How Surgical Positions Affect Cerebral Oxygenation

Abstract

How Surgical Positions Affect Cerebral Oxygenation? This study investigates the use of cerebral oximetry in various surgical positions and its impact on cerebral oxygenation. We conducted a literature review through Medline, and Ebscohost, focusing on articles published until October 30, 2023. Our findings indicate that: • Cerebral oxygenation is affected by all surgical positions, with the most significant clinical impact observed in the seated position. • Maintaining cerebral autoregulation is crucial for preventing cerebral hypoxia or desaturation. Upholding a mean arterial pressure above 60 mmHg is essential for this purpose. • Anesthesia can negatively impact cerebral oxygenation by potentially impairing cerebral autoregulation. • Inhalation anesthetics may have a more beneficial effect on cerebral oxygenation compared to intravenous anesthetics. • The risk of cerebral desaturation increases in elderly patients and those with comorbidities. • Standardization of cerebral desaturation definitions is needed to better assess its relationship with postoperative complications. • The position of the blood pressure transducer can affect the accuracy of intraoperative monitoring. In the seated position, placing it at the level of the acoustic meatus provides a more precise assessment. Our study highlights the importance of considering the effects of different surgical positions on cerebral oxygenation. This knowledge can assist anesthesiologists in monitoring patients intraoperatively and potentially preventing postoperative neurological complications. Keywords: Cerebral oximetry, Beach chair, cerebral oxygenation, Prone, Near-infrared spectroscopy

Keywords

• Cerebral oximetry
• Beach chair
• cerebral oxygenation
• Prone
• Near-infrared spectroscopy

References

1. 1. Bevegård S, Holmgren A, Jonsson B. The Effect of Body Position on the Circulation at Rest and During Exercise, with Special Reference to the Influence on the Stroke Volume. Acta Physiol Scand. 1960; 49(2–3):279-98.
2. 2. Rozet I, Vavilala MS. Risks and Benefits of Patient Positioning During Neurosurgical Care. Anesthesiol Clin. 2007; 25(3):631.
3. 3. Jöbsis FF. Noninvasive, Infrared Monitoring of Cerebral and Myocardial Oxygen Sufficiency and Circulatory Parameters. Science. 1977; 198(4323):1264-66.
4. 4. Tosh W, Patteril M. Cerebral oximetry. BJA Educ. 201; 16(12):417-21.
5. 5. Ali J, Cody J, Maldonado Y, Ramakrishna H. Near-Infrared Spectroscopy (NIRS) for Cerebral and Tissue Oximetry: Analysis of Evolving Applications. J Cardiothorac Vasc Anesth. 2022; 36(8):2758-66.
6. 6. Fox E, Jöbsis-Vander Vliet FF, Mitnick MH. Monitoring cerebral oxygen sufficiency in anesthesia and surgery. Adv Exp Med Biol. 1985; 191:849-54.
7. 7. Gelber PE, Reina F, Caceres E, Monllau JC. A comparison of risk between the lateral decubitus and the beach-chair position when establishing an anteroinferior shoulder portal: a cadaveric study. Arthroscopy. 2007; 23(5):522-28.
8. 8. Skyhar MJ, Altchek DW, Warren RF, Wickiewicz TL, O’Brien SJ. Shoulder arthroscopy with the patient in the beach-chair position. Arthroscopy. 1988; 4(4):256-59.

9. 9. Peruto CM, Ciccotti MG, Cohen SB. Shoulder arthroscopy positioning: lateral decubitus versus beach chair. Arthroscopy. 2009; 25(8):891-96.
10. 10. Pohl A, Cullen DJ. Cerebral ischemia during shoulder surgery in the upright position: a case series. J Clin Anesth. 2005; 17(6):463-69.
11. 11. Koh JL, Levin SD, Chehab EL, Murphy GS. Neer Award 2012: Cerebral oxygenation in the beach chair position: a prospective study on the effect of general anesthesia compared with regional anesthesia and sedation. J Shoulder Elb Surg. 2013; 22(10):1325-31.
12. 12. Murphy GS, Szokol JW, Marymont JH, et al. Cerebral oxygen desaturation events assessed by near-infrared spectroscopy during shoulder arthroscopy in the beach chair and lateral decubitus positions. Anesth Analg. 2010; 111(2):496-505.
13. 13. Salazar D, Sears BW, Aghdasi B, Only A, Francois A, Tonino P, et al. Cerebral desaturation events during shoulder arthroscopy in the beach chair position: patient risk factors and neurocognitive effects. J Shoulder Elb Surg. 2013; 22(9):1228-35.
14. 14. Aguirre JA, Märzendorfer O, Brada M, Saporito A, Borgeat A, Bühler P. Cerebral oxygenation in the beach chair position for shoulder surgery in regional anesthesia: impact on cerebral blood flow and neurobehavioral outcome. J Clin Anesth. 2016; 35:456-64.
15. 15. Rains DD, Rooke GA, Wahl CJ. Pathomechanisms and complications related to patient positioning and anesthesia during shoulder arthroscopy. Arthroscopy. 2011; 27(4):532-41.
16. 16. Soeding P. Effects of Positioning on Cerebral Oxygenation. Curr Anesthesiol Rep. 2013; 3(3):184-96.
17. 17. Smelt WL, de Lange JJ BL. Cardiorespiratory effects of the sitting position in neurosurgery. Acta Anaesthesiol Belg. 1988; 39(4):223-31.
18. 18. Armstead WM. Cerebral Blood Flow Autoregulation and Dysautoregulation. Anesthesiol Clin. 2016; 34(3):465-77.
19. 19. Rains DD, Rooke GA, Wahl CJ. Pathomechanisms and complications related to patient positioning and anesthesia during shoulder arthroscopy. Arthroscopy. 2011; 27(4):532-41.
20. 20. Silverman A, Petersen NH. Physiology, Cerebral Autoregulation. StatPearls. 2023.
21. 21. Babakhani B, Heroabadi A, Hosseinitabatabaei N, et al. Cerebral Oxygenation Under General Anesthesia Can Be Safely Preserved in Patients in Prone Position: A Prospective Observational Study. J Neurosurg Anesthesiol. 2017; 29(3):291-17.
22. 22. Deiner S, Chu I, Mahanian M, Lin HM, Hecht AC, Silverstein JH. Prone Position Is Associated with Mild Cerebral Oxygen Desaturation in Elderly Surgical Patients. PLoS One. 2014; 9(9):e106387.
23. 23. Jha A, Chen F, Mann S, Shah R, Abu-Youssef R, Pavey H, et al. Physiological effects and subjective tolerability of prone positioning in COVID-19 and healthy hypoxic challenge. ERJ Open Res. 2022; 8(1): 00524-2021.
24. 24. Dell’Anna AM, Carelli S, Cicetti M, Stella C, Bongiovanni F, Natalini D, et al. Hemodynamic response to positive end-expiratory pressure and prone position in COVID-19 ARDS. Respir Physiol Neurobiol. 2022; 298:103844.
25. 25. Closhen D, Engelhard K, Dette F, Werner C, Schramm P. Changes in cerebral oxygen saturation following prone positioning for orthopaedic surgery under general anaesthesia. Eur J Anaesthesiol. 2015; 32(6):381-86.
26. 26. Andersen JDH, Baake G, Wiis JT, Olsen KS. Effect of head rotation during surgery in the prone position on regional cerebral oxygen saturation: A prospective controlled study. Eur J Anaesthesiol. 2014; 31(2):98-103.
27. 27. Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Shear TD, Vender JS, et al. Effect of ventilation on cerebral oxygenation in patients undergoing surgery in the beach chair position: A randomized controlled trial. Br J Anaesth. 2014; 113(4):618-27.
28. 28. Zhang CJ, Ma JH, Jin F, Li XH, Jia HQ, Mu DL. Effect of one-lung ventilation on the correlation between left and right cerebral saturation. BMC Anesthesiol. 2023; 23(1):1-9.
29. 29. Kübra T, Arslan G, Geyik FD, Akın C, Demirhan R, Cevik B. The Effect of One-Lung Ventilation on Cerebral Oxygenation and Neurocognitive Functions. GKDA Derg. 2022; 28(1):7-14.
30. 30. Tobias JD, Johnson GA, Rehman S, Fisher R, Caron N. Cerebral oxygenation monitoring using near infrared spectroscopy during one-lung ventilation in adults. J Minim Access Surg. 2008; 4(4):104.
31. 31. Schramm P, Treiber AH, Berres M, Pestel G, Engelhard K, Werner C, et al. Time course of cerebrovascular autoregulation during extreme Trendelenburg position for robotic-assisted prostatic surgery. Anaesthesia. 2014; 69(1):58-63.
32. 32. Lee JR, Lee PB, Do SH, Jeon YT, Lee JM, Hwang JY, et al. The Effect of Gynaecological Laparoscopic Surgery on Cerebral Oxygenation. J Int Med Res. 2006; 34:531-36.
33. 33. Wiesinger C, Schoeb DS, Stockhammer M, et al. Cerebral oxygenation in 45-degree trendelenburg position for robot-assisted radical prostatectomy: a single-center, open, controlled pilot study. BMC Urol. 2020; 20(1): 198.
34. 34. Kim YJ, Chung RK, Kim DY, Kim YJ, Kim JH, Han JI. The effect of Trendelenburg position and pneumoperitoneum on regional cerebral oxygen saturation during gynecological laparoscopic surgery. Anesth Pain Med. 2012; 7(2):174-77.
35. 35. Özgün A, Sargin A, Karaman S, Günüşen İ, Alper I, Aşkar FZ. The relationship between the Trendelenburg position and cerebral hypoxia inpatients who have undergone robot-assisted hysterectomy and prostatectomy. Turk J Med Sci. 2017; 47(6):1797-803.
36. 36. Park EY, Koo BN, Min KT, Nam SH. The effect of pneumoperitoneum in the steep Trendelenburg position on cerebral oxygenation. Acta Anaesthesiol Scand. 2009; 53(7): 895-99.
37. 37. Kalmar AF, Foubert L, Hendrickx JFA, Mottrie A, Absalom A, Mortier EP, et al. Influence of steep Trendelenburg position and CO2 pneumoperitoneum on cardiovascular, cerebrovascular, and respiratory homeostasis during robotic prostatectomy. Br J Anaesth. 2010; 104(4):433-39.
38. 38. Heller JA, Demaria S, Govindaraj S, et al. Cerebral oximetry monitoring during sinus endoscopy. Laryngoscope. 2015; 125(4):E127-31.
39. 39. Yang W, Wang G, Li H, et al. The 15° reverse Trendelenburg position can improve visualization without impacting cerebral oxygenation in endoscopic sinus surgery-A prospective, randomized study. Int Forum Allergy Amp; Rhinol. 2021; 11(6):993-1000.
40. 40. Shilpakar O, Karki B, Rajbhandari B. Amitraz poisoning-tale of an unusual pesticide poisoning: A case report. J Nepal Med Assoc. 2020; 58(225):338-40.
41. 41. O’Grady JG, Schalm SW, Williams R. Acute liver failure: redefining the syndromes. Lancet 1993; 342(8866):273-75.
42. 42. Carvounis CP, Feinfeld DA. A simple estimate of the effect of the serum albumin level on the anion gap. Am J Nephrol. 2000;20(5):369-72.
43. 43. Picton P, Dering A, Alexander A, et al. Influence of Ventilation Strategies and Anesthetic Techniques on Regional Cerebral Oximetry in the Beach Chair Position: A Prospective Interventional Study with a Randomized Comparison of Two Anesthetics. Anesthesiology. 2015; 123(4):765-74.
44. 44. Doe A, Kumagai M, Tamura Y, Sakai A, Suzuki K. A comparative analysis of the effects of sevoflurane and propofol on cerebral oxygenation during steep Trendelenburg position and pneumoperitoneum for robotic-assisted laparoscopic prostatectomy. J Anesth. 2016; 30(6):949-55.
45. 45. Hayashi K, Yamada Y, Ishihara T, Tanabe K, Iida H. Comparison of regional cerebral oxygen saturation during one-lung ventilation under desflurane or propofol anesthesia: A randomized trial. Medicine. 2022; 101(41): e30030.
46. 46. Jeong H, Jeong S, Lim HJ, Lee J, Yoo KY. Cerebral oxygen saturation measured by near-infrared spectroscopy and jugular venous bulb oxygen saturation during arthroscopic shoulder surgery in beach chair position under sevoflurane-nitrous oxide or propofol-remifentanil anesthesia. Anesthesiology. 2012; 116(5):1047-56.
47. 47. Aguirre J, Borgeat A, Trachsel T, Cobo del Prado I, De Andrés J, Bühler P. 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; 61(2):64-72.
48. 48. Kocaoglu B, Ozgen SU, Toraman F, Karahan M, Guven O. Foreseeing the danger in the beach chair position: Are standard measurement methods reliable? Knee Surg Sports Traumatol Arthrosc. 2015; 23(9):2639-44.
49. 49. Hayashi K, Tanabe K, Minami K, Sakata K, Nagase K, Iida H. Effect of blood pressure elevation on cerebral oxygen desaturation in the beach chair position. Asian J Anesthesiol. 2017; 55(1):13-16.
50. 50. Woo JH, Kim YJ, Jeong JS, Chae JS, Lee YR, Chon JY. Compression stockings reduce the incidence of hypotension but not that of cerebral desaturation events in the beach-chair position: a randomized controlled trial. Korean J Anesthesiol. 2018; 71(2):127-34.
51. 51. Cox RM, Jamgochian GC, Nicholson K, Wong JC, Namdari S, Abboud JA. The effectiveness of cerebral oxygenation monitoring during arthroscopic shoulder surgery in the beach chair position: a randomized blinded study. J shoulder Elb Surg. 2018; 27(4):692-700.