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Hoffman RA, Green A, Paxton ES. Optimizing Visualization in Shoulder Arthroscopy: An Evidence-Based Guide. J Am Acad Orthop Surg 2024:00124635-990000000-01033. [PMID: 38996206 DOI: 10.5435/jaaos-d-23-01025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Indexed: 07/14/2024] Open
Abstract
Advances in arthroscopy have contributed toward improved understanding and management of diverse pathological conditions in the shoulder. As a result, arthroscopy is often preferred by both patients and surgeons. However, surgery can be complicated by limited visualization. Techniques to improve visualization include patient and portal positioning, mechanical débridement, radiofrequency ablation, epinephrine added to irrigation fluid, tranexamic acid administration, and controlled hypotensive anesthesia. Despite published literature on each, a thorough understanding of the evidence supporting these techniques and adjuvants is essential to interpret the clinical utility of each.
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Affiliation(s)
- Ryan A Hoffman
- From the Division of Shoulder and Elbow Surgery, Warren Alpert Medical School of Brown University, Providence, RI
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Li Z, Zhu Y, Qin S, Gao X, Kang Y, Li S, Chai J. Effects of permissive hypercapnia on intraoperative cerebral oxygenation and early postoperative cognitive function in older patients with non-acute fragile brain function undergoing laparoscopic colorectal surgery: protocol study. BMC Geriatr 2023; 23:581. [PMID: 37735369 PMCID: PMC10512528 DOI: 10.1186/s12877-023-04125-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 06/21/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Perioperative brain protection in older patients has been the focus of research recently; meanwhile, exploring the relationship between regional cerebral oxygen saturation (rSO2) and brain function in the perioperative period has been an emerging and challenging area-the difficulties related to the real-time monitoring of rSO2 and the choice of feasible interventions. As an advanced instrument for intraoperative rSO2 monitoring, the clinical application of near-infrared spectrum (NIRS) cerebral oxygen monitoring has gradually increased in popularity and is being recognized for its beneficial clinical outcomes in patients undergoing cardiac and noncardiac surgery. In addition, although sufficient evidence to support this hypothesis is still lacking, the effect of permissive hypercapnia (PHC) on rSO2 has expanded from basic research to clinical exploration. Therefore, monitoring intraoperative rSO2 in older patients with NIRS technology and exploring possible interventions that may change rSO2 and even improve postoperative cognitive performance is significant and clinically valuable. METHODS This study is a single-center randomized controlled trial (RCT). 76 older patients are enrolled as subjects. Patients who meet the screening criteria will be randomly assigned 1:1 to the control and intervention groups. PHC-based mechanical ventilation will be regarded as an intervention. The primary outcome is the absolute change in the percent change in rSO2 from baseline to the completion of surgery in the intervention and control groups. Secondary outcomes mainly include observations of intraoperative cerebral oxygenation and metabolism, markers of brain injury, and assessments of patients' cognitive function using scale through postoperative follow-up. DISCUSSION The findings of this RCT will reveal the effect of PHC on intraoperative rSO2 in older patients with nonacute fragile brain function (NFBF) and the approximate trends over time, and differences in postoperative cognitive function outcomes. We anticipate that the trial results will inform clinical policy decision-makers in clinical practice, enhance the management of intraoperative cerebral oxygen monitoring in older patients with comorbid NFBF, and provide guidance for clinical brain protection and improved postoperative cognitive function outcomes. TRIAL REGISTRATION ChiCTR, ChiCTR2200062093, Registered 9/15/2022.
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Affiliation(s)
- Zhichao Li
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Youzhuang Zhu
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Shangyuan Qin
- Department of Anesthesiology, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Xin Gao
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yihan Kang
- Department of Anesthesiology, The First Hospital of China Medical University, Shenyang, China
| | - Si Li
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jun Chai
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China.
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Dilmen OK, Akcil EF, Vehid H, Tunali Y. Cerebral oxygenation assessed by near-infrared spectroscopy in the sitting and prone positions during posterior fossa surgery: a prospective, randomized clinical study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:589-594. [PMID: 34626757 PMCID: PMC10533958 DOI: 10.1016/j.bjane.2021.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 09/09/2021] [Accepted: 09/18/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Sitting position (SP) or prone position (PP) are used for posterior fossa surgery. The SP induced reduction in cerebral blood flow and cerebral oxygen saturation (rSO2) has been shown in shoulder surgeries, but there is not enough data in intracranial tumor surgery. Studies showed that PP is safe in terms of cerebral oxygen saturation in patients undergoing spinal surgery. Our hypothesis is that the SP may improve cerebral oxygenation in the patients with intracranial pathologies due to reduction in intracranial pressure. Therefore, we compared the effects of the SP and PP on rSO2 in patients undergoing posterior fossa tumor surgery. METHODS Data were collected patients undergoing posterior fossa surgery, 20 patients in SP compared to 21 patients in PP. The rSO2 was assessed using INVOS monitor. Heart rate (HR), mean arterial pressure (MAP), EtCO2, BIS, and bilateral rSO2 were recorded preoperatively, and at 5, 8, and 11.ßminutes after the intubation and every 3.ßminutes after patient positioning until the initial surgical incision. RESULTS Cerebral oxygenation slowly reduced in both the sitting and prone position patients following the positioning (p.ß<.ß0.002), without any difference between the groups. The HR and MAP were lower in the sitting SP after positioning compared to the PP. CONCLUSION Neurosurgery in the SP and PP is associated with slight reduction in cerebral oxygenation. We speculate that if we rise the lower limit of MAP, we might have showed the beneficial effect of the SP on rSO2.
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Affiliation(s)
- Ozlem Korkmaz Dilmen
- Istanbul University-Cerrahpa..a, Cerrahpasa Faculty of Medicine, Department of Anesthesiology and Intensive Care, Istanbul, Turkey.
| | - Eren Fatma Akcil
- Istanbul University-Cerrahpa..a, Cerrahpasa Faculty of Medicine, Department of Anesthesiology and Intensive Care, Istanbul, Turkey
| | - Hayriye Vehid
- Demiroglu Bilim University, Department of Biostatistics, Istanbul, Turkey
| | - Yusuf Tunali
- Istanbul University-Cerrahpa..a, Cerrahpasa Faculty of Medicine, Department of Anesthesiology and Intensive Care, Istanbul, Turkey
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Lv H, Xiong C, Wu B, Lan Z, Xu D, Duan D, Huang X, Guo J, Yu S. Effects of targeted mild hypercapnia versus normocapnia on cerebral oxygen saturation in patients undergoing laparoscopic hepatectomy under low central venous pressure: a prospective, randomized controlled study. BMC Anesthesiol 2023; 23:257. [PMID: 37525100 PMCID: PMC10388477 DOI: 10.1186/s12871-023-02220-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 07/26/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Laparoscopic hepatectomy under low central venous pressure (LCVP) is associated with intraoperative organ hypoperfusion, including cerebral hypoperfusion. We hypothesized that a ventilation strategy designed to achieve targeted mild hypercapnia (TMH) (end-tidal carbon dioxide partial pressure [PetCO2] of 45 ± 5 mmHg) rather than targeted normocapnia (TN) (PetCO2 of 30 ± 5 mmHg) would increase regional cerebral oxygen saturation (rSO2) during laparoscopic hepatectomy under LCVP. METHODS Eighty patients undergoing laparoscopic hepatectomy under LCVP were randomly divided into the TMH group (n = 40) and the TN group (n = 40). Mechanical ventilation was adjusted to maintain the PetCO2 within the relevant range. Cerebral oxygenation was monitored continuously using the FORE-SIGHT system before anesthetic induction until the patient left the operating room. Patient and surgical characteristics, rSO2, intraoperative hemodynamic parameters (CVP, mean artery blood pressure [MAP], and heart rate), PetCO2, intraoperative blood gas analysis results, and postoperative complications were recorded. RESULTS No significant differences were observed in CVP, MAP, and heart rate between the two groups during surgery. The rSO2 was significantly lower in the TN group on both the left and right sides during the intraoperative period (P < 0.05), while the TMH group had a stable rSO2. In the TN group, the mean rSO2 decreased most during liver parenchymal transection when compared with the baseline value (P < 0.05). The mean (standard deviation) percentage change in rSO2 from baseline to parenchymal transection was - 7.5% (4.8%) on the left and - 7.1% (4.6%) on the right. The two groups had a similar incidence of postoperative complications (P > 0.05). CONCLUSION Our findings demonstrate that rSO2 is better maintained during laparoscopic hepatectomy under LCVP when patients are ventilated to a PetCO2 of 45 ± 5 mmHg (TMH) than a PetCO2 of 30 ± 5 mmHg (TN). TRIAL REGISTRATION ChiCTR2100051130(14/9/2021).
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Affiliation(s)
- Huayan Lv
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Chang Xiong
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Bo Wu
- Department of Hepatological Surgery, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Zhijian Lan
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Duojia Xu
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Dingnan Duan
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Xiaoxia Huang
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China
| | - Jun Guo
- Department of Anesthesiology, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China.
| | - Shian Yu
- Department of Hepatological Surgery, Jinhua Hospital Affiliated to Zhejiang University School of Medicine, Jinhua, Zhejiang Province, People's Republic of China.
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Verbesserung der Sichtverhältnisse bei der Schulterarthroskopie. ARTHROSKOPIE 2022. [DOI: 10.1007/s00142-022-00582-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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6
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Holst JM, Klitholm MP, Henriksen J, Vallentin MF, Jessen MK, Bolther M, Holmberg MJ, Høybye M, Lind PC, Granfeldt A, Andersen LW. Intraoperative Respiratory and Hemodynamic Strategies for Reducing Nausea, Vomiting, and Pain after Surgery: Systematic Review and Meta-Analysis. Acta Anaesthesiol Scand 2022; 66:1051-1060. [PMID: 35924389 PMCID: PMC9545575 DOI: 10.1111/aas.14127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 07/08/2022] [Accepted: 07/21/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite improved medical treatment strategies, post-operative pain, nausea, and vomiting remain major challenges. This systematic review investigated the relationship between perioperative respiratory and hemodynamic interventions and postoperative pain, nausea, and vomiting. METHODS PubMed and Embase were searched on March 8, 2021 for randomized clinical trials investigating the effect of perioperative respiratory or hemodynamic interventions in adults undergoing non-cardiac surgery. Investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Meta-analyses were performed when feasible. GRADE was used to assess the certainty in the evidence. RESULTS This review included 65 original trials; of these 48% had pain, nausea and/or vomiting as the primary focus. No reduction of postoperative pain was found in meta-analyses when comparing recruitment maneuvers with no recruitment, high (80%) to low (30%) fraction of oxygen, low (5-7 ml/kg) to high (9-12 ml/kg) tidal volume, or goal-directed hemodynamic therapy to standard care. In the meta-analysis comparing recruitment maneuvers with no recruitment maneuvers, patients undergoing laparoscopic gynecological surgery had less shoulder pain 24 hours postoperatively (mean difference in the numeric rating scale from 0 to 10: -1.1, 95% CI: -1.7, -0.5). In meta-analyses, comparing high to low fraction of inspired oxygen and goal-directed hemodynamic therapy to standard care in patients undergoing abdominal surgery, the risk of postoperative nausea and vomiting was reduced (odds ratio: 0.45, 95% CI: 0.24, 0.87 and 0.48, 95% CI: 0.27, 0.85). The certainty in the evidence was mostly very low to low. The results should be considered exploratory given the lack of pre-specified hypotheses and corresponding risk of Type 1 errors. CONCLUSION There is limited evidence regarding the impact of intraoperative respiratory and hemodynamic interventions on postoperative pain or nausea and vomiting. More definitive trials are needed to guide clinical care within this area. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Johanne M Holst
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Maibritt P Klitholm
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Jeppe Henriksen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Mikael F Vallentin
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
| | - Marie K Jessen
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Maria Bolther
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Mathias J Holmberg
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Anesthesiology and Intensive Care, Randers Regional Hospital, Randers, Denmark
| | - Maria Høybye
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Peter Carøe Lind
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Asger Granfeldt
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lars W Andersen
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark.,Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Prehospital Emergency Medical Services, Central Denmark Region, Aarhus, Denmark
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Cerebral Tissue Oxygen Saturation Is Enhanced in Patients following Transcatheter Aortic Valve Implantation: A Retrospective Study. J Clin Med 2022; 11:jcm11071930. [PMID: 35407537 PMCID: PMC8999949 DOI: 10.3390/jcm11071930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 03/24/2022] [Accepted: 03/28/2022] [Indexed: 11/16/2022] Open
Abstract
Transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement. The aim of this study was to evaluate whether a relevant alteration in cerebral tissue oxygen saturation (rSO2) could be detected following TAVI. Retrospective data analysis included 275 patients undergoing TAVI between October 2016 and December 2020. Overall, rSO2 significantly increased following TAVI (64.6 ± 10% vs. 68.1 ± 10%, p < 0.01). However, a significant rise was only observed in patients with a preoperative rSO2 < 60%. Of the hemodynamic confounders studied, hemoglobin, mean arterial pressure and blood pH were lowered, while central venous pressure and arterial partial pressure of carbon dioxide (PaCO2) were slightly elevated (PaCO2: 39 (36−43) mmHg vs. 42 (37−47) mmHg, p = 0.03; pH: 7.41 (7.3−7.4) vs. 7.36 (7.3−7.4), p < 0.01). Multivariate linear regression modeling identified only hemoglobin as a predictor of altered rSO2. Patients with a EuroScore II above 4% and an extended ICU stay were found to have lower rSO2, while no difference was observed in patients with postoperative delirium or between the implanted valve types. Further prospective studies that eliminate differences in potential confounding variables are necessary to confirm the rise in rSO2. Future research should provide more information on the value of cerebral oximetry for identifying high-risk patients who will require further clinical interventions in the setting of the TAVI procedure.
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Park CG, Jung WS, Park HY, Kim HW, Kwak HJ, Jo YY. Comparison of the Effects of Normocapnia and Mild Hypercapnia on the Optic Nerve Sheath Diameter and Regional Cerebral Oxygen Saturation in Patients Undergoing Gynecological Laparoscopy with Total Intravenous Anesthesia. J Clin Med 2021; 10:jcm10204707. [PMID: 34682830 PMCID: PMC8540822 DOI: 10.3390/jcm10204707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/06/2021] [Accepted: 10/11/2021] [Indexed: 11/16/2022] Open
Abstract
Cerebral hemodynamics may be altered by hypercapnia during a lung-protective ventilation (LPV), CO2 pneumoperitoneum, and Trendelenburg position during general anesthesia. The purpose of this study was to compare the effects of normocapnia and mild hypercapnia on the optic nerve sheath diameter (ONSD), regional cerebral oxygen saturation (rSO2), and intraoperative respiratory mechanics in patients undergoing gynecological laparoscopy under total intravenous anesthesia (TIVA). Sixty patients (aged between 19 and 65 years) scheduled for laparoscopic gynecological surgery in the Trendelenburg position. Patients under propofol/remifentanil total intravenous anesthesia were randomly assigned to either the normocapnia group (target PaCO2 = 35 mmHg, n = 30) or the hypercapnia group (target PaCO2 = 50 mmHg, n = 30). The ONSD, rSO2, and respiratory and hemodynamic parameters were measured at 5 min after anesthetic induction (Tind) in the supine position, and at 10 min and 40 min after pneumoperitoneum (Tpp10 and Tpp40, respectively) in the Trendelenburg position. There was no significant intergroup difference in change over time in the ONSD (p = 0.318). The ONSD increased significantly at Tpp40 when compared to Tind in both normocapnia and hypercapnia groups (p = 0.02 and 0.002, respectively). There was a significant intergroup difference in changes over time in the rSO2 (p < 0.001). The rSO2 decreased significantly in the normocapnia group (p = 0.01), whereas it increased significantly in the hypercapnia group at Tpp40 compared with Tind (p = 0.002). Alveolar dead space was significantly higher in the normocapnia group than in the hypercapnia group at Tpp40 (p = 0.001). In conclusion, mild hypercapnia during the LPV might not aggravate the increase in the ONSD during CO2 pneumoperitoneum in the Trendelenburg position and could improve rSO2 compared to normocapnia in patients undergoing gynecological laparoscopy with TIVA.
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Affiliation(s)
| | | | | | | | - Hyun-Jeong Kwak
- Correspondence: (H.-J.K.); (Y.-Y.J.); Tel.: +82-322-460-3637 (H.-J.K.); +82-322-460-3651 (Y.-Y.J.); Fax: 82-32-469-6319 (H.-J.K. & Y.-Y.J.)
| | - Youn-Yi Jo
- Correspondence: (H.-J.K.); (Y.-Y.J.); Tel.: +82-322-460-3637 (H.-J.K.); +82-322-460-3651 (Y.-Y.J.); Fax: 82-32-469-6319 (H.-J.K. & Y.-Y.J.)
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9
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Coşarcan SK, Gurkan Y, Doğan AT, Koyuncu Ö, Erçelen Ö. Could Interscalene Block Possibly be Protective Against Cerebral Ischemia During Shoulder Surgery in a Beach Chair Position? Cureus 2021; 13:e16773. [PMID: 34476141 PMCID: PMC8404480 DOI: 10.7759/cureus.16773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction Arthroscopic shoulder surgeries are usually performed in a sitting position. The sitting position is known to cause physiological changes related to cardiovascular adaptation. Interscalene nerve blocks (ISB) are the most commonly used techniques and are considered gold standard regional anesthesia methods for shoulder surgeries. Cerebral vessels located around sympathetic ganglia provide sympathetic system integrity. This local anesthetic spreading during ISB could be a side effect or provide a protective effect on cerebral ischemia. Our study aimed to investigate the cerebral protective effect of the ISB in arthroscopic shoulder surgeries in a sitting position. Material and methods After the approval of Koç University Clinical Research Ethics Committee (2020.020.IRB1.011), records of patients between January and December 2019 with shoulder arthroscopy at the Vehbi Koç Foundation (VKV) American hospital were retrospectively reviewed. Records of the hemodynamic response, INVOSTM (Medtronic, Minneapolis, USA) (rSO2) parameters, pain scores, and additional analgesic needs of all cases were examined in the intraoperative and postoperative period. Results Data of 40 patients who met the criteria to be included in the study was analyzed. Our study showed that the sitting position leading to hypotension coincided with a decrease in INVOS values. Nevertheless, we did not record any significant hypotension after ISB, and this may be due to the use of a minimal dose of local anesthetic. There was a certain increase in near-infrared spectroscopy (NIRS) values after ISB. We saw that the value of regional oxygen saturation (rSO2) increased on both the ISB side and the non-ISB side. This shows that the ISB can have a global impact on the brain. Specificially, the increase in rSO2 values in the ISB side compared to the other side suggests that ISB has possible positive effects on cerebral blood flow. Conclusion Our study has shown that ISB may transiently increase the rSO2 levels in the sitting position during shoulder surgery.
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Affiliation(s)
| | | | | | - Özgür Koyuncu
- Orthopaedics and Traumatology, VKV American Hospital, Istanbul, TUR
| | - Ömür Erçelen
- Anesthesiology, VKV American Hospital, Istanbul, TUR
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10
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Tantry TP, Bg M, Karanth H, Shetty PK, Shenoy SP, Kadam D, Tantry G, Shetty R. Prophylactic measures to prevent cerebral oxygen desaturation events in elective beach-chair position shoulder surgeries; a systematic review and meta-analysis. Korean J Anesthesiol 2021; 74:422-438. [PMID: 34167290 PMCID: PMC8497913 DOI: 10.4097/kja.21069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/20/2021] [Indexed: 11/16/2022] Open
Abstract
Background Prophylaxis 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. Methods We 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. Results Twelve 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. Conclusions Targeted 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.
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Affiliation(s)
- Thrivikrama P Tantry
- Department of Anaesthesiology, A J Institute of Medical Sciences & Research Centre, Kuntikana, Mangalore, India
| | - Muralishankar Bg
- Department of Anaesthesiology, A J Institute of Medical Sciences & Research Centre, Kuntikana, Mangalore, India
| | - Harish Karanth
- Department of Anaesthesiology, A J Institute of Medical Sciences & Research Centre, Kuntikana, Mangalore, India
| | - Pramal K Shetty
- Department of Anaesthesiology, A J Institute of Medical Sciences & Research Centre, Kuntikana, Mangalore, India
| | - Sunil P Shenoy
- Department of Urology and Renal transplant, A J Institute of Medical Sciences & Research Centre, Kuntikana, Mangalore, India
| | - Dinesh Kadam
- Department of Plastic and Reconstructive Surgery, A J Institute of Medical Sciences & Research Centre, Kuntikana, Mangalore, India
| | - Gururraj Tantry
- Department of Anaesthesiology, A J Institute of Medical Sciences & Research Centre, Kuntikana, Mangalore, India
| | - Rithesh Shetty
- Department of Anaesthesiology, A J Institute of Medical Sciences & Research Centre, Kuntikana, Mangalore, India
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11
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Hansen ML, Hyttel-Sørensen S, Jakobsen JC, Gluud C, Kooi EMW, Mintzer J, de Boode WP, Fumagalli M, Alarcon A, Alderliesten T, Greisen G. The clinical effects of cerebral near-infrared spectroscopy monitoring (NIRS) versus no monitoring: a protocol for a systematic review with meta-analysis and trial sequential analysis. Syst Rev 2021; 10:111. [PMID: 33863369 PMCID: PMC8052775 DOI: 10.1186/s13643-021-01660-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 04/01/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Multiple clinical conditions are associated with cerebral hypoxia/ischaemia and thereby an increased risk of hypoxic-ischaemic brain injury. Cerebral near-infrared spectroscopy monitoring (NIRS) is a tool to monitor brain oxygenation and perfusion, and the clinical uptake of NIRS has expanded over recent years. Specifically, NIRS is used in the neonatal, paediatric, and adult perioperative and intensive care settings. However, the available literature suggests that clinical benefits and harms of cerebral NIRS monitoring are uncertain. As rates of clinically significant hypoxic-ischaemic brain injuries are typically low, it is difficult for randomised clinical trials to capture a sufficiently large number of events to evaluate the clinical effect of cerebral NIRS monitoring, when focusing on specific clinical settings. The aim of this systematic review will be to evaluate the benefits and harms of clinical care with access to cerebral NIRS monitoring versus clinical care without cerebral NIRS monitoring in children and adults across all clinical settings. METHODS We will conduct a systematic review with meta-analysis and trial sequential analysis. We will only include randomised clinical trials. The primary outcomes are all-cause mortality, moderate or severe persistent cognitive or neurological deficit, and proportion of participants with one or more serious adverse events. We will search CENTRAL, EMBASE, MEDLINE, and the Science Citation Index Expanded from their inception and onwards. Two reviewers will independently screen all citations, full-text articles, and extract data. The risk of bias will be appraised using the Cochrane risk of bias tool version 2.0. If feasible, we will conduct both random-effects meta-analysis and fixed-effect meta-analysis of outcome data. Additional analysis will be conducted to explore the potential sources of heterogeneity (e.g. risk of bias, clinical setting). DISCUSSION As we include trials across multiple clinical settings, there is an increased probability of reaching a sufficient information size. However, heterogeneity between the included trials may impair our ability to interpret results to specific clinical settings. In this situation, we may have to depend on subgroup analyses with inherent increased risks of type I and II errors. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42020202986 . This systematic review protocol has been submitted for registration in the International Prospective Register of Systematic Reviews (PROSPERO) (http://www.crd.york.ac.uk/prospero) on the 12th of October 2020 and published on the 12th of November 2020 (registration ID CRD42020202986 ).
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Affiliation(s)
- Mathias Lühr Hansen
- Department of Neonatology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Simon Hyttel-Sørensen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, The Capital Region of Denmark, Denmark.,Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, The Capital Region of Denmark, Denmark.,Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Elisabeth M W Kooi
- Division of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jonathan Mintzer
- Department of Pediatrics, Division of Newborn Medicine, Mountainside Medical Center, Montclair, NJ, USA
| | - Willem P de Boode
- Division of Neonatology, Department of Pediatrics, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, Netherlands
| | - Monica Fumagalli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Via Francesc Sforza 35, 20122, Milano, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Via Festa del Perdono 7, 20122, Milano, Italy
| | - Ana Alarcon
- Department of Neonatology, Hospital Sant Joan de Deu, Passeig de Sant Joan de Deu 2, 08950 Esplugues de Llobregat, Barcelona, Spain
| | - Thomas Alderliesten
- Department of Neonatology, University Medical Center Utrecht Brain Center, Utrecht University, Utrecht, Netherlands
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
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12
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Stetson WB, Morgan SA, Polinsky S, Chung B, Hung NJ. Cost Effective Technique of Shoulder Arthroscopy Without the Use of Epinephrine in Irrigation Solution. Arthrosc Tech 2021; 10:e411-e418. [PMID: 33680773 PMCID: PMC7917405 DOI: 10.1016/j.eats.2020.10.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/17/2020] [Indexed: 02/03/2023] Open
Abstract
Arthroscopic surgery of the shoulder joint and the subacromial space requires adequate visualization to be effectively performed. Visual clarity is essential to perform a safe and successful arthroscopic procedure. The major determinants to provide visualization in the subacromial space and the glenohumeral joint include adequate inflow (dependent on the dimension of the inflow cannula), flow rate versus pressure, pump system versus gravity, the use of electrocautery and radiofrequency devices, blood pressure control and hypotensive anesthesia, and the type of irrigation solution used with or without the use of epinephrine. In 2012, the cost of a 30-mL (30-mg) vial of epinephrine was $6 (adrenalin/epinephrine injection, USP, Par Pharmaceuticals), and approximately 3 to 4 bottles would be used on average for a single shoulder arthroscopy. In 2019, the same 30-mL bottle of epinephrine cost $237, a nearly 40-fold increase. The purpose of our study is to describe the various factors and techniques that can be used to maintain visual clarity in shoulder arthroscopy without the use of epinephrine in the irrigation solution and the cost savings associated without the use of epinephrine.
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Affiliation(s)
- William B. Stetson
- Stetson Lee Orthopedics and Sports Medicine, Burbank, California, U.S.A.,Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A.,Address correspondence to William B. Stetson, M.D., Stetson Lee Orthopedics and Sports Medicine, 191 South Buena Vista St., Ste. #470, Burbank, CA 91505.
| | | | - Samuel Polinsky
- Stetson Lee Orthopedics and Sports Medicine, Burbank, California, U.S.A
| | - Brian Chung
- Stetson Lee Orthopedics and Sports Medicine, Burbank, California, U.S.A.,Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Nicole J. Hung
- Stetson Lee Orthopedics and Sports Medicine, Burbank, California, U.S.A
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13
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Golz AG, Davis WJ, Perry MW, Tonino PM, Garbis NG, Salazar DH. Improving the safety of shoulder arthroscopy in the beach chair position: a prospective randomized trial investigating the effect of compression stockings on cerebral desaturation events in obese patients. J Shoulder Elbow Surg 2020; 29:2027-2035. [PMID: 32590064 DOI: 10.1016/j.jse.2020.05.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/20/2020] [Accepted: 05/24/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Devastating transient and permanent postoperative neurocognitive complications in previously healthy, low-risk patients have been observed after elective shoulder arthroscopy in the beach chair position (BCP). Continuous monitoring of cerebral oxygen saturation has been recommended to identify cerebral desaturation events (CDEs) and improve patient safety. However, the relatively high cost and limited availability of monitoring may not be cost-effective. More cost-effective and available measures, including the use of thigh-high compression stockings (CS), have been investigated. However, efficacy data of CS usage is limited, especially for obese patients, who have been shown to be at increased risk for CDEs. The purpose of this was study was to determine if the intraoperative addition of thigh-high compression stockings decreases the incidence, frequency, and magnitude of CDEs in obese patients undergoing shoulder arthroscopy in the BCP. METHODS Thirty-three patients in the treatment group wore both thigh-high compression stockings (CS) and sequential compression devices (SCDs), and the remaining 33 patients in the control group wore SCDs alone. Cerebral oximetry was monitored during surgery using near-infrared spectroscopy. RESULTS The incidence of CDEs was equal between groups, with 9 patients (27%) in each experiencing desaturation events. The median number of CDEs per patient was 3 for the control group and 1 for patients wearing CS (P = .29). There was no difference between groups in terms of median time from induction of anesthesia to onset of CDE (P = .79), median time from upright positioning to onset of CDE (P = .60), mean CDE duration per patient (P = .22), and median cumulative CDE duration (P = .19). The median maximal desaturation from baseline was also not different between groups: 27.6% in the control group and 24.3% in the treatment group (P = .35). CONCLUSION The combination of thigh-high CS and SCDs did not decrease the incidence, frequency, or magnitude of CDEs in patients undergoing shoulder arthroscopy in the BCP. Twenty-seven percent of patients undergoing shoulder arthroscopy in the BCP demonstrated CDEs with or without the use of CS. Therefore, further research is required to identify cost-effective, minimally invasive, and universally available methods of decreasing the incidence of CDEs during this common surgical procedure.
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Affiliation(s)
- Andrew G Golz
- Loyola University Medical Center, Stritch School of Medicine, Department of Orthopaedic Surgery and Rehabilitation, Maywood, IL, USA.
| | - William J Davis
- Loyola University Medical Center, Stritch School of Medicine, Department of Orthopaedic Surgery and Rehabilitation, Maywood, IL, USA
| | - Michael W Perry
- Loyola University Medical Center, Stritch School of Medicine, Department of Orthopaedic Surgery and Rehabilitation, Maywood, IL, USA
| | - Pietro M Tonino
- Loyola University Medical Center, Stritch School of Medicine, Department of Orthopaedic Surgery and Rehabilitation, Maywood, IL, USA
| | - Nickolas G Garbis
- Loyola University Medical Center, Stritch School of Medicine, Department of Orthopaedic Surgery and Rehabilitation, Maywood, IL, USA
| | - Dane H Salazar
- Loyola University Medical Center, Stritch School of Medicine, Department of Orthopaedic Surgery and Rehabilitation, Maywood, IL, USA
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14
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Tantry TP, Karanth H, Koteshwar R, Shetty PK, Adappa KK, Shenoy SP, Kadam D, Bhandary S. Adverse heart rate responses during beach-chair position for shoulder surgeries - A systematic review and meta-analysis of their incidence, interpretations and associations. Indian J Anaesth 2020; 64:653-667. [PMID: 32934399 PMCID: PMC7457979 DOI: 10.4103/ija.ija_228_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/02/2020] [Accepted: 07/07/2020] [Indexed: 12/17/2022] Open
Abstract
Background and Aims Evaluations of adverse heart rate (HR)-responses and HR-variations during anaesthesia in beach-chair-position (BCP) for shoulder surgeries have not been done earlier. We analysed the incidence, associations, and interpretations of adverse HR-responses in this clinical setting. Methods We performed a meta-analysis of trials that reported HR-related data in anaesthetised subjects undergoing elective shoulder surgeries in BCP. Studies included prospective, randomised, quasi-randomised and non-randomised, controlled clinical trials as well as observational cohorts. Literature search was conducted in MEDLINE, EMBASE, CINHAL and the Cochrane Central Register of Controlled Trials of the 21st century. In the first analysis, we studied the incidence and associations of bradycardia/hypotension-bradycardia episodes (HBE) with respect to the type of anaesthesia and different pharmacological agents. In the second, we evaluated anaesthetic influences, associations and inter-relationships between monitored parameters with respect to HR-behaviours. Results Among the trials designed with bradycardia/HBE as a primary end point, the observed incidence of bradycardia was 9.1% and that of HBE, 14.9% and 22.7% [(for Interscalene block (ISB) ± sedation) subjects and general anaesthesia (GA) + ISB, respectively]. There was evidence of higher observed risk of developing adverse HR-responses for GA subjects over ISB (Risk Difference, P < 0.05). Concomitant use of β-agonists did not increase risk of HBEs (P = 0.29, I 2= 11.4%) or with fentanyl (P = 0.45, I 2= 0%) for ISB subjects (subgroup analysis). Fentanyl significantly influenced the HR-drop over time [meta-regression, estimates (standard error), 14.9 (5.4), 9.8 (4.3) and 17 (2.6); P = 0.007, 0.024 and <0.001; for early, mid and delayed periods, respectively] in GA subjects. With respect to number of subjects experiencing cerebral desaturation events (CDEs), total intravenous anaesthesia (TIVA)- propofol had higher risk over inhalational anaesthesia (P = 0.006, I 2 = 86.7%). Meta-correlation analysis showed relationships between the HR and rSO2(regional cerebral oxygen saturation) or SjvO2(jugular venous oxygen saturation) values (r = 0.608, 95%CI, 0.439 to 0.735, P < 0.001, I 2= 77.4% and r = 0.397, 95%CI, 0.151 to 0.597, P < 0.001, I 2= 64.3%, respectively). Conclusions There is not enough evidence to claim the associations of adverse HR-responses with any specific factor. HR-fall is maximal with fentanyl and its variability is associated with changes in rSO2. Fall in rSO2 could be the common link triggering adverse HR-responses in BCP.
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Affiliation(s)
- Thrivikrama Padur Tantry
- Department of Anaesthesiology, A J Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, Karnataka, India
| | - Harish Karanth
- Department of Anaesthesiology, A J Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, Karnataka, India
| | - Reshma Koteshwar
- Department of Anaesthesiology, A J Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, Karnataka, India
| | - Pramal K Shetty
- Department of Anaesthesiology, A J Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, Karnataka, India
| | - Karunakara K Adappa
- Department of Anaesthesiology, A J Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, Karnataka, India
| | - Sunil P Shenoy
- Department of Urology, A J Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, Karnataka, India
| | - Dinesh Kadam
- Department of Plastic and Reconstructive Surgery, A J Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, Karnataka, India
| | - Sudarshan Bhandary
- Department of Orthopedics, Arthroscopy and Sports Medicine, A J Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, Karnataka, India
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15
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Wong C, Churilov L, Cowie D, Tan CO, Hu R, Tremewen D, Pearce B, Pillai P, Karalapillai D, Bellomo R, Weinberg L. Randomised controlled trial to investigate the relationship between mild hypercapnia and cerebral oxygen saturation in patients undergoing major surgery. BMJ Open 2020; 10:e029159. [PMID: 32066598 PMCID: PMC7045198 DOI: 10.1136/bmjopen-2019-029159] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES The effects of hypercapnia on regional cerebral oxygen saturation (rSO2) during surgery are unclear. We conducted a randomised controlled trial to investigate the relationship between mild hypercapnia and rSO2. We hypothesised that, compared with targeted normocapnia (TN), targeted mild hypercapnia (TMH) during major surgery would increase rSO2. DESIGN A prospective, randomised, controlled trial in adult participants undergoing elective major surgery. SETTING A single tertiary centre in Heidelberg, Victoria, Australia. PARTICIPANTS 40 participants were randomised to either a TMH or TN group (20 to each). INTERVENTIONS TMH (partial pressure of carbon dioxide in arterial blood, PaCO2, 45-55 mm Hg) or TN (PaCO2 35-40 mm Hg) was delivered via controlled ventilation throughout surgery. PRIMARY AND SECONDARY OUTCOME MEASURES The primary endpoint was the absolute difference between the two groups in percentage change in rSO2 from baseline to completion of surgery. Secondary endpoints included intraoperative pH, bicarbonate concentration, base excess, serum potassium concentration, incidence of postoperative delirium and length of stay (LOS) in hospital. RESULTS The absolute difference between the two groups in percentage change in rSO2 from the baseline to the completion of surgery was 19.0% higher in both hemispheres with TMH (p<0.001). On both sides, the percentage change in rSO2 was greater in the TMH group than the TN group throughout the duration of surgery. The difference between the groups became more noticeable over time. Furthermore, postoperative delirium was higher in the TN group (risk difference 0.3, 95% CI 0.1 to 0.5, p=0.02). LOS was similar between groups (5 days vs 5 days; p=0.99). CONCLUSION TMH was associated with a stable increase in rSO2 from the baseline, while TN was associated with a decrease in rSO2 in both hemispheres in patients undergoing major surgery. This resulted in a clear separation of percentage change in rSO2 from the baseline between TMH and TN over time. Our findings provide the rationale for larger studies on TMH during surgery. TRIAL REGISTRATION NUMBER The Australian New Zealand Clinical Trials Registry (ACTRN12616000320459).
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Affiliation(s)
- Clarence Wong
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Leonid Churilov
- The Department of Medicine, Austin Health, The Univesity of Melbourne, Heidelberg, Victoria, Australia
| | - Dean Cowie
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Chong Oon Tan
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Raymond Hu
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - David Tremewen
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Brett Pearce
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | - Param Pillai
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
| | | | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia
| | - Laurence Weinberg
- Department of Anaesthesia, Austin Health, Heidelberg, Victoria, Australia
- Department of Surgery, Austin Health, The University of Melbourne, Heidelberg, Victoria, Australia
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16
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Cerebral Desaturation Events During Shoulder Arthroscopy in the Beach Chair Position. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2019; 3:e007. [PMID: 31592504 PMCID: PMC6754215 DOI: 10.5435/jaaosglobal-d-19-00007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The beach chair position (BCP) is commonly used position in upper extremity surgery. Although there are many advantages to surgery in this position, there are also potential drawbacks and described complications including devastating neurologic outcomes. The etiology of these complications is postulated to be due to the gravitational effects of the seated position leading to cerebral hypoperfusion. We review the current literature on intraoperative cerebral monitoring and neurocognitive complications with shoulder surgery performed in the BCP. A previous systematic review estimated the incidence of neurocognitive complications after surgery in the BCP to be 0.004%. However, the true incidence is unknown and is likely much more common. Reports of neurologic complications have revealed a need for heightened vigilance, alternative anesthesia techniques, and improved monitoring. Methods for monitoring have included near-infrared spectroscopy, a measurement of cerebral oximetry shown to reliably detect cerebral hypoperfusion. In this literature review, we sought to update the incidence of intraoperative cerebral desaturation events (CDEs) to investigate the relationship of CDEs to neurocognitive complications and to review recent reported cases of neurocognitive complications. Existing literature suggest that accurate intraoperative monitoring of cerebral perfusion may improve patient safety.
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17
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Cerebral Oxygenation in the Sitting Position Is Not Compromised During Spontaneous or Positive-Pressure Ventilation. HSS J 2019; 15:167-175. [PMID: 31327949 PMCID: PMC6609774 DOI: 10.1007/s11420-018-9642-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 09/26/2018] [Indexed: 02/07/2023]
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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18
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Murphy GS, Greenberg SB, Szokol JW. Safety of Beach Chair Position Shoulder Surgery. Anesth Analg 2019; 129:101-118. [DOI: 10.1213/ane.0000000000004133] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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19
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Orebaugh S, Palmeri S, Lin C, YaDeau J. Daring discourse: is nerve block with sedation the safest anesthetic for beach chair position? Reg Anesth Pain Med 2019; 44:707-712. [PMID: 30928909 DOI: 10.1136/rapm-2018-100230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 03/02/2019] [Accepted: 03/06/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Steven Orebaugh
- Anaesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shawn Palmeri
- Anaesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Charles Lin
- Anaesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jacques YaDeau
- Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College, New York City, New York, USA
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20
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Editorial Commentary: "A Rush of Blood From the Head"-Predicting and Preventing Cerebral Deoxygenation During Beach-Chair Shoulder Surgery. Arthroscopy 2019; 35:731-733. [PMID: 30827426 DOI: 10.1016/j.arthro.2018.11.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 11/30/2018] [Indexed: 02/02/2023]
Abstract
Orthopaedic surgeons and anesthesiologists need to work together to avoid catastrophic cerebral ischemic injuries when surgery is performed with patients in the beach-chair position. Patient risk factors include body mass index but are not strongly predictive. Anesthetic management choices, such as regional anesthesia with sedation or normotensive general anesthesia with gradual and limited head elevation and hypercapnia, can significantly decrease the risk of cerebral deoxygenation.
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21
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Different ventilation techniques and hemodynamic optimization to maintain regional cerebral oxygen saturation (rScO 2) during laparoscopic bariatric surgery: a prospective randomized interventional study. J Anesth 2018; 32:394-402. [PMID: 29626267 DOI: 10.1007/s00540-018-2493-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 03/26/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE The purpose of this study was to assess the changes in regional cerebral oxygen saturation (rScO2) in response to different ventilation strategies: inspired oxygen concentration (FiO2), end-tidal carbon dioxide (EtCO2), and positive end expiratory pressure (PEEP) in addition to optimizing mean arterial pressure (MAP) in obese patients subjected to laparoscopic bariatric surgery in the reverse trendelenburg position. METHODS 50 obese patients were randomly assigned into one of two groups. Each group is 25 patients. Control patients subjected to a ventilation strategy aimed to maintain FiO2 0.4 and EtCO2 30 mmHg without PEEP. Study patients were assigned to specific protocol; T0, baseline rScO2; T1, 5 min following induction; T2, PP/RTP (10 min after pneumoperitoneum and reverse trendelenburg position); T3, PEEP 10 cmH2O; T4, FiO2 1.0; T5, EtCO2 40 mmHg and T6, MAP/BL; MAP back to baseline in both groups. MAIN RESULTS 10 min after PP/RTP, there was a significant decrease in rScO2 in both groups. At T4, with FiO2 1.0, there was significant improvement in rScO2 when compared to T2. At T5, with EtCO2 40 mmHg, rScO2 significantly enhanced when compared to EtCO2 30 mmHg. At T4 and T5, we observed highly significance difference between both groups. At the end of the procedure and when MAP increased back to baseline (T6) in both groups, rScO2 statistically increased in both groups when compared to T2. CONCLUSION In obese patients, subjected to laparoscopic bariatric surgery in reverse trendelenburg position, adjustment of ventilation strategies and hemodynamic optimization succeeded to improve rScO2.
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Nontshe M, Khan S, Mandebvu T, Merrifield B, Rodseth RN. Sample-size determination and adherence in randomised controlled trials published in anaesthetic journals. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2018. [DOI: 10.1080/22201181.2018.1439602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- M Nontshe
- Metropolitan Department of Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - S Khan
- Metropolitan Department of Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - T Mandebvu
- Metropolitan Department of Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - B Merrifield
- Metropolitan Department of Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - RN Rodseth
- Metropolitan Department of Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal, Pietermaritzburg, South Africa
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA
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Benni PB, MacLeod D, Ikeda K, Lin HM. A validation method for near-infrared spectroscopy based tissue oximeters for cerebral and somatic tissue oxygen saturation measurements. J Clin Monit Comput 2017; 32:269-284. [PMID: 28374103 PMCID: PMC5838152 DOI: 10.1007/s10877-017-0015-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 03/23/2017] [Indexed: 12/19/2022]
Abstract
We describe the validation methodology for the NIRS based FORE-SIGHT ELITE® (CAS Medical Systems, Inc., Branford, CT, USA) tissue oximeter for cerebral and somatic tissue oxygen saturation (StO2) measurements for adult subjects submitted to the United States Food and Drug Administration (FDA) to obtain clearance for clinical use. This validation methodology evolved from a history of NIRS validations in the literature and FDA recommended use of Deming regression and bootstrapping statistical validation methods. For cerebral validation, forehead cerebral StO2 measurements were compared to a weighted 70:30 reference (REF CXB) of co-oximeter internal jugular venous and arterial blood saturation of healthy adult subjects during a controlled hypoxia sequence, with a sensor placed on the forehead. For somatic validation, somatic StO2 measurements were compared to a weighted 70:30 reference (REF CXS) of co-oximetry central venous and arterial saturation values following a similar protocol, with sensors place on the flank, quadriceps muscle, and calf muscle. With informed consent, 25 subjects successfully completed the cerebral validation study. The bias and precision (1 SD) of cerebral StO2 compared to REF CXB was −0.14 ± 3.07%. With informed consent, 24 subjects successfully completed the somatic validation study. The bias and precision of somatic StO2 compared to REF CXS was 0.04 ± 4.22% from the average of flank, quadriceps, and calf StO2 measurements to best represent the global whole body REF CXS. The NIRS validation methods presented potentially provide a reliable means to test NIRS monitors and qualify them for clinical use.
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Affiliation(s)
- Paul B Benni
- CAS Medical Systems (CASMED), Inc., Branford, CT, USA.
| | - David MacLeod
- Human Pharmacology & Physiology Lab, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Keita Ikeda
- Human Pharmacology & Physiology Lab, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Kwak HJ, Lee JY, Wha Lee J, Kim HS, Hur HJ, Kim JY. Effect of Mild Hypercapnia on Lung Oxygenation in Sitting Position During Shoulder Arthroscopy Under General Anesthesia. Med Sci Monit 2017; 23:843-849. [PMID: 28202896 PMCID: PMC5325044 DOI: 10.12659/msm.899801] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Mild hypercapnia is permitted during surgeries in sitting position under general anesthesia to maintain cerebral regional oxygen saturation (rSO2). However, since hypoventilation may cause gas exchange impairment, we evaluated effects of mild hypercapnia on lung oxygenation during shoulder arthroscopy in sitting position. Material/Methods Forty patients were randomly allocated to a normocapnia group (ETCO2 35 mmHg, n=20) or a hypercapnia group (45 mmHg, n=20). The mean arterial pressure (MAP), heart rate (HR), and rSO2 were measured 5 min after intubation in supine position (T0), and at 2, 4, 6, 8, 10, 20, 30, 40, 50, and 60 min of remaining in sitting position (T1–10). Arterial blood gas was analyzed at T0 and T5. The oxygenation index (PaO2/FiO2) and dead-space ventilation ratio (Vd/Vt) were calculated. Results There were no differences in PaO2/FiO2 at T0 and T5 between the 2 groups. At T5, the Vd/Vt was higher in the normocapnia group than in the hypercapnia group (p=0.04). The Vd/Vt at T5 increased from T0 in the normocapnia group. The incidence of cerebral desaturation in the hypercapnia group (0/20) was lower than in the normocapnia group (5/20) (p=0.047). Among rSO2, MAP, and HR, only changes in rSO2 over time between the 2 groups differed significantly (p=0.048). Conclusions Mild hypercapnia did not decrease lung oxygenation in sitting position, probably due to attenuation of the increase in dead-space ventilation ratio. Since hypercapnia maintained rSO2 without changes in oxygenation index and hemodynamic parameters, mild hypercapnia should be maintained during shoulder arthroscopy in sitting position under general anesthesia.
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Affiliation(s)
- Hyun Jeong Kwak
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, South Korea
| | - Ji Yeon Lee
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, South Korea
| | - Jong Wha Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine , Seoul, South Korea
| | - Hong Soon Kim
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, South Korea
| | - Ho Jin Hur
- Department of Anesthesiology and Pain Medicine, Gachon University, Gil Medical Center, Incheon, South Korea
| | - Ji Young Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine , Seoul, South Korea
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Tsai HI, Chung PCH, Lee CW, Yu HP. Cerebral perfusion monitoring in acute care surgery: current and perspective use. Expert Rev Med Devices 2016; 13:865-75. [DOI: 10.1080/17434440.2016.1219655] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Cerebral tissue oxygen saturation values in volunteers and patients in the lateral decubitus and beach chair positions: a prospective observational study. Can J Anaesth 2016; 63:537-43. [DOI: 10.1007/s12630-016-0604-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 10/18/2015] [Accepted: 01/27/2016] [Indexed: 10/22/2022] Open
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Kim SY, Chae DW, Chun YM, Jeong KH, Park K, Han DW. Modelling of the Effect of End-Tidal Carbon Dioxide on Cerebral Oxygen Saturation in Beach Chair Position under General Anaesthesia. Basic Clin Pharmacol Toxicol 2016; 119:85-92. [DOI: 10.1111/bcpt.12549] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 12/09/2015] [Indexed: 01/01/2023]
Affiliation(s)
- So Yeon Kim
- Department of Anesthesiology and Pain Medicine; Anesthesia and Pain Research Institute; Seoul Korea
| | - Dong Woo Chae
- Department of Pharmacology; Yonsei University College of Medicine; Seoul Korea
| | - Yong-Min Chun
- Department of Orthopedic Surgery; Yonsei University College of Medicine; Seoul Korea
| | - Kyu Hee Jeong
- Department of Anesthesiology and Pain Medicine; Anesthesia and Pain Research Institute; Seoul Korea
| | - Kyungsoo Park
- Department of Pharmacology; Yonsei University College of Medicine; Seoul Korea
| | - Dong Woo Han
- Department of Anesthesiology and Pain Medicine; Anesthesia and Pain Research Institute; Seoul Korea
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Espinoza Ugarte AM, Bollini C. Cirugía de hombro en posición en silla de playa: prevención de complicaciones isquémicas. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.rchot.2016.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Influence of Ventilation Strategies and Anesthetic Techniques on Regional Cerebral Oximetry in the Beach Chair Position: A Prospective Interventional Study with a Randomized Comparison of Two Anesthetics. Anesthesiology 2015; 123:765-74. [PMID: 26244887 DOI: 10.1097/aln.0000000000000798] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Beach chair positioning during general anesthesia is associated with cerebral oxygen desaturation. Changes in cerebral oxygenation resulting from the interaction of inspired oxygen fraction (FIO2), end-tidal carbon dioxide (PETCO2), and anesthetic choice have not been fully evaluated in anesthetized patients in the beach chair position. METHODS This is a prospective interventional within-group study of patients undergoing shoulder surgery in the beach chair position that incorporated a randomized comparison between two anesthetics. Fifty-six patients were randomized to receive desflurane or total intravenous anesthesia with propofol. Following induction of anesthesia and positioning, FIO2 and minute ventilation were sequentially adjusted for all patients. Regional cerebral oxygenation (rSO2) was the primary outcome and was recorded at each of five set points. RESULTS While maintaining FIO2 at 0.3 and PETCO2 at 30 mmHg, there was a decrease in rSO2 from 68% (SD, 12) to 61% (SD, 12) (P < 0.001) following beach chair positioning. The combined interventions of increasing FIO2 to 1.0 and increasing PETCO2 to 45 mmHg resulted in a 14% point improvement in rSO2 to 75% (SD, 12) (P <0.001) for patients anesthetized in the beach chair position. There was no significant interaction effect of the anesthetic at the study intervention points. CONCLUSIONS Increasing FIO2 and PETCO2 resulted in a significant increase in rSO2 that overcomes desaturation in patients anesthetized in the beach chair position and that appears independent of anesthetic choice.
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