RESUMO
Beach chair position is require for Shoulder surgery frequently for proper resolution. The stroke associated with shoulder surgery is a rare complication and probably underreported. The objective of this article is to review the pathophysiology of the ischemic damage associated with beach chair position, learn about strategies and develop recommendations to minimize risks.
La cirugía de hombro (CH), requiere y requerirá colocar a los pacientes en la posición en silla de playa (PSP), cada vez con mayor frecuencia para su adecuada resolución. El asociado a CH, es una complicación poco frecuente y probablmente subreportada. El objetivo de esta revisión, es repasar la fisiopatología del daño isquémico asociado a PSP, conocer estrategias y elaborar recomedaciones destinadas a minimizar riesgos.
Assuntos
Humanos , Artroscopia/métodos , Ombro/cirurgia , Acidente Vascular Cerebral/prevenção & controle , Posicionamento do Paciente , Anestesia/métodos , Circulação Cerebrovascular/fisiologia , Fatores de Risco , Medição de Risco , Acidente Vascular Cerebral/fisiopatologia , Pressão Arterial/fisiologia , Hemodinâmica , Isquemia/fisiopatologia , Isquemia/prevenção & controleRESUMO
La cirugía artroscópica de hombro en posición de silla de playa es una cirugía frecuente y se asocia a buenos resultados. Causa preocupación el reporte de casos de isquemia cerebral asociados a morbimortalidad. Este artículo hace una revisión de la literatura referente a estos casos, realizando un análisis de los factores involucrados y de los cambios que ocurren al sentar a un paciente bajo el efecto de la anestesia general y/o regional. Es muy importante que el equipo quirúrgico comprenda las limitaciones de la técnica y concilie una buena exposición quirúrgica junto con el menor impacto hemodinámico. Actualmente se sugiere sentar a los pacientes con ángulos no mayores a 45°, evitar errores en la lectura de la presión arterial, que traduzcan un adecuado flujo sanguíneo cerebral. Cuando se mide oxigenación cerebral mediante NIRS (ScO2) las mayores caídas de los valores se asocian a anestesia general en ventilación mecánica con hiperventilación y en ángulos de posición de 80-90°. La anestesia regional se asocia a menores caídas de ScO2, pero requiere de un equipo con experiencia...
Shoulder arthroscopic surgery performed in the beach chair position is common and is associated with good results. The report of cases of cerebral ischaemia associated with morbidity and mortality is a cause for concern. This article presents a review of the literature concerning these cases, as well as an analysis of the factors involved and the changes that occur in patients when the beach chair position is used under general or regional anaesthesia. It is very important that the surgical team understands the limitations of the technique, and combines a good surgical exposure along with the least haemodynamic impact. Beach chair positions with angles not greater than 45°, are now suggested in order avoid errors in the blood pressure reading, which may lead to an adequate cerebral blood flow. When measuring cerebral oxygenation using NIRS (ScO2), the biggest drops in the values are associated with general anaesthesia and mechanical ventilation with hyperventilation and position angles of 80-90 degrees. Regional anaesthesia is associated with lower falls of ScO2, but requires an experienced team...
Assuntos
Humanos , Artroscopia/efeitos adversos , Artroscopia/métodos , Ombro/cirurgia , Isquemia Encefálica/prevenção & controle , Pressão Arterial , Anestésicos/efeitos adversos , Complicações Pós-Operatórias/prevenção & controle , Hemodinâmica , Isquemia Encefálica/etiologia , Consumo de Oxigênio , Posicionamento do Paciente , Postura , Fatores de RiscoRESUMO
La posición en silla de playa para la cirugía artroscópica de hombro, presenta ventajas para el cirujano, anestesiólogo y paciente. Sin embargo se han reportado casos graves de complicaciones neurológicas probablemente ligados a la presión de perfusión cerebral. El correcto posicionamiento, un adecuado manejo hemodinámico y el monitoreo de la oxigenación cerebral son claves en esta posición quirúrgica para evitar complicaciones graves, sobre todo cuando se utiliza la anestesia general. Los eventos de desaturación cerebral en posición silla de playa bajo anestesia general son muy frecuentes, no así cuando se utiliza anestesia regional y sedación. Cuando no se cuenta con Monitoreo de la oxigenación cerebral es recomendable mantener la presión arterial media ≥ 70 mmHg no permitiendo descensos de la presión arterial mayores a un 20% de los valores basales. Una saturación regional de O2 por encima del 55% o no permitir descensos de más de un 15% de los valores basales asegura un correcto flujo sanguíneo cerebral y previenen las complicaciones neurológicas centrales. Nivel de evidencia: V. Tipo de estudio: Revisión Bibliográfica...
Beach chair position for arthroscopic shoulder surgery has advantages for the surgeon, anesthesiologist and patient. Severe neurological complications probably linked to cerebral perfusion pressure are reported by different authors. Correct positioning, adequate hemodynamic management and monitoring of cerebral oxygenation, are keys to prevent complications. The events of cerebral desaturation in beach chair position under general anesthesia are common but not when regional anesthesia and sedation is used. Without cerebral oxygenation monitor, it is recommended to maintain a mean arterial pressure ≥ 70 mmHg, not allowing blood pressure descents greater than 20% of baseline values. Proper brain blood flow and central neurological complications are prevented using a cerebral oxygen monitoring device, it is recommended to mainain regional cerebral O2 saturation above 55%, not allowing descents of more than 15% of baseline values. Level of Evidence: Level V. Type Studio: Review...
Assuntos
Humanos , Anestesia/métodos , Articulação do Ombro/cirurgia , Artroscopia/métodos , Posicionamento do PacienteRESUMO
Como resultado de inestabilidad o cambios degenerativos del tendón, el compromiso de la porción larga del bíceps es una fuente frecuente de dolor del hombro en la práctica diaria. A pesar de los buenos resultados reportados de la tenotomía, la tenodesis del bíceps es preferible para los pacientes de alta demanda. Con respecto a la fuerza de flexión y la supinación del antebrazo y el resultado estético, la tenodesis supera los resultados de la tenotomía. La tenodesis proximal tiene una alta incidencia de dolor postoperatorio a nivel de la corredera, por lo cual realizar tenodesis más distales llevaría a prevenir este dolor luego del procedimiento. En el presente artículo, describimos la técnica quirúrgica de la Tenodesis Bicipital Supra-pectoral Artroscópica.
As a result of tendon instability or degenerative changes, the involvement of the long head of the biceps tendon constitutes a common source of shoulder pain in daily practice. Despite the rewarding results obtained with biceps tenotomy, biceps tenodesis is preferable in patients with high demands. The biceps tenodesis yields to improved outcomes as regards forearm flexion and supination strength and cosmesis. Proximal biceps tenodesis has a high incidence of postoperative soreness at the groove. Thus it may be beneficial to move distal with the tenodesis to prevent postoperative pain. In the present article, we describe the surgical technique of the Arthroscopic Supra-pectoral Biceps Tenodesis.
Assuntos
Humanos , Articulação do Ombro/cirurgia , Artroscopia , Tendões/cirurgia , Tenodese/métodos , Parafusos Ósseos , Traumatismos dos Tendões/cirurgia , Técnicas de SuturaRESUMO
OBJECTIVE: To determine the needle-to-nerve distances during electrical nerve location in dogs at different currents and pulse duration using a peripheral nerve stimulator (PNS) under ultrasound control (US), and the minimal electrical thresholds (MET) necessary to obtain a motor response (MR) after achieving needle-to-nerve contact. STUDY DESIGN: Prospective in vivo experimental trial in a clinical setting ANIMALS: Thirty dogs, scheduled for locoregional anaesthesia of the sciatic nerve. METHODS: Needle-to-nerve distance was measured ultrasonographically after obtaining the MR of sciatic nerve with 2, 1 and 0.5 mA and pulse duration 0.1 ms (NS0.1). Thereafter the needle was placed in contact with the nerve and MET was determined. The procedure was repeated with 0.3 ms (NS0.3). Finally the needle was reintroduced to contact the sciatic nerve guided only by US, thus MET-US was determined. Data were analysed using Kruskal-Wallis or Mann-Whitney tests. RESULTS: Needle-to-nerve distances were greater when MR was obtained with 2 mA than with 1 and 0.5 mA at 0.1 and 0.3 ms. No significant differences were observed between the needle-to-nerve distances using 0.1 or 0.3 ms. The MET [median (range)] was 0.4 (0.18-1.3) mA in NS0.1, 0.32 (0.12-0.8) mA in NS0.3; while MET-US was 0.7 (0.32-1.5) mA. When the needle contacted the nerve, the MR achieved with currents below 0.3 mA was obtained in 17.2, 40 and 0% of cases using NS0.1, NS0.3 and US respectively. CONCLUSIONS AND CLINICAL RELEVANCE: The electrical current necessary to obtain a MR decreased as the needle moved towards the nerve. However when the needle tip contacted the nerve, an MR with low current intensity could not be obtained. Thus the absence of motor response at currents below 0.3 mA cannot rule out needle-epineurium contact. When ultrasound is combined with PNS, it is more important to assess the correct needle position than searching for an MR at low currents.
