Anesthesia and the beach chair position Paul Picton Associate Professor Senior Associate Chair of Clinical Affairs and Quality University of Michigan Medical School, Ann Arbor
NIH UL1TR000433 Disclosures
Objectives 1. To understand the potential impact of cerebral hypoperfusion for patients anesthetized in the beach chair position. 2. To be aware of potential cerebral monitoring options. 3. To understand the various influences on cerebral oxygenation for patients anesthetized in the beach chair position. 4. To be aware of the latest research concerning patients at potential risk of cerebral hypoperfusion under anesthesia.
Demographics Chiang AC, et al. J Bone Joint Surg 2012
Catastrophic neurological injury 1 case visual loss / opthalmoplegia Bhatti MT, et al. Anesth Analg 2003 4 cases severe CNS injury Pohl A, Cullen DJ. J Clin Anesth 2005 8 cases stroke reported in a survey of ASESS Friedman DJ, et al. Orthopedics 2009 24% cervical cord injury recorded in closed claim data base occurred in BCP Hindman BJ,et al. Anesthesiology 2011 1 case hemiplegic stroke Drummond JC, et al. Anesth Analg 2011 8 cases severe neurological injury (unreported) discussed in editorial Murphy GS & Szokol JW. Can J Anesth 2011
Abnormal circle of Willis Drummond JC, et al, Anesth Analg 2011
J Clin Anesth 2005, 17(6):463-469
Autoregulation Drummond JC, Patel PM. Neurosurgical anesthesia. In: Miller RD, Cucchiara RF, Miller ED, Jr., et al., eds. Anesthesia, 5th ed. Philadelphia: Churchill Livingstone, 2000:1903-5. Drummond JC. Anesthesiology 1997;86:1431-1433
Autoregulation is impaired in the beach chair position Prospective observational, LDC vs BCP, autoregulation measured by Cox, n=218 Laflam A. et al. Anesth Analg 2015
No relationship between pre-op BP and LLA in the beach chair position Prospective observational, LDC vs BCP, autoregulation measured by Cox, n=218 Laflam A. et al. Anesth Analg 2015
Syphon vs waterfall
Beach chair position and EEG evidence of ischemia Prospective, controlled hypotension (90-100mmHg SBP), n=52 Gillespie R. et al. J Bone Joint Surg Am. 2012;94:1284-90
MAP and safety? Pin-on P, et al. Anesth Analg 2013, 116(6):1317-1324
Summary 1 1) Catastrophic neurological injury has occurred with BCP 2) Lower limit of autoregulation likely much higher than 50mmHg and has wide interindividual variability 3) Autoregulation is impaired in beach chair position 3) Correct for hydrostatic gradient
Monitoring Nelson T and Picton P. Chapt 26. In: Case Studies in Neuroanesthesia and Neurocritical Care, 2011.
Near infrared spectroscopy (NIRS) Casati A et al Minerva Anestesiol 2006;72:605-25
Cerebral desaturation (measured by NIRS) and neurologic injury
Summary 2 1) rso 2 provides a non-invasive continuous measure of cerebral oxygenation 2) It is far from perfect! 3) A decrease from baseline of 20% associated with neurological injury
Cerebral desaturation in the beach chair position Murphy GS, et al. Anesth Analg 2010, 111(2):496-505
Increased Oxygen Administration Improves Cerebral Oxygenation in Patients Undergoing Awake Carotid Surgery Stoneham MD, et al. Anesth Analg 2008;107:1670-5
The influence of basic ventilation strategies on cerebral oxygenation Picton P, et al. J Clin Monit Comput 2010;24:421-425 Picton P, et al. Br J Anaesth, 2012 Feb; 108 (2):326-7
Inspired oxygen fraction and end tidal carbon dioxide during CEA with GA Picton P, et al. Anesth Analg. 2010 Feb 1;110(2):581-7
End tidal carbon dioxide in the beach chair position Murphy G S et al. Brit J Anaesth 2014, 113:618-27
Summary 3 1) BCP with GA results in cerebral desaturation 2) Small increases in CaO 2 may make a significant difference to under-perfused brain 3) Increasing FiO 2 results in a measurable improvement in cerebral oxygenation 4) Modulating PaCO 2 may change cerebral oxygenation
Anesthetic choice Picton P, Deakin CD. Trauma Critical Care 2007 (2):1-22
Beach chair position and anesthetic choice Jeong H, et al. Anesthesiology 2012, 116(5):1047-1056.
Cerebral oxygenation, ventilation strategy and anesthetic choice Prospective within-group evaluation of ventilation strategy with randomized comparison of anesthetic choice, n=56 Picton P et al. Anesthesiology 2015
Blood pressure and anesthetic choice in beach chair position Picton P et al. Anesthesiology 2015
Blood pressure and anesthetic choice in beach chair position Picton P et al. Unpublished data
Blood pressure and anesthetic choice in beach chair position Picton P et al. Unpublished data
Which vasoactive drug? PE EPH Meng L. et al. Brit J Anaesth 107 (2): 209-17 (2011)
Which pressor / inotrope? Meng L. et al. Brit J Anaesth 108 (5): 815-22 (2012)
Summary 4 1) Anesthetic agents have differing effects on brain circulation and metabolism 2) Choice of agent for patients at risk of cerebral hypo-perfusion is under investigated 3) BCP related cerebral desaturation is attenuated by normocarbic hyperoxia and moderate hypercarbia independent of anesthetic agent 4) Ephedrine may have advantage over phenylephrine
High risk patients? Retrospective, GA ETT, BCP, n=384 Trentman TL, Fassett SL, Thomas JK, et al. Can J Anesth 2011; 58
Risk factors for and risk of perioperative stroke Mashour GA, et al. Anesthesiology. 2011 Jun;114(6):1289-96
Patients with cerebrovascular disease 200 S100β ng/l 180 160 140 120 100 80 60 40 20 CVD Control 0 Baseline POD1 POD2 POD3 Prospective observational study patients undergoing major surgery (supine), CVD vs matched controls, n=48 Vlisides P, Mashour GA, Picton P et al. Unpublished data
Patients with cerebrovascular disease Composite Score - Test Battery Cognitive Function Score Trends - CVD vs. Control 7000 6000 5000 4000 3000 2000 1000 0 Baseline POD1 POD2 POD3 Timeframe CVD Controls Vlisides P, Mashour GA, Picton P et al. Unpublished data
Patients with cerebrovascular disease Composite Score - Test Battery 6000 5000 4000 3000 2000 1000 Cognitive Function Score Trends - Desat vs. Non-Desat Desat Group (N=6) Non-Desat Group (N=39) 0 Baseline POD1 POD2 POD3 Timeframe Vlisides P, Mashour GA, Picton P et al. Unpublished data
PbrO2 vs rso2 in normal human brain with changes in ventilation strategy Excision Canal Licox Probe Tumor Recruitment underway Jennifer Lucaj Picton P et al. NCT03128957
Conclusions Surgeries requiring beach chair positioning increasing in frequency Devastating neurological sequelae in healthy patients have been reported Lower limit of autoregulation? Allow for hydrostatic gradient and keep the blood pressure up No widely agreed monitoring standard Increasing FiO 2 and ETCO 2 results in a measurable improvement in cerebral oxygenation for patients anesthetized in the beach chair position Anesthetic agents have differing effects on the brain but there is no proven benefit of one approach over another for patients in BCP
NIH UL1TR000433 Thanks to
Thanks to George A. Mashour, MD, PhD Andrew Dering, MBChB, FRCA Mary Neff, CRNA Bruce Miller, MD, MS Amy Shanks, MS,PhD Michelle Housey, MPH
Thanks to Phil Vlisides, MD Magnus Teig, MBChB, FRCA Amy McKinney, MA Jason Heth, MD