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- Title
Empfehlung: Perioperatives anästhesiologisches Management bei neurochirurgischen Operationen in sitzender oder halbsitzender Position.
- Authors
Michels, P.; Söhle, M.; Klingler, W.; Bräuer, A.; Drexler, B.
- Abstract
In neurosurgery, positioning the patient in a (semi-)sitting position is particularly popular for surgical treatment of processes in the area of the posterior cranial fossa, as this can offer the disciplines involved a number of advantages compared to other forms of positioning. In addition to ensuring adequate cerebral blood flow, it is particularly important to recognise and treat a venous air embolism (VAE). The underlying mechanism of VAE is due to the elevated surgical area in relation to the heart and the resulting hydrostatic pressure difference between an open vein and the heart. If the incoming air enters the pulmonary arterial vascular bed, the effects are primarily equivalent to a pulmonary artery embolism and can lead to right heart failure and the need for resuscitation. It should be emphasised that the effects of a VAE do not depend primarily on the volume of air that has entered the vasculature, but rather on the volume that has entered per unit of time. A special risk constellation occurs during operations in a (semi-)sitting position if the patient presents with a persistent foramen ovale (PFO). In this situation, the direct transfer of air bubbles from the right to the left heart can lead to cerebral and coronary vascular embolisms with consecutive stroke and myocardial infarction. Therefore, there is need for anaesthesia to recognise and assess both a PFO before the start of positioning and an intraope r ative VAE, as well as to treat this in a targeted manner in communication with the surgeon. Using transoesophageal echocardiography (TEE), a VAE can be directly visualised. Depending on the severity of the VAE, various measures must be taken: informing the surgeon, avoidance of further air entry, treatment of the haemodynamic depression, evaluation of the grade of VAE and, if necessary, aspiration of the entered air or the so-called "air lock". This recommendation of the Scientific Working Group on Neuroanesthesia (WAKNA) from the German Society of Anaesthesia and Intensive Care (DGAI) describes aspects such as implementation, risks as well as advantages and Guidelines and Recommendations Special Articles disadvantages of this special surgical positioning, physiological changes caused by the sitting position itself, haemodynamic monitoring of the patient and in-traoperative ventilation. A special focus has been set on the topic of pathophysiology, incidence, and TEE diagnosis of VAE in (semi-)sitting position, including a discussion on the potential existence of a PFO. The present recommendation replaces its precursor entitled "Monitoring during neurosurgical operations in a sitting or semi-sitting position" published by the WAKNA in 2008.
- Subjects
HEART failure risk factors; MYOCARDIAL infarction; TRANSESOPHAGEAL echocardiography; NEUROSURGERY; HEART septum; RESUSCITATION; HEMODYNAMICS; CEREBRAL circulation; GAS embolism; STROKE; PATIENT monitoring; PERIOPERATIVE care; ANESTHESIA; PATIENT positioning; DISEASE complications
- Publication
Anaesthesiologie & Intensivmedizin, 2024, Vol 65, p316
- ISSN
0170-5334
- Publication type
Article
- DOI
10.19224/ai2024.316