Tough Case: Beach Chair Position

[BLADEMDA]

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The evidence is pretty clear that if you decide to go with MAP lower than 70 you better have a darn good reason.

In conclusion, in healthy patients in the beach-chair position, CBF as estimated using ICA blood velocity appears to be maintained during
[FONT=Dutch801 Rm BT,Dutch801 Rm BT][FONT=Dutch801 Rm BT,Dutch801 Rm BT]sevoflurance anaesthesia when MAP is above ..70 mmHg.

http://www.cairnsanaes.org/page11/files/Soeding.PDF

 

[BLADEMDA]

The important clinical consequence is that in many patients, as MAP approaches 50 mmHg, we already may be well below the true LLA. Therefore, we may already be encroaching on the CBF reserve, and there may be a much smaller margin for error with respect to CNS ischemic injury than we have commonly believed.

John C. Drummond, MD

LLA= Lower Limitis of autoregulation

 

[BLADEMDA]

If the Orthopod insisted on a mean BP of 60 I would place the transducer near the ear/tragus. The actual mean at the cuff would be higher. This trick would satiisfy the surgeon while preserving safety for the patients.

1 inch up from the cuff= 2mm of mean pressure lower

 

[TheSweetness]

Very good key points. Thanks!

 

[imfrankie]

The important clinical consequence is that in many patients, as MAP approaches 50 mmHg, we already may be well below the true LLA. Therefore, we may already be encroaching on the CBF reserve, and there may be a much smaller margin for error with respect to CNS ischemic injury than we have commonly believed.

John C. Drummond, MD

LLA= Lower Limitis of autoregulation

Sarcasm would dictate a strong remark about independent CRNA practice for a case like this

 

[critter81]

What is the recommended MAP for beach chair position for a 43 year old healthy male, arm tucked at the side and blood pressure cuff on the arm?

 

[deleted59964]

Not sure if anyone other than blade is meant to post in this thread, but ...

HIs main concern is "stroke" from the anesthesia as he was informed by the surgeon his position will be beach chair for 2.5 hours.

That is a misconception I'd be fixing ... it's the surgeon who wants him in beach chair for hours

 

[deleted162650]

Not sure if anyone other than blade is meant to post in this thread, but ...

😆

 

[dhb]

If BP is not well controlled and because he took his ACEI the morning of surgery and with a HbA1c of 9+% i would recommend to this anxious patient to postpone surgery to fix thede issues and document this if his choose to proceed.
Do case as ususal probably an asleep a-line for documentation.

 

[anbuitachi]

What is the recommended MAP for beach chair position for a 43 year old healthy male, arm tucked at the side and blood pressure cuff on the arm?

Normal MAP.

 

[critter81]

I have a case where the MAP dropped to 74 at 10:20 and then down to 66 at 10:41 and did not get back to normal until 11:04 anthesiologist is arguing that is normal in the BCP , arm tucked at the side and cuff on the arm, the patient has still has post operative memory loss 7 months out from surgery

 

[Ronin786]

I have a case where the MAP dropped to 74 at 10:20 and then down to 66 at 10:41 and did not get back to normal until 11:04 anthesiologist is arguing that is normal in the BCP patient has still has post operative memory loss 7 months out from surgery

Go find some other place to troll for business.

 

[critter81]

Go find some other place to troll for business.

No offense sir, but in full disclosure I AM THE PATIENT! and no one is listening to me about the fact that I have lost my memory and after cognitive testing I am in the less than 1percentile of new memory capability and people are telling me this is a normal outcome from surgery and all the doctors I talk to have been telling me to go pound sand. I am just looking for some answers to figure out how to fix myself.

 

[Arch Guillotti]

No offense sir, but in full disclosure I AM THE PATIENT! and no one is listening to me about the fact that I have lost my memory and after cognitive testing I am in the less than 1percentile of new memory capability and people are telling me this is a normal outcome from surgery and all the doctors I talk to have been telling me to go pound sand. I am just looking for some answers to figure out how to fix myself.

This forum is not the appropriate venue to discuss your medical condition.

 

[critter81]

This forum is not the appropriate venue to discuss your medical condition.

And why would that be? The evidence is quite clear according to the other post that normal MAP should be maintained and nothing below 70 are you worried about something? I simply asked a few questions and the folks on this board are calling me a troll, I guess all you "Doctors" are the same, you just feel like you can tell people to pound sand

 

[IlDestriero]

Sounds like you need to talk to an attorney and not folks on an anesthesia forum.
This forum is for physicians not patients, and not for medical advice.
Nobody here can tell you what happened to you or why.
Best of luck on a full recovery.
PS Us "Doctors" get paid for their expert opinions, so if you want an evaluation of your situation don't expect to get it here, after all you get what you pay for.
PPS Things aren't as black and white as you may see portrayed on this forum.


--
Il Destriero

 

[fakin' the funk]

My beach chair shoulder practice:

MAP 80-90 at the arm, to maintain 65-70 at the brain. Surgeons have never said a peep about bleeding. I'd tolerate a little lower in a very healthy patient, but most of the ones I've done have been redos in old arthritic crusty people. This requires phenylephrine gtt 90+% of the time. I would not jump to defend my colleagues who run MAPs in the 50s at the arm during such cases, out of laziness to draw up the dang neo drip.

 

[Hoya11]

Not sure if anyone other than blade is meant to post in this thread, but ...

HIs main concern is "stroke" from the anesthesia as he was informed by the surgeon his position will be beach chair for 2.5 hours.

That is a misconception I'd be fixing ... it's the surgeon who wants him in beach chair for hours

If he were to lay in a beach chair awake would he be at the same risk of stroke as under GA and in a beach chair?

It is indeed the anesthesia that puts him at risk for stroke.

I would do this case with a pre-op block, LMA, and fenantyl to increase ETCO2 to 50 or so. Neo gtt PRN to keep pressure 140s.. Hell be fine

 

[deleted171991]

It's actually the surgery (i.e. hypercoagulability) that puts him at risk for stroke, awake or not. Or a bad anesthesia provider who doesn't adjust his BP correctly. It's not the anesthesia per se, or the surgeon.

Beach chair is just another position. Yes, lateral is safer, but just because of lazy anesthesia providers. Otherwise it's simple math: target MAP = baseline MAP + biceps to tragus (or vertex for extra safety) distance in cm/1.36 (less if the patient is much closer to supine than sitting). For most people that's an extra 20+/-5 mmHg of blood pressure (hence the ischemic stroke risk when people are lazy/stupid). Neo drip - easy fix.

 

[deleted162650]

Otherwise it's simple math: target MAP = baseline MAP + biceps to tragus (or vertex for extra safety) distance in cm/1.36 (less if the patient is much closer to supine than sitting).

I'll bet that "baseline BP" was obtained at the bicep with the pt in an upright sitting position. Keeping the BP there without adding back the bicep to ear distance should be just fine - unless of course the pt was having TIA's every time he sat up. No one can argue that keeping it a few points higher doesn't give a little margin of safety though.

 

[twoliter]

It's actually the surgery (i.e. hypercoagulability) that puts him at risk for stroke, awake or not. Or a bad anesthesia provider who doesn't adjust his BP correctly. It's not the anesthesia per se, or the surgeon.

Beach chair is just another position. Yes, lateral is safer, but just because of lazy anesthesia providers. Otherwise it's simple math: target MAP = baseline MAP + biceps to tragus (or vertex for extra safety) distance in cm/1.36 (less if the patient is much closer to supine than sitting). For most people that's an extra 20+/-5 mmHg of blood pressure (hence the ischemic stroke risk when people are lazy/stupid). Neo drip - easy fix.

Thromboembolic stroke --> surgery/hypercoaguability; Ischemic stroke --> anesthesia/hypoperfusion; no?
It's like you're basically agreeing with his statement but saying you disagree. You're basically saying that anesthesia does cause an ischemic stroke risk which must be offset by vasopressors and other techniques by a non-lazy anesthesiologist.

 

[deleted171991]

Thromboembolic stroke --> surgery/hypercoaguability; Ischemic stroke --> anesthesia/hypoperfusion; no?
It's like you're basically agreeing with his statement but saying you disagree. You're basically saying that anesthesia does cause an ischemic stroke risk which must be offset by vasopressors and other techniques by a non-lazy anesthesiologist.

Something like that. The surgery-related thromboembolic stroke (even if rarer) is much more difficult to prevent than the anesthesia-related ischemic stroke.

What I am trying to say is that the main culprit for a patient suffering a stroke after a beach-chair-position surgery is nobody else but the OR anesthesia provider. Not the surgeon, not the "anesthesia". Let's be honest.

 

[deleted171991]

I'll bet that "baseline BP" was obtained at the bicep with the pt in an upright sitting position. Keeping the BP there without adding back the bicep to ear distance should be just fine - unless of course the pt was having TIA's every time he sat up. No one can argue that keeping it a few points higher doesn't give a little margin of safety though.

Most people induce/intubate with the patient supine. Hence the initial/pre-induction BP is usually obtained in supine position. If using that BP as the baseline (like most anesthesia providers), the formula I quoted applies.

Your solution is correct if you have a baseline BP that was obtained in the holding area, with the patient lying on the stretcher in a very similar beach chair position.

 

[deleted59964]

If he were to lay in a beach chair awake would he be at the same risk of stroke as under GA and in a beach chair?

It is indeed the anesthesia that puts him at risk for stroke.

I would do this case with a pre-op block, LMA, and fenantyl to increase ETCO2 to 50 or so. Neo gtt PRN to keep pressure 140s.. Hell be fine

Really - would his risk of stroke be the same if he was lateral. Position requirement = surgical issue.

 

[deleted59964]

Pressure doesn't equal flow.
Pushing pressure up in beach chair is of course a good idea, but let's face it we have no idea in these cases what happens to cardiac output, and cerebral blood flow.

 

[deleted171991]

Really - would his risk of stroke be the same if he was lateral. Position requirement = surgical issue.

Yes, with a vigilent anesthesia provider.

We are not talking about blindness associated with prone position, or other outcomes that cannot be 100% avoided. This one can.

 

[deleted171991]

Pressure doesn't equal flow.
Pushing pressure up in beach chair is of course a good idea, but let's face it we have no idea in these cases what happens to cardiac output, and cerebral blood flow.

Except in severe CHF, phenylephrine does not decrease cardiac output. And ephedrine obviously doesn't.

I don't know why beach chair is such a big deal. Most neurosurgical patients are in a modified beach chair position that we manage by measuring the BP at the level of the tragus and adjusting it with pressors as needed, this while also having to avoid a CBF increase. And I don't see ischemic strokes happening there.

 

[deleted87051]

Except in severe CHF, phenylephrine does not decrease cardiac output. And ephedrine obviously doesn't.

I don't know why beach chair is such a big deal. Most neurosurgical patients are in a modified beach chair position that we manage by measuring the BP at the level of the tragus and adjusting it with pressors as needed, this while also having to avoid a CBF increase. And I don't see ischemic strokes happening there.

Besides a handful of case reports, I don't see ischemic strokes in beach chair shoulder surgery either. I wonder if the magnitude of the problem is exaggerated. If I was concerned I'd use cerebral oximetry but I don't.

 

[deleted59964]

Except in severe CHF, phenylephrine does not decrease cardiac output.

Source?

 

[deleted171991]

Source?

While I usually appreciate more when somebody posts opposing references (instead of the lazy "Source?"), this time my memory was wrong and I had made a mistake.

The right quote is that "except in CHF, phenylephrine does not decrease stroke volume". It may decrease cardiac output by reflex bradycardia, which is much more frequent with boluses than infusions. Here's a great review on the subject: Pulmcrit - An alternative viewpoint on phenylephrine infusions .

Browsing through the literature, the autoregulation of the CBF does not have a clear relationship with the CO. Phenylephrine is clearly a cerebral vasoconstrictor, but I have no idea what it does to CBF (and I don't think anybody else has either). However, consider this: Cerebral Blood Flow and the Alpha-1 Agonist Bogeyman : Anesthesia & Analgesia .

It remains possible that decreased CBF may occur in the circumstances of abruptly increased BP associated with bolus rather than infusion administration.8 Nonetheless, the available data indicate that when phenylephrine is used by infusion, the probable effects will be either an increase or, at worst, no change in CNS bloodflow.

 

[chocomorsel]

Not sure if anyone other than blade is meant to post in this thread, but ...

HIs main concern is "stroke" from the anesthesia as he was informed by the surgeon his position will be beach chair for 2.5 hours.

That is a misconception I'd be fixing ... it's the surgeon who wants him in beach chair for hours

I was thinking the exact same thing. But this is very typical of Blade. He asks a questions for discussion, and then discusses it with mostly himself. He loves arguing with and countering himself. I bet he is a hoot in real life. Maybe he loves to hear himself talk.
Have you ever thought about being a lawyer Blade?

 

[deleted171991]

I was thinking the exact same thing. But this is very typical of Blade. He asks a questions for discussion, and then discusses it with mostly himself. He loves arguing with and countering himself. I bet he is a hoot in real life. Maybe he loves to hear himself talk.
Have you ever thought about being a lawyer Blade?

This is what smart people do. They doubt themselves and their own dogmas all the time. Charlie Munger is one example.

I have always enjoyed @BLADEMDA's supposed "monologues".

 

[chocomorsel]

This is what smart people do. They doubt themselves and their own dogmas all the time.

I have always enjoyed his supposed "monologues".

Ahh, thanks for that little bit of knowledge. I just thought he loves to hear himself talk.

 

[deleted171991]

Ahh, thanks for that little bit of knowledge. I just thought he loves to hear himself talk.

That, too, I am sure. That's also something that smart (and not so smart) people do.

One cannot get to thousands of posts without that. 🙂

Btw, I appreciate (and deserve) the sarcasm.

 

[deleted162650]

While I usually appreciate more when somebody posts opposing references (instead of the lazy "Source?"), this time my memory was wrong and I had made a mistake.

The right quote is that "except in CHF, phenylephrine does not decrease stroke volume". It may decrease cardiac output by reflex bradycardia, which is much more frequent with boluses than infusions. Here's a great review on the subject: Pulmcrit - An alternative viewpoint on phenylephrine infusions .

Browsing through the literature, the autoregulation of the CBF does not have a clear relationship with the CO. Phenylephrine is clearly a cerebral vasoconstrictor, but I have no idea what it does to CBF (and I don't think anybody else has either). However, consider this: Cerebral Blood Flow and the Alpha-1 Agonist Bogeyman : Anesthesia & Analgesia .

Very cool links @FFP. I'll need to start checking out that Pulmcrit site regularly. I'll also say that John Drummond is perhaps the smartest human I've ever met, and one hell of a clinician on top of it. If he says something, I pretty much treat it as if God himself said it and passed it down engraved on stone tablets.

 

[deleted171991]

Very cool links @FFP. I'll need to start checking out that Pulmcrit site regularly. I'll also say that John Drummond is perhaps the smartest human I've ever met, and one hell of a clinician on top of it. If he says something, I pretty much treat it as if God himself said it and passed it down engraved on stone tablets.

I stand on shoulders of giants, many of them authors of great blogs and books, many of them intensivists or EM physicians, many of them from other countries. PulmCrit and the parent blog (EmCrit) are among the best, and I would encourage everybody to read them regularly. There are many others, too.

Here is some of my list, in the order copied and pasted from my RSS reader. The bolded ones are consistently outstanding.

http://www.scancrit.com
PulmCCM
LITFL: Life in the Fast Lane Medical Blog
University of Maryland | CCP Network
EMCrit Blog - Emergency Department Critical Care & Resuscitation
St.Emlyn's - Emergency Medicine #FOAMed
thinking critical care
Home - Ultrasound Podcast
Emergency Medicine PharmD
emdocs - Emergency Medicine Education
icuroom.net Archive
Deranged Physiology
Emergency Medicine Cases | EM Cases
FOAMcast
emergency medicine updates
First10EM
The PharmERToxGuy
Fluid physiology
Core EM
Ultrasound of the Week - learn bedside ultrasound, one week at a time
Critical Care Northampton
5 minute sono | 5 Minute Sono Blog

 

[Psai]

While I usually appreciate more when somebody posts opposing references (instead of the lazy "Source?"), this time my memory was wrong and I had made a mistake.

The right quote is that "except in CHF, phenylephrine does not decrease stroke volume". It may decrease cardiac output by reflex bradycardia, which is much more frequent with boluses than infusions. Here's a great review on the subject: Pulmcrit - An alternative viewpoint on phenylephrine infusions .

Browsing through the literature, the autoregulation of the CBF does not have a clear relationship with the CO. Phenylephrine is clearly a cerebral vasoconstrictor, but I have no idea what it does to CBF (and I don't think anybody else has either). However, consider this: Cerebral Blood Flow and the Alpha-1 Agonist Bogeyman : Anesthesia & Analgesia .

Dude if you make an assetion, it is on you to prove it, not for others to disprove.

 

[deleted171991]

Dude if you make an assetion, it is on you to prove it, not for others to disprove.

Nope, not in a friendly discussion on a forum.

If everybody had to prove everything they say, in a scientific paper manner, there would be no more professional discussions here (except for Blade talking to Blade).

 

[chocomorsel]

That, too, I am sure. That's also something that smart (and not so smart) people do.

One cannot get to thousands of posts without that. 🙂

Btw, I appreciate (and deserve) the sarcasm.

Totally wasn't being sarcastic at all. You are one of my favorites on here.

 

[deleted59964]

While I usually appreciate more when somebody posts opposing references (instead of the lazy "Source?"), this time my memory was wrong and I had made a mistake.

The right quote is that "except in CHF, phenylephrine does not decrease stroke volume". It may decrease cardiac output by reflex bradycardia, which is much more frequent with boluses than infusions. Here's a great review on the subject: Pulmcrit - An alternative viewpoint on phenylephrine infusions .

Browsing through the literature, the autoregulation of the CBF does not have a clear relationship with the CO. Phenylephrine is clearly a cerebral vasoconstrictor, but I have no idea what it does to CBF (and I don't think anybody else has either). However, consider this: Cerebral Blood Flow and the Alpha-1 Agonist Bogeyman : Anesthesia & Analgesia .

Thanks for the correction and link.
My point is that cerebral blood flow and the micro circulation is complex.
in a patient with an unknown amount of cerebrovascular disease, and often even an unknown amount of macro vascular disease (carotid Doppler) putting them in beach chair, and thinking that all is good if the BP is ok ... is simplistic

 

[CardioDad]

If I may humbly Blade:
(*realizing that this article is 2 years old and most likely familiar to you...)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4308465/
Shoulder Surgery in the Beach Chair Position is Associated with Diminished Cerebral Autoregulation but no Differences in Postoperative Cognition or Brain Injury Biomarker Levels Compared with Supine Positioning: The Anesthesia Patient Safety Foundation Beach Chair Study
Introduction
Approximately two-thirds of the more than 400,000 shoulder surgery procedures performed annually in the United States are performed with the patient’s head elevated above the horizontal, a position know as the “beach chair” position (BCP).1,2 This position affords better intraarticular visualization and less risk of neurovascular trauma than when patients are placed in the lateral decubitus position (LDP).3 The BCP, however, has been reported to be associated with rare but devastating neurologic complications, including stroke, spinal cord ischemia, and transient visual loss.1,4–8 The mechanism of these complications is unknown. Arterial blood pressure is measured from the brachial artery or even the popliteal artery (when the blood pressure cuff is placed on the lower leg) during shoulder surgery. There is currently intense debate in the anesthesiology community regarding whether cerebral hypotension from failing to consider the gravitational effects of head elevation on cerebral perfusion might increase susceptibility of patients to neurologic complications of surgery in the BCP.9–13

 

[ranvier]

Everything like this should be in the private forum.

 

[dchz]

Everything like this should be in the private forum.

I second this motion