gms | German Medical Science

59th Annual Meeting of the German Society of Neurosurgery (DGNC)
3rd Joint Meeting with the Italian Neurosurgical Society (SINch)

German Society of Neurosurgery (DGNC)

1 - 4 June 2008, Würzburg

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A standardized protocol for the prevention of clinically relevant venous air embolism during neurosurgical interventions in the semi-sitting position

Ein standardisiertes Protokoll zur Prävention klinisch relevanter venöser Luftembolien bei Operationen in der halbsitzenden Lagerung.

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  • corresponding author S. Jadik - Neurochirurgische Klinik, Neurozentrum
  • H. Wissing - Klinik für Anaesthesiologie, Johann-Wolfgang-Goethe-Universität, Frankfurt am Main, Deutschland
  • K. Friedrich - Klinik für Anaesthesiologie, Johann-Wolfgang-Goethe-Universität, Frankfurt am Main, Deutschland
  • V. Seifert - Neurochirurgische Klinik, Neurozentrum
  • A. Raabe - Neurochirurgische Klinik, Neurozentrum

Deutsche Gesellschaft für Neurochirurgie. Società Italiana di Neurochirurgia. 59. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie e.V. (DGNC), 3. Joint Meeting mit der Italienischen Gesellschaft für Neurochirurgie (SINch). Würzburg, 01.-04.06.2008. Düsseldorf: German Medical Science GMS Publishing House; 2008. DocMI.06.04

The electronic version of this article is the complete one and can be found online at: http://www.egms.de/en/meetings/dgnc2008/08dgnc238.shtml

Published: May 30, 2008

© 2008 Jadik et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.

Outline

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Objective: We report the results and complications associated with a standardized intraoperative management designed for the prevention of hemodynamically relevant venous air embolism during surgery performed in the semi-sitting position.

Methods: A protocol for preoperative evaluation and intraoperative monitoring was developed and was applied in 187 consecutive patients that were operated in the semi-sitting position between 1999 and 2004. The protocol included preoperative transesophageal echocardiography examination (TEE), intraoperative TEE-monitoring, catheterization of the right atrium and a combination of fluid input, PEEP and standardized positioning aiming at a positive pressure in the transverse and sigmoid sinus. Data were collected retrospectively from the charts and intraoperative anesthesiological protocols of the patients to determine the incidence of clinically relevant air embolism (i.e. TEE diagnosed air embolism plus a decrease in end-tidal CO2 or hemodynamic changes) and other complications related to the semi-sitting position.

Results: 3 cases (1.6 %) of relevant venous air embolism occurred in 187 patients. Only one case (0,5%) was hemodynamically relevant with a temporary arterial blood pressure decrease and heart rate increase. Pneumatocephalus leading to lethargy was a frequent postoperative finding, which resolved spontaneously in all except one cases with epileptic seizure and oculomotor nerve palsy attributable to space-occupying subdurally trapped air, which had to be treated surgically. There was no permanent morbidity or mortality related to the semi-sitting position.

Conclusions: Fear of massive venous air embolism is one reason for the dramatic decline in the use of the semi-sitting position in neurosurgical practice. We found that strict adherence to a standardized protocol using TEE monitoring before and during surgery, exclusion of patients with PFO, and a combination of PEEP, fluid input and standardized position aiming for a positive pressure in the transverse and sigmoid sinus helped to greatly minimize this complication to a rate of 0,5% for hemodynamically relevant events.