oxygen saturation in patients undergoing arthroscopic shoulder surgery. Arthroscopy 2011;27(7):889–894.CrossRefPubMed

10.

Mazzon D, Danelli G, Poole D, Marchini C, Bianchin C. Beach chair position, general anesthesia and deliberated hypotension during shoulder surgery: a dangerous combination!. Minerva Anestesiol. 2009;75(5):281–282.PubMed

11.

McCulloch TJ, Liyanagama K, Petchell J. Relative hypotension in the beach-chair position: effects on middle cerebral artery blood velocity. Anaesth Intensive Care. 2010;38(3):486–491.CrossRefPubMed

12.

Meng L, Cannesson M, Alexander BS, et al. Effect of phenylephrine and ephedrine bolus treatment on cerebral oxygenation in anaesthetized patients. Br J Anaesth. 2011;107(2):209–217.CrossRefPubMedPubMedCentral

13.

Murphy GS, Szokol JW, Avram MJ, et al. Effect of ventilation on cerebral oxygenation in patients undergoing surgery in the beach chair position: a randomized controlled trial. Br J Anaesth. 2014;113:618–627.CrossRefPubMed

14.

Murphy GS, Szokol JW, Marymont JH, et al. Cerebral oxygen desaturation events assessed by near-infrared spectroscopy during shoulder arthroscopy in the beach chair and lateral decubitus positions. Anesth Analg. 2010;111(2):496–505.CrossRefPubMed

15.

Ono M, Zheng Y, Joshi B, Sigl JC, Hogue CW. Validation of a stand-alone near infrared spectroscopy system for monitoring cerebral autoregulation during cardiac surgery. Anesth Analg. 2013;116(1):198–204.CrossRefPubMed

16.

Paul JE, Ling E, Lalonde C, Thabane L. Deliberate hypotension in orthopedic surgery reduces blood loss and transfusion requirements: a meta-analysis of randomized controlled trials. Can J Anaesth. 2007;54(10):799–810.CrossRefPubMed

17.

Picton P, Dering A, Alexander A, et al. Influence of ventilation strategies and anesthetic techniques on regional cerebral oximetry in the beach chair position. Anesthesiology. 2015;123(4):765–774.CrossRefPubMedPubMedCentral

18.

Pin-on P, Schroeder D, Munis J. 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. Anesth Analg. 2013;116(6):1317–1324.CrossRefPubMed

19.

Pohl A, Cullen DJ. Cerebral ischemia during shoulder surgery in the upright position: a case series. J Clin Anesth. 2005;17:463–469.CrossRefPubMed

20.

Porter JM, Pidgeon C, Cunningham AJ. The sitting position in neurosurgery: a critical appraisal. Br J Anaesth. 1999;82(1):117–128.CrossRefPubMed

21.

Salazar D, Sears BW, Andre J, Tonino P, Marra G. Cerebral desaturation during shoulder arthroscopy: a prospective observational study. Clin Orthop Relat Res. 2013;471:4027–4034.CrossRefPubMedPubMedCentral

22.

So J, Shin WJ, Shim JH. A cardiovascular collapse occurred in the beach chair position for shoulder arthroscopy under general anesthesia—a case report. Korean J Anesthesiol. 2013;64(3):265–267.CrossRefPubMedPubMedCentral

23.

Soeding PF, Hoy S, Hoy G, Evans M, Royse CF. Effect of phenylephrine on the haemodynamic state and cerebral oxygen saturation during anesthesia in the upright position. Br J Anaesth. 2013;111(2):229–234.CrossRefPubMed

24.

Triplet JJ, Lonetta CM, Levy JC, Everding NG, Moor MA. Cerebral desaturation events in the beach chair position: correlation of noninvasive blood pressure and estimated temporal mean arterial pressure. J Shoulder Elbow Surg. 2015;34:135–137.

25.

Ya Deau JT. CORR Insights: hypotensive epidural anesthesia reduces blood loss in pelvic and sacral bone tumor resections. Clin Orthop Relat Res. 2017;475(3):641–642.CrossRef

26.

Ya Deau JT, Casciano M, Liu SS, et al. Stroke, regional anesthesia in the sitting position, and hypotension: a review of 4169 ambulatory surgery patients. Reg Anesth Pain Med. 2011;123(4):765–774.

27.

Ya Deau JT, Liu SS, Bang H, et al. Cerebral oximetry desaturation during shoulder surgery performed in a sitting position under regional anesthesia. Can J Anaesth. 2011;58(11):986–992.CrossRef

Title: Cerebral Oxygenation in the Sitting Position Is Not Compromised During Spontaneous or Positive-Pressure Ventilation
Authors: Jacques T. YaDeau, MD, PhD
Richard L. Kahn, MD
Yi Lin, MD, PhD
Enrique A. Goytizolo, MD
Michael A. Gordon, MD
Yuliya Gadulov, MD
Sean Garvin, MD
Kara Fields, MS
Amanda Goon, BA
Isabel Armendi, BSc
David M. Dines, MD
Edward V. Craig, MD, MPH
Publication date: 01-07-2019
Publisher: Springer US
Published in: HSS Journal ® / Issue 2/2019
Print ISSN: 1556-3316
Electronic ISSN: 1556-3324
DOI: https://doi.org/10.1007/s11420-018-9642-4

At a glance: The STEP trials

Springer Medicine

Cerebral Oxygenation in the Sitting Position Is Not Compromised During Spontaneous or Positive-Pressure Ventilation

Abstract

Background

Purposes/Questions

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Purposes/Questions

Methods

Results

Conclusions

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