Hands-Up Positioning During Asymmetric Sternal Retraction for Internal Mammary Artery Harvest

Evaluation of Safety of Overhead Upper Extremity Positioning During Fenestrated-Branched Endovascular Repair of Thoracoabdominal Aortic Aneurysms

PURPOSE

Peripheral nerve and brachial plexus injury can occur from compression or stretching during positioning for operative procedures. The aim of this study was to evaluate the safety of overhead upper extremity positioning to optimize imaging during fenestrated-branched endovascular aortic repair (FB-EVAR) of pararenal (PRA) and thoracoabdominal aortic aneurysms (TAAAs).

METHODS

Forty-four consecutive patients enrolled in a prospective non-randomized study underwent FB-EVAR with overhead upper extremity positioning. Patients underwent intra-operative neuromonitoring of upper and lower extremities and neurological examination prior to discharge and at 2 months following the procedure. End points were peripheral or brachial plexus nerve injury, quality of lateral projection and cone beam computed tomography (CBCT) and major adverse event (MAEs).

RESULTS

There were 28 (64%) male patients with mean age of 74 ± 8 years treated for 10 PRAs (23%) and 34 (78%) TAAAs. Mean body mass index was 29 ± 7 kg/m², with 17 obese patients (39%). Open surgical upper extremity access was used in 19 patients (43%). Three patients (16%) had access-related complications, all focal brachial artery dissections treated by patch angioplasty. Two patients (5%) developed upper extremity changes in neuromonitoring, which immediately resolved with repositioning of the upper extremity. Technical success was 95%. Lateral projection and rotational CBCT were feasible in all patients with satisfactory imaging quality for catheterization and stenting of the celiac axis and superior mesenteric artery. There was one mortality (2%) at 30 days, and six patients (14%) had MAEs. There were no upper extremity neurological injuries.

CONCLUSION

Overhead upper extremity position allows optimal imaging on lateral projections and rotational CBCT during FB-EVAR. There were no upper extremity neurological injuries in this study.

Somatosensory evoked potential: Preventing brachial plexus injury in transaxillary robotic surgery

OBJECTIVES/HYPOTHESIS

The potential for brachial plexopathy due to arm positioning is a major concern regarding the robotic transaxillary approach. Intraoperative nerve monitoring via somatosensory evoked potential (SSEP) has been suggested to prevent such injury. In this study, we examined the use of SSEP in detecting imminent brachial plexus traction during robotic transaxillary thyroid and parathyroid surgery.

STUDY DESIGN

Retrospective case series.

METHODS

A analysis was performed for all patients undergoing robotic transaxillary surgery with continuous intraoperative SSEP monitoring at a North American institution between 2015 and 2017. A significant intraoperative SSEP change was defined as a decrease in signal amplitude of >50% or an increase in latency of >10% from baseline established during preoperative positioning.

RESULTS

One hundred thirty-seven robotic transaxillary surgeries using SSEP monitoring were performed on 123 patients. Seven patients (5.1%) developed significant changes, with an average SSEP amplitude reduction of 73% ± 12% recorded at the signals' nadir. Immediate arm repositioning resulted in recovery of signals and complete return to baseline parameters in 14.3 ± 9.2 minutes. There was no difference in age (40.4 ± 9.4 years vs. 44.5 ± 13.4 years; P = .31) or body mass index (27.3 ± 3.7 kg/m² vs. 26.9 ± 6.1 kg/m² ; P = .79) between cases with and without SSEP change. Operative time was shorter for patients with significant SSEP change (131.6 ± 14.7 minutes vs. 146.5 ± 46.7 minutes; P = .048). There were no postoperative positional brachial plexus injuries.

CONCLUSIONS

SSEP is a novel, safe, and reliable tool in detection of position-related brachial plexus neuropathy. Intraoperative monitoring using SSEP can play a vital role in early recognition and prevention of injury during robotic transaxillary thyroid and parathyroid surgery.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:2663-2668, 2019.

Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies 2018

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“Other” Neurologic Complications After Cardiac Surgery

Compared to the neurologic morbidity of stroke and cognitive dysfunction, “other” neurologic complications involving injuries to the brachial plexus, phrenic nerve, cranial nerves, other peripheral nerves, as well as the visual pathways, have been disproportionately underrepresented in the cardiac surgery and anesthesiology literature. These injuries are often missed in the early postoperative period when attention is focused principally on recovery from the acute trespass of cardiac surgery and cardiopulmonary bypass. However, when these problems do become apparent, they can cause considerable discomfort and morbidity. An overview of the current concepts of injury mechanisms/etiology, diagnosis, prognosis, and when possible, prevention of these injuries is presented.

Preventing perioperative peripheral nerve injuries

Peripheral nerve injuries are largely preventable injuries that can result from incorrect patient positioning during surgery. Patients who are diabetic, are extremely thin or obese, use tobacco, or undergo surgery lasting more than four hours are at increased risk for developing these injuries. When peripheral nerve injuries occur, patients may experience numbness, burning, or tingling and may have difficulty getting out of bed, walking, gripping objects, or raising their arms. These symptoms can interrupt activities of daily living and impede recovery. Signs and symptoms of peripheral nerve injury may appear within 24 to 48 hours of surgery or may take as long as a week to appear. Careful attention to body alignment and proper padding of bony prominences when positioning patients for surgery is necessary to prevent peripheral nerve injury. The use of a preoperative assessment tool to identify at-risk patients, collaboration between physical therapy and OR staff members regarding patient positioning, and neurophysiological monitoring can help prevent peripheral nerve injuries.

Somatosensory evoked potentials help prevent positioning-related brachial plexus injury during skull base surgery

OBJECTIVE

Evaluate the use of somatosensory evoked potentials (SSEP) monitoring to detect positioning-related brachial plexus injury during skull base surgery.

STUDY DESIGN

Prospective cohort observational study.

SETTING

University Hospital.

SUBJECTS AND METHODS

Patients undergoing skull base surgery had a focused neurologic exam of the brachial plexus performed before and after surgery. Under stable anesthesia, brachial plexus SSEP values were obtained before and after surgical positioning. Significant SSEP changes required a readjustment of arm or neck positions. SSEPs were assessed every 30 minutes. If changes were noted, position was readjusted and SSEPs were reassessed until surgical completion. Demographic data, neurologic exams, SSEP latency, and amplitude values were recorded. Persistent changes were correlated with postoperative neurologic findings.

RESULTS

Sixty-five patients, 15 to 77 years old, were studied. Six patients (9.2%) developed SSEP amplitude changes after positioning (average amplitude decrease 72.8%). One patient had a significant latency increase. The sensitivity of SSEP for detection of injury was 57%, while specificity was 94.7%. The average body mass index (BMI) of patients with normal and abnormal SSEPs was 28.7 ± 5.6 versus 29.2 ± 8.0, respectively. Average BMI of patients with postoperative symptoms regardless of SSEP findings was 33.8 ± 4.3. Two patients who had persistent SSEP changes after positioning had BMIs of 40.1 and 31.2 kg/m(2), respectively. Improvement in neurologic findings occurred in all patients after surgery.

CONCLUSIONS

This study demonstrates that upper extremity nerve stress can be detected in real time using SSEP and may be of value in protecting patients from nerve injury undergoing lateral skull base surgery.

Robot-assisted thoracoscopic thymectomy: perianaesthetic concerns

BACKGROUND

Robot-assisted thoracoscopic thymectomy has brought new challenges to the anaesthesiologists. Here we present a study of 17 patients undergoing robotic thymectomy.

PATIENTS AND METHODS

The present study was a prospective study, which included 17 patients with myasthenia gravis scheduled for robot-assisted thoracoscopic thymectomy. Preoperatively, all scheduled medications were continued along with incentive spirometry.In the operating room, routine monitors were attached. Radial artery cannula and central venous catheter were inserted. Anaesthesia was induced with fentanyl, propofol and sevoflurane in oxygen and nitrous oxide. The neuromuscular blockade was achieved with atracurium. Airway was secured with double lumen tube. The capnography, entropy, neuromuscular junction and temperature monitoring were initiated. After patient positioning, one-lung ventilation was initiated prior to insertion of trocar. Thereafter, the robot was docked and surgery was started. During the surgical dissection, capnomediastinum was created. At the end of the surgery, double lumen tube was changed to single lumen endotracheal tube size. After extubation in ICU, continuous positive airway pressure of 5 mmHg was administered.

RESULTS

Intraoperatively, all patients had transient episodes of arrhythmias and hypotension. The airway pressure increased from 23.7 +/- 2 to 28 +/- 2.7 cmH2O and central venous pressure increased from 12.9 +/- 1 to 19.2 +/- 1.6 mmHg after creation of capnomediastinum. The accidental rent in the right-sided pleura occurred in two patients. Intraoperatively, ventilatory difficulty was encountered in another two patients. One patient had brachial plexus injury. Two patients had hoarseness of voice.

SUMMARY

Refinement of the surgical technique is required to avoid compression by robotic arms on any portion of the patient, particularly the upper extremities. The use of beanbag for positioning of the ipsilateral arm needs to be evaluated further. The double lumen tube is to be positioned in such a way as to avoid any obstacle in the movement of robotic arm. We suggest pulse oximeter and arterial blood pressure monitoring in the abducted arm ipsilateral to the surgical approach. The airway pressure and capnography are to be monitored continuously for detection of capnothorax. Patient of robot-assisted thoracoscopic thymectomy should be observed for any nerve injury.

[The involvement of the brachial plexus in cardiac surgery with median sternotomy for the revascularization of the myocardium: clinical evaluation]

To evaluate the involvement of brachial plexus in cardiac surgery with median sternotomy for the revascularization of the myocardium 113 patients (87 men and 26 women) were clinically examined in the preoperative and between the fifth and eight post-operative days. The internal thoracic artery was used in 65 of the 113 patients. The electroneuromyography was not effected in any of the patients. A lesion of the brachial plexus was found in three patients though the internal thoracic artery was used in only one patient. We believe that factors such as posture of the patient, hypothermia, thoracic braces and use of the internal thoracic artery are relevant in the lesions. Hence one must be attentive to all the factors mentioned above so as to avoid or minimize the lesions.

Somatosensory evoked potential monitoring used to compare the effect of three asymmetric sternal retractors on brachial plexus function

We compared the effect of three different asymmetric sternal retractors on brachial plexus dysfunction using intraoperative somatosensory evoked potentials (SSEPs). We studied 60 patients undergoing coronary bypass and internal mammary harvest. Assessment of brachial plexus function was performed pre- and postoperatively. Patients were assigned the use of a Pittman (MN Scientific Instruments Inc., Minneapolis, MN), Rultract (Rultract Inc., Cleveland, OH), or Delacroix-Chevalier (Delacroix-Chevalier, Paris, France) asymmetric sternal retractor for internal mammary exposure. SSEP changes from baseline during asymmetric retractor use and removal were determined, and average changes were compared among the retractor groups. Patient demographics and baseline SSEP values were similar. Fewer patients in the Delacroix-Chevalier group had decreases in SSEP amplitudes after retractor placement. Of the patients in the Rultract and Pittman groups, 45% and 25%, respectively, had amplitude decreases of >50%, compared with only 5% of the Delacroix-Chevalier patients. Three patients in both the Pittman and Rultract groups and one patient in the Delacroix-Chevalier group suffered brachial plexus symptoms postoperatively. We conclude that the Delacroix-Chevalier retractor is associated with less neurophysiologic evidence of brachial plexus dysfunction during asymmetric sternal retraction compared with either the Pittman or Rultract sternal retractors.

IMPLICATIONS

We used somatosensory evoked potentials to assess the effect of several different asymmetric sternal retractors on brachial plexus dysfunction and to determine which produced the least evidence of nerve damage during surgical exposure of the internal mammary artery.

Perioperative neuropathies

Neuropathies are infrequent but potentially debilitating complications in surgical patients. Although the most common of these affect the peripheral ulnar and sciatic nerves, more centrally located sets of nerves such as the brachial plexus and lumbosacral nerve roots also can be affected perioperatively. Traditionally, these neuropathies have been considered avoidable and associated with inappropriate patient positioning intraoperatively. Recent epidemiologic and anatomic studies suggest, however, that various factors other than intraoperative positioning may contribute to the development of neuropathies. For example, it is now clear that a large proportion of surgical patients who subsequently have development of ulnar neuropathies are asymptomatic during the first several postoperative days. Further delineation of the epidemiology and causes of the various perioperative neuropathies should lead to innovative interventions and clinical trials of their effectiveness to decrease the frequency and severity of these complications in surgical patients.