Original ContributionCerebral oxygenation in the beach chair position for shoulder surgery in regional anesthesia: impact on cerebral blood flow and neurobehavioral outcome☆
Introduction
Beach chair position (BCP) is commonly used for shoulder surgery compared with the lateral decubitus position (LDP) to facilitate shoulder joint access and optimal visualization [1]. However, these advantages are contrasted by challenging hemodynamic changes, and several case reports are blaming the BCP for devastating central neurologic complications [2] such as cranial nerve injury [3], visual loss [4], and cerebral infarction [5], [6]. However, the real impact of BCP on these severe complications remains unclear [7], [8].
Combining BCP and head fixation can lead to cerebral tissue hypoperfusion during surgery caused by mechanical obstruction of cerebral blood flow (CBF) due to the extreme rotation of the head in combination with the traction in the operated arm [9]. Additional risk factors for reduced CBF are the frequently used combination of general anesthesia and controlled hypotension for shoulder arthroscopy as well as open shoulder surgery [10]. Furthermore, congenital variations of the circle of Willis anatomy with incomplete expression have been described in 59% to 79% of adults [11], [12]. These congenital variations present an additional risk for patients in the BCP undergoing shoulder surgery [13]. Near-infrared spectroscopy (NIRS) constitutes a useful tool to improve current monitoring by providing additional information regarding the regional cerebral tissue oxygenation [7]. Recent studies have shown that when NIRS is used for a cerebral oximetry monitoring, it reliably detects cerebral hypoperfusion during shoulder surgery in the BCP [14], [15]. In 1 case, a cause and effect relation between regional cerebral (capillary) oxygen saturation (rSco2), mean arterial pressure (MAP), and end-tidal CO2 was reported. [15] Murphy et al. compared the incidence of cerebral desaturation during shoulder surgery under general anesthesia in the BCP vs the LDP, demonstrating a significant reduction of cerebral oxygen saturation in the BCP and highlighting the importance of this position in cerebral desaturation [14]. Recently, 2 studies have reported the importance of maintaining an adequately high systemic blood pressure in the BCP to allow for cerebral autoregulation and adequate CBF [16], [17]. However, no study has described the correlation between CBF [18] and cerebral oxygenation in a controlled hypotension protocol for shoulder surgery in the BCP.
The aim of this prospective, observational, assessor-blinded study was to evaluate the prevalence of regional cerebral oxygen desaturation in American Society of Anesthesiologists (ASA) I-II patients undergoing shoulder surgery in the BCP under regional anesthesia with conscious sedation and a controlled hypotension protocol (systolic blood pressure 80-100 mm Hg at heart level) [19]. Our hypothesis was that NIRS reliably detects changes in cerebral oxygenation during regional anesthesia in the BCP and that the incidence of cerebral desaturation events (CDEs) would correlate with CBF impairment and neurobehavioral decline. Our primary outcome was the incidence of CDEs (expressed as a drop of absolute rSco2 to a value <55% for >15 seconds of baseline and in relative terms as a decrease in rSco2 ≥ 20% compared with the baseline value) [5] during regional anesthesia with conscious sedation under controlled hypotension protocol.
Secondary outcomes were the effects of blood pressure (measured at heart level and at the level of the acoustic meatus) on rSco2, the effects of the CDEs on the neurological and neurobehavioral outcome, as well as the effects of BCP on CBF and the correlations between CDEs, neurobehavioral, and CBF decline.
Section snippets
Materials and methods
The study was approved by the local Ethics Committee (Kantonale Ethikkommission Zürich, KEK-Zh-Nr: 2012-0112). Written informed consent was obtained from each patient. Forty ASA I-II adult patients scheduled for elective, unilateral shoulder surgery were included in this prospective, assessor-blinded, single-center cohort study. Exclusion criteria were a history of central neurological diagnosis (transient ischemic attack, stroke, bleeding, syncope, chronic headache, cervical disk herniation,
Results
No patient had to be excluded from the study. The patient and surgical characteristics are summarized in Tables 1 and 2. Hemodynamic alterations were seen 5 minutes after beach chair positioning with a drop in MAP measured at heart (P = .004) and acoustic meatus (P < .001) level (Fig. 1). There was no concomitant drop in the Vmax MCA (P = .212) at the same time point (Fig. 2). No significant change in heart rate was registered at any time point. At baseline, bilateral rSco2 values were equivalent
Discussion
This study showed a low incidence (5%) of CDEs in ASA I-II patients after regional anesthesia in BCP for shoulder surgery, and only 5% of patients had to be treated for hypotension (SAPheart < 80 mm Hg). A partial impact on neurocognitive outcome 24 hours after surgery without any neurological consequences artery was identified (Table 2).
The incidence of stroke during shoulder surgery in the BCP is rare (0.003%-0.07%) [30], [32]. However, the 2 reviews by YaDeau et al. [30] and Rohrbaugh et al.
Acknowledgments
The authors would like to acknowledge the help provided by Gina Votta-Velis, MD, PhD, (University of Illinois at Chicago) for her precious help in manuscript preparation and language/grammar corrections.
References (44)
- et al.
Severe cerebral desaturation during shoulder arthroscopy in the beach-chair position
Arthroscopy
(2010) - et al.
Tapia's syndrome following shoulder surgery
Br J Anaesth
(2002) - et al.
Cerebral ischemia during shoulder surgery in the upright position: a case series
J Clin Anesth
(2005) - et al.
Cerebral oxygenation using near-infrared spectroscopy in the beach-chair position during shoulder arthroscopy under general anesthesia
Arthroscopy
(2014) - et al.
Effect of phenylephrine on the haemodynamic state and cerebral oxygen saturation during anaesthesia in the upright position
Br J Anaesth
(2013) Strategies for minimizing blood loss in orthopedic surgery
Semin Hematol
(2004)- et al.
Statement of consensus on assessment of neurobehavioral outcomes after cardiac surgery
Ann Thorac Surg
(1995) - et al.
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) The post-anesthesia recovery score revisited
J Clin Anesth
(1995)- et al.
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)
Cerebral desaturation events during shoulder arthroscopy in the beach chair position: patient risk factors and neurocognitive effects
J Shoulder Elbow Surg
Effect of phenylephrine and ephedrine bolus treatment on cerebral oxygenation in anaesthetized patients
Br J Anaesth
Association between temporal mean arterial pressure and brachial noninvasive blood pressure during shoulder surgery in the beach chair position during general anesthesia
J Shoulder Elbow Surg
Cerebral oxygenation in the beach chair position before and during general anesthesia in patients with and without cardiovascular risk factors
J Clin Anesth
Comparison of the lateral decubitus and beach-chair positions for shoulder surgery: advantages and complications
J Am Acad Orthop Surg
Visual loss and ophthalmoplegia after shoulder surgery
Anesth Analg
A cerebral watershed infarction after general anaesthesia in a patient with increased anti-cardiolipin antibody level
Anaesthesist
Systematic review of near-infrared spectroscopy determined cerebral oxygenation during non-cardiac surgery
Front Physiol
Effects of change of head, limb and body position on cephalic circulation
N Engl J Med
Cerebral oxygen desaturation during beach chair position
Eur J Anaesthesiol
How often does an incomplete circle of Willis predispose to cerebral ischemia during closure of carotid artery? Postmortem and clinical imaging studies
Acta Neurochir
The fetal variant of the circle of Willis and its influence on the cerebral collateral circulation
Cerebrovasc Dis
Cited by (20)
Anesthesia for the Patient Undergoing Shoulder Surgery
2022, Clinics in Sports MedicineCitation Excerpt :Venous pooling can also occur in the beach chair position leading to a decrease in cardiac output and hypotension. An understanding of the cardiovascular effects in the beach chair position is important because blood pressure measurements at the level of the arm do not accurately reflect cerebral perfusion, which can cause brain hypoperfusion and postoperative neurologic events.12 Anesthesiologists should be aware of the unique considerations of the beach chair position as it relates to the patient’s airway.
Ultrasound-guided interscalene block anesthesia performed by an orthopedic surgeon: a study of 1322 cases of shoulder surgery
2022, JSES InternationalCitation Excerpt :These studies also demonstrated that regional anesthesia had greater hemodynamic stability than general anesthesia. Furthermore, CDE is correlated with coronary artery disease.3 Regional anesthesia is safe in terms of maintaining blood perfusion, which may have contributed to the avoidance of life-threatening complications.
Enhanced Recovery After Shoulder Arthroplasty
2018, Anesthesiology ClinicsCitation Excerpt :Moreover, shoulder surgery can be prolonged with unpleasant stimuli, such as reaming of the humerus that, although not necessarily painful in the setting of an effective block, sometimes cannot be attenuated with sedation.26 Furthermore, although having an awake patient reduces some concerns over inadequate cerebral oxygenation in the beach chair position, having limited access to an unsecured airway is challenging for the anesthesiologist.27,28 Regional anesthesia is still underused in the management of upper extremity surgeries and underimplemented in ERAS pathways.29
The effectiveness of cerebral oxygenation monitoring during arthroscopic shoulder surgery in the beach chair position: a randomized blinded study
2018, Journal of Shoulder and Elbow SurgeryCitation Excerpt :There may be too many patient-specific factors to reliably identify at-risk patients, including intraluminal atherosclerosis, carotid stenosis, compression of carotid and vertebral vessels by osteophytes, and variations in vascular anatomy.9,21,22 Various different screening tools have been used to investigate the cognitive effects of shoulder surgery in the beach chair position; however, no studies have shown any significant cognitive decline.1,5,10,19 We chose to use the MoCA to assess cognitive function in our study because a study by Kara et al showed that patients undergoing coronary artery bypass grafting without NIRS monitoring had significantly decreased postoperative MoCA scores compared with patients receiving NIRS monitoring.7
Postoperative cognitive dysfunction after beach chair positioning compared to supine position in orthopaedic surgery in the elderly
2024, Archives of Orthopaedic and Trauma Surgery
- ☆
Disclosures: This work was supported by a grant of the European Society of Regional Anesthesia and Pain Medicine.