Artikel
Surgery in semisitting position for patients with patent foramen ovale: how dangerous is it?
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Autoren
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Guenther C. Feigl
- Department of Neurosurgery, University of Tuebingen Medical Center, Germany
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Karlheinz Decker
- Department of Anesthesiology, University of Tuebingen Medical Center, Germany
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Boris Krischek
- Department of Neurosurgery, University of Tuebingen Medical Center, Germany
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Rainer Ritz
- Department of Neurosurgery, University of Tuebingen Medical Center, Germany
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Kristofer Ramina
- Department of Neurosurgery, University of Tuebingen Medical Center, Germany
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Alireza Gharbaghi
- Department of Neurosurgery, University of Tuebingen Medical Center, Germany
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Marcos S. Tatagiba
- Department of Neurosurgery, University of Tuebingen Medical Center, Germany
| Veröffentlicht: | 16. September 2010 |
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Gliederung
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Objective: The actual risk for patients with patent foramen ovale (PFO) to suffer a clinically relevant air embolism during surgery in the semisitting position is not known. The semisitting position has been widely used in several centers for surgeries in the posterior cranial fossa (PCF). It reduces intracranial pressure and venous bleeding; it enhances anatomical orientation since the view to surgical field is not obscured by pooling of blood or irrigation fluid. Nevertheless, there is still an ongoing controversy regarding the benefits, disadvantages and most of all risks of this positioning to patients. Particularly, the presence of a PFO has been considered a contra-indication for semisitting positioning. This is the first prospective study with a large group of patients analysing the impact of PFO on surgeries in semisitting position.
Methods: In a prospective study performed between January 2008 and December 2009, 200 consecutive patients with lesions in the PCF, pineal region or occipital region were included. All procedures were performed under general anesthesia and in the semisitting position. Transesophageal echocardiography (TEE) and capnometry were used intraoperatively to monitor for air bubbles in the venous system.
Results: Out of these 200 consecutive patients, 52 patients (26%) were diagnosed with PFO. Rates of PAE according to our five scale grading showed following patient distribution: Grade I (air bubbles in the TEE): 22 (42•3%), Grade II (air bubbles in the TEE with a drop of EtCO2 ≤3mmHg): 2 (3•8%), Grade III (air bubbles in the TEE with a drop of EtCO2 >3mmHg): 4 (7•7%) and Grade IV (as Grade III but with a drop of the middle arterial pressure ≥20% and / or an increase of heart rate ≥40%): 1 patient (1•9%), Grade V (PAE causing arrhythmia with haemodynamic instability requiring cardiopulmonary resuscitation): 0 (0%). In this series, no mortalities and no new or unexplained neurological deficits were caused by PAE.
Conclusions: This study shows that under standardized anesthesiological and neurosurgical protocols even patients with PFO can be operated safely in a semisitting position. Thus, PFO does not seem to represent a contra-indication for surgeries in the semisitting position any longer.
