Anesthesia and Surgery in the Seated Position: Analysis of 554 Cases

Neurosurgery ◽  
1985 ◽  
Vol 17 (5) ◽  
pp. 695-702 ◽  
Author(s):  
Jane Matjasko ◽  
Patricia Petrozza ◽  
Melvin Cohen ◽  
Polly Steinberg
Keyword(s):  
Severe Hypertension ◽  
Air Embolism ◽  
Morbidity And Mortality ◽  
Anesthetic Technique ◽  
Neurosurgical Procedures ◽  
Atherosclerotic Cardiovascular Disease ◽  
Cervical Stenosis ◽  
Venous Air Embolism ◽  
Continued Use ◽  
The Impact

Abstract Because controversy exists regarding continued use of the seated position for neurosurgical procedures, this prospective (1981-1983) and retrospective (1972-1981) analysis of 554 seated patients was done to establish the incidence and severity of venous air embolism (VAE) related to type of surgical procedure and anesthetic technique; to examine the impact of specific monitoring practices on detection, morbidity, and mortality; and to establish the incidence of other complications related to the seated position (hypotension, quadriplegia, and arterial air embolism (AAE)). The overall morbidity and mortality related to the seated position was 1% (2 VAE, 1 AAE, 2 hypotension, 1 myocardial infarction) and 0.9% (1 VAE, 1 AAE, 2 hypotension, 1 quadriplegia), respectively. There has been no mortality since 1975. N2O did not seem to increase the incidence or severity of VAE. The seated position is safe in experienced hands if appropriate surgical and anesthetic skills are exercised in patient selection and management. Caution is advised in patients with atherosclerotic cardiovascular disease, severe hypertension, cervical stenosis, and right to left intracardiac shunts.

Image-Guided Lateral Suboccipital Approach: Part 2—Impact on Complication Rates and Operation Times

2008 ◽  
Vol 62 (suppl_1) ◽  
pp. ONS24-ONS29 ◽  
Author(s):  
Alireza Gharabaghi ◽  
Steffen K. Rosahl ◽  
Günther C. Feigl ◽  
Sam Safavi-Abbasi ◽  
Javad M. Mirzayan ◽  
...  
Keyword(s):  
Image Guidance ◽  
Postoperative Morbidity ◽  
Three Dimensional ◽  
Air Embolism ◽  
Venous Sinus ◽  
Complication Rates ◽  
Venous Air Embolism ◽  
Image Guided ◽  
Neurosurgical Planning ◽  
The Impact

Abstract Objective: Image-guidance systems are widely available for surgical planning and intraoperative navigation. Recently, three-dimensional volumetric image rendering technology that increasingly applies in navigation systems to assist neurosurgical planning, e.g., for cranial base approaches. However, there is no systematic clinical study available that focuses on the impact of this image-guidance technology on outcome parameters in suboccipital craniotomies. Methods: A total of 200 patients with pathologies located in the cerebellopontine angle were reviewed, 100 of whom underwent volumetric neuronavigation and 100 of whom underwent treatment without intraoperative image guidance. This retrospective study analyzed the impact of image guidance on complication rates (venous sinus injury, venous air embolism, postoperative morbidity caused by venous air embolism) and operation times for the lateral suboccipital craniotomies performed with the patient in the semi-sitting position. Result: This study demonstrated a 4% incidence of injury to the transverse-sigmoid sinus complex in the image-guided group compared with a 15% incidence in the non-image-guided group. Venous air embolisms were detected in 8% of the image-guided patients and in 19% of the non-image-guided patients. These differences in terms of complication rates were significant for both venous sinus injury and venous air embolism (P < 0.05). There was no difference in postoperative morbidity secondary to venous air embolism between both groups. The mean time for craniotomy was 21 minutes in the image-guided group and 39 minutes in non-image-guided group (P = 0.036). Conclusion: Volumetric image guidance provides fast and reliable three-dimensional visualization of sinus anatomy in the posterior fossa, thereby significantly increasing speed and safety in lateral suboccipital approaches.

scholarly journals Intraoperative oxygen embolus and tension pneumocephalus: Is hydrogen peroxide the culprit?

2017 ◽  
Vol 04 (02) ◽  
pp. 114-116
Author(s):  
Supriya Dsouza ◽  
Anil Parakh ◽  
Chitra Sarma ◽  
Adarsh Kulkarni ◽  
Ajit Baviskar
Keyword(s):  
Hydrogen Peroxide ◽  
Supine Position ◽  
Air Embolism ◽  
Neurological Complications ◽  
Neurosurgical Procedures ◽  
Sitting Position ◽  
Tension Pneumocephalus ◽  
Venous Air Embolism ◽  
Intracranial Surgery

AbstractHydrogen peroxide (H2O2) irrigation is commonly utilised in neurosurgical and non-neurosurgical procedures for its bactericidal and haemostatic effects. Tension pneumocephalus and venous air embolism are potentially disastrous neurological complications mostly seen after intracranial surgery in sitting position and trauma. We present a case of oxygen embolus and tension pneumocephalus after H2O2 irrigation during craniotomy in supine position.

Comparison of Surgical and Anesthetic Complications in Neurosurgical Patients Experiencing Venous Air Embolism in the Sitting Position

Neurosurgery ◽  
1986 ◽  
Vol 18 (2) ◽  
pp. 157-161 ◽  
Author(s):  
Marie L. Young ◽  
David S. Smith ◽  
Frederick Murtagh ◽  
Angel Vasquez ◽  
Jerry Levitt
Keyword(s):  
Case Reports ◽  
Perioperative Complications ◽  
Operative Procedure ◽  
Air Embolism ◽  
Morbidity And Mortality ◽  
Sitting Position ◽  
Perioperative Morbidity ◽  
Venous Air Embolism ◽  
Neurosurgical Patients ◽  
Anesthetic Complications

Abstract Because venous air embolism (VAE) has been considered to be a major deterrent to use of the sitting position, records of 255 patients undergoing neurosurgery in the sitting position from 1975 to 1982 were reviewed to determine the nature of morbidity and mortality in relation to the surgical procedure as well as to the occurrence of VAE. Complications were classified as surgical or anesthetic during joint review by a neurosurgeon and two neuroanesthesiologists. Outcome was classified on the basis of postoperative hospital course and discharge examination. The incidence of VAE was 30%. Although there was a variety of perioperative complications in patients with and without VAE, most of the complications were related to the operative procedure, not the sitting position or VAE. The episodes of VAE did not seem to be significant factors in the perioperative morbidity and mortality in our series of patients operated upon in the sitting position. Two case reports are discussed in detail.

Prevention of Air Embolism with Positive End Expiratory Pressure

Neurosurgery ◽  
1983 ◽  
Vol 12 (5) ◽  
pp. 503-506 ◽  
Author(s):  
Rand M. Voorhies ◽  
Richard A. R. Fraser ◽  
Alan Van Poznak
Keyword(s):  
Air Embolism ◽  
Right Heart Catheterization ◽  
Right Atrial ◽  
Heart Catheterization ◽  
Neurosurgical Procedures ◽  
Positive End Expiratory Pressure ◽  
Right Heart ◽  
Venous Air Embolism ◽  
Therapeutic Modalities ◽  
Atrial Catheter

Abstract Pulmonary air embolism is recognized as a possible complication of neurosurgical procedures performed with the patient in the sitting position. A variety of preventive and therapeutic modalities have been proposed in the literature. We have used a consistent regimen consisting of precordial Doppler monitoring, measurement of end expiratory CO2, the semireclining position, and positive end expiratory pressure (PEEP). A right atrial catheter was not used. This approach has given good results in 81 patients: there was significant air embolism in only 1 case (1.2%). We believe that PEEP is as important in the prevention as it is in the treatment of pulmonary air embolism. By flexibly adjusting the level of PEEP, one may recreate the hemodynamic equivalent of the prone position, thereby eliminating the risk of venous air embolism and simultaneously the need for right heart catheterization.

Transcranial Doppler Ultrasonography as a Screening Technique for Detection of a Patent Foramen Ovale before Surgery in the Sitting Position

2000 ◽  
Vol 93 (4) ◽  
pp. 971-975 ◽  
Author(s):  
Ruediger Stendel ◽  
Hans-Joachim Gramm ◽  
Klaus Schröder ◽  
Conny Lober ◽  
Mario Brock
Keyword(s):  
Patent Foramen Ovale ◽  
Doppler Ultrasonography ◽  
Air Embolism ◽  
Neurosurgical Procedures ◽  
Sitting Position ◽  
Preoperative Screening ◽  
Reference Standard ◽  
Foramen Ovale ◽  
Venous Air Embolism ◽  
Contrast Enhanced

Background Venous air embolism has been reported to occur in 23-45% of patients undergoing neurosurgical procedures in the sitting position. If venous air embolism occurs, a patent foramen ovale (PFO) is a risk factor for paradoxical air embolism and its sequelae. Preoperative screening for a PFO is therefore recommended by some investigators. The reference standard for identifying a PFO is contrast-enhanced transesophageal echocardiography (c-TEE). Contrast-enhanced transcranial Doppler ultrasonography (c-TCD) and contrast-enhanced transthoracic echocardiography (c-TTE) are noninvasive alternative methods, but so far there are no studies as to their diagnostic validity in neurosurgical patients. Methods The sensitivity and specificity of c-TCD and c-TTE in detecting a PFO were determined in a prospective study using c-TEE as the reference standard. Preoperative c-TCD, c-TTE, and c-TEE studies were performed during the Valsalva maneuver after intravenous echo-contrast medium (D-Galactose, Echovist-300, Schering AG, Berlin, Germany) was administered in 92 consecutive candidates (47 men and 45 women; mean age, 51 yr; range, 25-72 yr) before neurosurgical procedures in the sitting position. Results A PFO was detected in 24 of the 92 patients (26.0%) using c-TEE. c-TCD correctly identified 22 patients, whereas c-TTE only correctly identified 10. This corresponds to a sensitivity of 0.92 for c-TCD and 0.42 for c-TTE. The negative predictive value was 0.97 for c-TCD compared with 0.83 for c-TTE. The prevalence of a PFO in patients with a posterior fossa lesion was 27%, and in the group with cervical disc herniation was 24% as detected by c-TEE. The incidence of intraoperative venous air embolism was 35% in cases of cervical foraminotomy and 75% in posterior fossa surgery as detected by c-TEE. Conclusions c-TCD is a highly sensitive and highly specific method for detecting a PFO. Because c-TCD is noninvasive, it may be more suitable than c-TEE for routine preoperative screening for a PFO. C-TTE is not reliable in detecting a PFO.

A new catheter for detection and treatment of venous air embolism

1980 ◽  
Vol 52 (4) ◽  
pp. 595-598 ◽  
Author(s):  
Henry C. Hicks ◽  
James C. Hummel
Keyword(s):  
Right Atrium ◽  
Central Venous Access ◽  
Air Embolism ◽  
Central Line ◽  
Guidance System ◽  
Right Atrial ◽  
Neurosurgical Procedures ◽  
Content Type ◽  
Venous Air Embolism ◽  
The Right

✓ The authors report the successful application of the No. 8 French multi-orifice flow-directed catheter designed for pulmonary angiography in the monitoring and treatment of venous air embolism during neurosurgical procedures. Delays in operating room time were reduced with this technique, which ensures rapid and precise placement of a right atrial central line and which also eliminates the need for a chest film as a method of confirming placement of the central line in the right atrium. The flow-directed guidance system permits reliable introduction of the catheter via any central venous access route, including the basilic vein, and eliminates the usual difficulties associated with placement of conventional single-orifice polyethylene catheters. No complications associated with placement of this catheter into the right atrium have occurred in 20 cannulations.

scholarly journals Venous Air Embolism

2011 ◽  
Vol 115 (3) ◽  
pp. 626-629 ◽  
Author(s):  
Maurice S. Albin ◽  
David S. Warner
Keyword(s):  
Air Embolism ◽  
Lateral Position ◽  
Right Atrial ◽  
Neurosurgical Procedures ◽  
Venous Air Embolism ◽  
Air Bubble ◽  
Bubble Detection ◽  
Gravitational Gradients ◽  
Atrial Catheter ◽  
The Right

Clinical Considerations Concerning Detection of Venous Air Embolism. By Maurice S. Albin, Robert G. Carroll, Joseph C. Maroon. Neurosurgery 1978; 3:380-84. Abstract used with permission from the Congress of Neurological Surgeons, copyright 1978. Venous air embolism during neurosurgical procedures (detected by Doppler ultrasound and aspiration via a right atrial catheter) was noted in 100 of 400 patients in the sitting position, 5 of 60 patients in the lateral position, 7 of 48 patients in the supine position, and 1 of 10 patients in the monitored prone position. We confirmed venous air embolism in many of these patients by using serial technetium-microaggregated albumin lung scans. Gravitational gradients from the venous portal of entrance to the right side of the heart were as small as 5.0 cm, with aspiration of 200 ml of air occurring. Doppler ultrasonic air bubble detection and aspiration through a previously inserted right atrial catheter are critical factors in the diagnosis and treatment of this condition.

scholarly journals Occurrence and Severity of Venous Air Embolism During Neurosurgical Procedures in Semi-Sitting Versus Supine Position

2021 ◽  
Author(s):  
Franziska Magdalena Konrad ◽  
Angela S Mayer ◽  
Lina Maria Serna-Higuita ◽  
Helene Hurth ◽  
Marcos Tatagiba ◽  
...  
Keyword(s):  
Supine Position ◽  
Air Embolism ◽  
Central Venous Line ◽  
Neurosurgical Procedures ◽  
Sitting Position ◽  
Venous Air Embolism ◽  
Standardized Protocol ◽  
Single Center Study ◽  
Cranial Fossa ◽  
A Prospective Study

Abstract Background: Patients undergoing neurosurgical procedures in the posterior cranial fossa can be placed in different positions: the semi-sitting position or the supine position. The major risk of the semi-sitting positioning is venous air embolism (VAE). However, VAEs may also occur in the supine position.Objective: In a prospective study, we investigated the incidence of VAE based on the positioning of the patients (trial registration 553/2013BO1).Methods: In a single-center study with 137 patients, we prospectively evaluated the occurrence of VAEs in patients in the supine and semi-sitting position over the period from January 2014 to April 2015. All patients were monitored for VAE by the use of a transesophageal echocardiography (TEE).Results: 50% of all participating patients experienced a VAE (with 56% of these patients undergoing surgery in the semi-sitting position and 11% in the prone position). 86% of the VAEs were just detected by the use of a TEE. We only observed VAEs with a decrease in EtCO2 in the semi-sitting position. However, none of the patients had any hemodynamic changes due to the VAE. We found that surgeries in patients with a preexisting intracardial shunt such as a patent foramen ovale (PFO) less likely resulted in VAEs (42% vs. 58%).Conclusion: The semi-sitting position with TEE monitoring and a standardized protocol, including a deep central venous line is a safe and advantageous technique, taking also account of a significant rate of VAEs. VAEs also occur in the supine position, however, less frequently.

Effect of the degree of head elevation on the incidence and severity of venous air embolism in cranial neurosurgical procedures with patients in the semisitting position

2018 ◽  
Vol 128 (5) ◽  
pp. 1560-1569 ◽  
Author(s):  
Hatice Türe ◽  
M. Volkan Harput ◽  
Nural Bekiroğlu ◽  
Özgül Keskin ◽  
Özge Köner ◽  
...  
Keyword(s):  
Transesophageal Echocardiography ◽  
Air Embolism ◽  
Neurosurgical Procedures ◽  
Hemodynamic Changes ◽  
Venous Air Embolism ◽  
Head Elevation ◽  
Significant Difference ◽  
Group 2 ◽  
Anesthetic Complications ◽  
Group 1

OBJECTIVEThe semisitting position of a patient confers numerous advantages in various neurosurgical procedures, but venous air embolism is one of the associated complications of this position. To date, no prospective studies of the relationship between the degree of head elevation and the rate and severity of venous air embolism for patients undergoing a procedure in this position have been performed. In this study, the authors compared changes in the severity of venous air embolism according to the degree of head elevation (30° or 45°) in patients undergoing an elective cranial neurosurgical procedure in the semisitting position.METHODSOne hundred patients undergoing an elective infratentorial craniotomy in the semisitting position were included, and each patient was assigned to 1 of 2 groups. In Group 1, each patient’s head was elevated 30° during surgery, and in Group 2, each patient’s head elevation was 45°. Patients were assigned to their group according to the location of their lesion. During surgery, the standard anesthetic protocol was used with total intravenous anesthesia, and transesophageal echocardiography was used to detect air in the blood circulation. Any air embolism seen on the echocardiography screen was classified as Grade 0 to 4. If multiple events occurred, the worst graded attack was used for statistical analysis. During hemodynamic changes caused by emboli, fluid and vasopressor requirements were recorded. Surgical and anesthetic complications were recorded also. All results were compared statistically, and a p value of < 0.05 was considered statistically significant.RESULTSThere was a statistically significant difference between groups for the total rates of venous air emboli detected on transesophageal echocardiography (22.0% [n = 11] in Group 1 and 62.5% [n = 30] in Group 2; p < 0.0001). The rate and severity of air embolism were significantly lower in Group 1 than in Group 2 (p < 0.001). The rates of clinically important venous air embolism (Grade 2, 3, or 4, venous air embolism with decreased end-tidal carbon dioxide levels and/or hemodynamic changes) were 8.0% (n = 4) in Group 1 and 50.0% (n = 24) in Group 2 (p < 0.0001). There was no association between the rate and severity of venous air embolism with patient demographics (p > 0.05). An association was found, however, between the rate of venous air embolism and the type of surgical pathology (p < 0.001); venous embolism occurred more frequently in patients with a meningioma. There were no major surgical or anesthetic complications related to patient position during the postoperative period.CONCLUSIONSFor patients in the semisitting position, an increase in the degree of head elevation is related directly to a higher rate of venous air embolism. With a 30° head elevation and our standardized technique of positioning, the semisitting position can be used safely in neurosurgical practice.

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