Cerebral Oxygen Desaturation Events Assessed by Near-Infrared Spectroscopy During Shoulder Arthroscopy in the Beach Chair and Lateral Decubitus Positions

Department of Anesthesiology, NorthShore University HealthSystem, University of Chicago Pritzker School of Medicine, 2650 Ridge Ave., Evanston, IL 60201, USA.
Anesthesia and analgesia (Impact Factor: 3.47). 08/2010; 111(2):496-505. DOI: 10.1213/ANE.0b013e3181e33bd9
Source: PubMed


Patients undergoing shoulder surgery in the beach chair position (BCP) may be at risk for adverse neurologic events due to cerebral ischemia. In this investigation, we sought to determine the incidence of cerebral desaturation events (CDEs) during shoulder arthroscopy in the BCP or lateral decubitus position (LDP).
Data were collected on 124 patients undergoing elective shoulder arthroscopy in the BCP (61 subjects) or LDP (63 subjects). Anesthetic management was standardized in all patients. Regional cerebral tissue oxygen saturation (Scto(2)) was quantified using near-infrared spectroscopy. Baseline heart rate, mean arterial blood pressure, arterial oxygen saturation, and Scto(2) were measured before patient positioning and then every 3 minutes for the duration of the surgical procedure. Scto(2) values below a critical threshold (> or = 20% decrease from baseline or absolute value < or = 55% for >15 seconds) were defined as a CDE and treated using a predetermined protocol. The number of CDEs and types of intervention used to treat low Scto(2) values were recorded. The association between intraoperative CDEs and impaired postoperative recovery was also assessed.
Anesthetic management was similar in the BCP and LDP groups, with the exception of more interscalene blocks in the LDP group. Intraoperative hemodynamic variables did not differ between groups. Scto(2) values were lower in the BCP group throughout the intraoperative period (P < 0.0001). The incidence of CDEs was higher in the BCP group (80.3% vs 0% LDP group), as was the median number of CDEs per subject (4, range 0-38 vs 0, range 0-0 LDP group, all P < 0.0001). Among all study patients without interscalene blocks, a higher incidence of nausea (50.0% vs 6.7%, P = 0.0001) and vomiting (27.3% vs 3.3%, P = 0.011) was observed in subjects with intraoperative CDEs compared with subjects without CDEs.
Shoulder surgery in the BCP is associated with significant reductions in cerebral oxygenation compared with values obtained in the LDP.

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    • "Starting tidal volume will be set at 6–8 cm3/kg. The first measurement point in beach chair position will be obtained 15 min after positioning (at which point the maximal decrease in cerebral oxygen saturation is observed to occur [7]) or immediately if severe cerebral desaturation (absolute value rSO2 < 55% or a decrease from baseline of ≥ 20%) is sustained for ≥ 3 min in either hemisphere. It has been shown that the change in rSO2 is complete and stable within 5 min following a change in inspired gas composition [4]. "
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    ABSTRACT: Background Beach chair positioning during general anesthesia is associated with a high incidence of cerebral desaturation; poor neurological outcome is a growing concern. There are no published data pertaining to changes in cerebral oxygenation seen with increases in the inspired oxygen fraction or end-tidal carbon dioxide in patients anesthetized in the beach chair position. Furthermore, the effect anesthetic agents have has not been thoroughly investigated in this context. We plan to test the hypothesis that changes in inspired oxygen fraction or end-tidal carbon dioxide correlate to a significant change in regional cerebral oxygenation in anesthetized patients in beach chair position. We will also compare the effects that inhaled and intravenous anesthetics have on this process. Methods/design This is a prospective within-group study of patients undergoing shoulder arthroscopy in the beach chair position which incorporates a randomized comparison between two anesthetics, approved by the Institutional Review Board of the University of Michigan, Ann Arbor. The primary outcome measure is the change in regional cerebral oxygenation due to sequential changes in oxygenation and ventilation. A sample size of 48 will have greater than 80% power to detect an absolute 4-5% difference in regional cerebral oxygenation caused by changes in ventilation strategy. The secondary outcome is the effect of anesthetic choice on cerebral desaturation in the beach chair position or response to changes in ventilation strategy. Fifty-four patients will be recruited, allowing for drop out, targeting 24 patients in each group randomized to an anesthetic. Regional cerebral oxygenation will be measured using the INVOS 5100C monitor (Covidien, Boulder, CO). Following induction of anesthesia, intubation and positioning, inspired oxygen fraction and minute ventilation will be sequentially adjusted. At each set point, regional cerebral oxygenation will be recorded and venous blood gas analysis performed. The overall statistical analysis will use a repeated measures analysis of variance with Tukey’s HSD procedure for post hoc contrasts. Discussion If simple maneuvers of ventilation or anesthetic technique can prevent cerebral hypoxia, patient outcome may be improved. This is the first study to investigate the effects of ventilation strategies on cerebral oxygenation in patients anesthetized in beach chair position. Trial registration NCT01535274
    BMC Anesthesiology 09/2012; 12(1):23. DOI:10.1186/1471-2253-12-23 · 1.38 Impact Factor
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    • "In these operations, cerebral desaturation is provoked either by postural hypotension, by head and neck manipulation leading to changes in cerebral blood flow, or by thromboembolic events. Compared to the lateral decubitus position, patients undergoing shoulder arthroscopy in the beach chair position suffered significantly more cerebral desaturations (80 vs. 0 %) despite similar baseline rSO2 values [50]. Consequently, patients suffering from cerebral desaturation had higher rates of postoperative nausea (50 vs. 7 %) and vomiting (27 vs. 3 %), whereas no neurologic deficits were observed, likely because of the limited duration of the surgical procedure [50]. "
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    ABSTRACT: Conventional cardiovascular monitoring may not detect tissue hypoxia, and conventional cardiovascular support aiming at global hemodynamics may not restore tissue oxygenation. NIRS offers non-invasive online monitoring of tissue oxygenation in a wide range of clinical scenarios. NIRS monitoring is commonly used to measure cerebral oxygenation (rSO(2)), e.g. during cardiac surgery. In this review, we will show that tissue hypoxia occurs frequently in the perioperative setting, particularly in cardiac surgery. Therefore, measuring and obtaining adequate tissue oxygenation may prevent (postoperative) complications and may thus be cost-effective. NIRS monitoring may also be used to detect tissue hypoxia in (prehospital) emergency settings, where it has prognostic significance and enables monitoring of therapeutic interventions, particularly in patients with trauma. However, optimal therapeutic agents and strategies for augmenting tissue oxygenation have yet to be determined.
    International Journal of Clinical Monitoring and Computing 03/2012; 26(4):279-87. DOI:10.1007/s10877-012-9348-y · 1.99 Impact Factor
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    ABSTRACT: Postural change during anesthesia has a complex effect on the systemic and cerebral circulations which can potentially decrease cerebral blood flow and oxygenation. Cerebral oximetry is emerging as a monitor of cerebral perfusion with widespread application in many types of surgery. The technology is based on the differential absorption of oxygenated and deoxygenated hemoglobin to near-infrared light. However, the dynamic coupling that exists between cerebral arterial, venous and cerebrospinal fluid volumes may influence oximetric readings during postural change. Interpretation of cerebral oxygen saturation measurement must account for these changes in cerebral physiology if monitoring is to predict neurological outcome.
    09/2013; 3(3). DOI:10.1007/s40140-013-0020-y
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