Child's Nervous System

, Volume 7, Issue 7, pp 368–374 | Cite as

The lounging position for posterior fossa surgery: anesthesiological considerations regarding air embolism

  • Hans-Henning von Gösseln
  • Madjid Samii
  • Dieter Suhr
  • Walter Bini
Original Papers
Received:

Abstract

The sitting position for operations in the posterior fossa remains controversial in both adults and children, primarily because of the risk of air embolism. The reports on the incidence of this complication are varied. We retrospectively reviewed the data on 704 patients (age range 1–82 years) operated on in a lounging position for varied posterior fossa pathology from January 1984 up to December 1989. As diagnostic monitoring, we uniformly employed a Doppler ultrasound device, an atrial catheter, and capnometry. In 37 adults (5.5%) and 9 children (9/34) air embolism was diagnosed, without either morbidity or mortality. A lounging position, together with adequate infusion therapy and ventilation with PEEP, considerably reduces the risk of air embolism.

Key words

Venous air embolism Lounging position Posterior fossa Ventilation with PEEP 
This is a preview of subscription content, log in to check access.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Adornato DC, Gildenberg PL, Ferrario CM, Smart J, Frost EAM (1978) Pathophysiology of intravenous air embolism in dogs. Anesthesiology 49:120–127Google Scholar
  2. 2.
    Albin MS (1984) The paradox of paradoxic air embolism-PEEP, Valsalva, and patent foramen ovale. Should the sitting position be abandoned? Anesthesiology 61:222–223Google Scholar
  3. 3.
    Albin M, Carroll RG, Maroon JC (1978) Clinical considerations concerning detection of venous air embolism. Neurosurgery 3:380–384Google Scholar
  4. 4.
    Bedford RF, Perkins-Pearson NAK (1982) PEEP for treatment of venous air embolism. Anesthesiology 57:A379Google Scholar
  5. 5.
    Bedford RF, Marshall WK, Butler A, Welsh JE (1981) Cardiac catheters for diagnosis and treatment of venous air embolism. J Neurosurg 55:610–614Google Scholar
  6. 6.
    Black S, Ockert DB, Oliver WC, Cucchiara RF (1988) Outcome following posterior fossa craniectomy in patients in the sitting or horizontal positions. Anesthesiology 69:49–56Google Scholar
  7. 7.
    Black S, Cucchiara RF, Nishimura RA, Michenfelder JD (1989) Parameters affecting occurrence of paradoxical air embolism. Anesthesiology 71:235–241Google Scholar
  8. 8.
    Brechner TM, Brechner VL (1977) An audible alarm for monitoring air embolism during neurosurgery. J Neurosurg 47:201–204Google Scholar
  9. 9.
    Cabezudo JM, Gilsanz F, Vaquero J, Areito E, Martinez R (1981) Air embolism from wounds from a pin-type head-holder as a complication of posterior fossa surgery in the sitting position. Neurosurg 55:147–148Google Scholar
  10. 10.
    Campkin TV (1981) Posture and ventilation during posterior fossa and cervical operations. Br J Anaesth 53:881–884Google Scholar
  11. 11.
    Colohan ART, Perkins NAK, Bedford RF, Jane JA (1985) Intravenous fluid loading as prophylaxis for paradoxical air embolism. J Neurosurg 62:839–842Google Scholar
  12. 12.
    Cucchiara RF (1985) Monitoring and anesthetic management of the anesthetized sitting patient. In: Popp AJ, Nelson LR, Bourke RS, Kimelberg HK (eds) Seminars in neurological surgery. Raven Press, New York, 112, pp 1–6Google Scholar
  13. 13.
    Cucchiara RF, Bowers B (1982) Air embolism in children undergoing suboccipital craniotomy. Anesthesiology 57:338–339Google Scholar
  14. 14.
    Cucchiara RF, Nugent M, Seward JB, Messick JM (1984) Air embolism in upright neurosurgical patients. Detection and localisation of two-dimensional transesophageal echocardiography. Anesthesiology 60:353–355Google Scholar
  15. 15.
    Cucchiara RF, Seward JB, Nishimura RA, Nugent M, Faust RJ (1985) Identification of a patent foramen ovale during sitting position craniotomy by transesophageal echocardiography with positive airway pressure. Anesthesiology 63:107–109Google Scholar
  16. 16.
    Cucchiara RF, Nishimura RA, Black S (1989) Failure of preoperative echo testing to prevent paradoxical air embolism: report of two cases. Anesthesiology 71:604–607Google Scholar
  17. 17.
    Durant TM, Oppenheimer MJ, Webster MR, Long J (1949) Arterial air embolism. Am Heart J 38:481–500Google Scholar
  18. 18.
    Edwards JE (1960) Congenital malformations of the heart and the great vessels. In: Gould SE (ed) Pathology of the heart, 2nd edn. Thomas, Springfield, Ill, pp 260–261Google Scholar
  19. 19.
    Furuya H, Okumura F (1984) Detection of paradoxical air embolism by transesophageal echocardiography. Anesthesiology 60:374–377Google Scholar
  20. 20.
    Furuya H, Suzuki T, Okumura F, Kishi Y, Uefuji T (1983) Detection of air embolism by transesophageal echocardiography. Anesthesiology 58:124–129Google Scholar
  21. 21.
    Gildenberg PL, O'Brien RP, Britt WJ, Frost EAM (1981) The efficacy of Doppler monitoring for the detection of venous air embolism. J Neurosurg 54:75–78Google Scholar
  22. 22.
    Gilsanz FJ, Avello F (1982) Positive endexpiratory pressure and air embolism in the sitting position. Br J Anaesth 54:110–111Google Scholar
  23. 23.
    Glenski JA, Cucchiara RF (1986) Transcutaneous O2 and CO2 monitoring of neurosurgical patients: detection of air embolism. Anesthesiology 64:546–550Google Scholar
  24. 24.
    Glenski JA, Cucchiara RF, Michenfelder JD (1986) Transesophageal echocardiography and transcutaneous O2 and CO2 for detection of venous air embolism. Anesthesiology 64:541–545Google Scholar
  25. 25.
    Goldfarb D, Bahnson HT (1963) Early and late effects on the heart of small amounts of air in the coronary circulation. J Thorac Cardiovasc Surg 46:368–378Google Scholar
  26. 26.
    Grady MS, Bedford RF, Park TS (1986) Changes in superior sagittal sinus pressure in children with head elevation, jugular venous compression and PEEP. J Neurosurg 65:199–202Google Scholar
  27. 27.
    Gronert GA, Messick JM, Cucchiara RF, Michenfelder JD (1979) Paradoxical air embolism from a patent foramen ovale. Anesthesiology 50:548–549Google Scholar
  28. 28.
    Große Ophoff B, Frowein RA, Köning W, Loeschcke GC, Luckhaupt U, Polwin W (1982) Zum Problem der Prophylaxe, Erkennung und Behandlung der Luftembolie bei Eingriffen in sitzender Position. Anaesthesist 31:506Google Scholar
  29. 29.
    Guggiari M, Lechat P, Garen-Colonne C, Fusciardi J, Viars P (1988) Early detection of patent foramen ovale by two-dimensional contrast echocardiography for prevention of paradoxical air embolism during sitting position. Anesth Analg 67:192–194Google Scholar
  30. 30.
    Hagen PT, Scholz DG, Edwards WD (1984) Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 59:17–20Google Scholar
  31. 31.
    Harris MM, Yemen TA, Davidson A, Strafford MA, Rowe RW, Sanders SP, Rockoff MA (1987) Venous air embolism during craniectomy in supine infants. Anesthesiology 67:816–819Google Scholar
  32. 32.
    Hey O, Fischer F, Reinery G, Steingass U, Knorre D (1983) Erkennung und Verhütung von Luftembolien während neurochirurgischer Eingriffe in sitzender Position. In: Ahnefeld FW, Dick W, Kilian J, Schuster H-P (eds) Anästhesie in der Neurochirurgie. Springer, Berlin Heidelberg New York, pp 197–209Google Scholar
  33. 33.
    Hills BA, Butler BD (1983) Air embolism: further basic facts relevant to the placement of central venous catheters and Doppler monitors. Anesthesiology 59:163Google Scholar
  34. 34.
    Iwabuchi T, Sobata E, Suzuki M, Yamashita M (1983) Dural sinus pressure as related to neurosurgical positions. Neurosurgery 12:203–207Google Scholar
  35. 35.
    Krier C, Wiedemann K (1978) Luftembolie. Prakt Anästh 13:386–397Google Scholar
  36. 36.
    Lee DS, Lichtmann MW, Weintraub HD (1981) Effect of PEEP on air embolism during sitting neurosurgical procedures. Anesth Analg 60:262Google Scholar
  37. 37.
    Lodrini S, Montolivo M, Pluchino F, Borroni V (1989) Positive endexpiratory pressure in supine and sitting positions: its effects on intrathoracic and intracranial pressures. Neurosurgery 24:873–877Google Scholar
  38. 38.
    Marshall WK, Bedford RF (1980) Use of a pulmonary-artery catheter for detection and treatment of venous air embolism. Anesthesiology 52:131–134Google Scholar
  39. 39.
    Marshall WK, Bedford RF, Miller ED (1983) Cardiovascular responses in the seated position — impact of four anesthetic techniques. Anesth Analg 62:648–653Google Scholar
  40. 40.
    Matjasko J, Petrozza P, Cohen M, Steinberg P (1985) Anesthesia and surgery in the seated position: analysis of 554 cases. Neurosurgery 17:695–702Google Scholar
  41. 41.
    Matjasko J, Petrozza P, Mackenzie CF (1985) Sensitivity of end-tidal nitrogen in venous air embolism detection in dogs. Anesthesiology 63:418–423Google Scholar
  42. 42.
    Mehta M, Sokoll MD, Gergis SD (1984) Effects of venous air embolism on the cardiovascular system and acid balance in the presence and absence of nitrous oxide. Acta Anaesthesiol Scand 28:226–231Google Scholar
  43. 43.
    Müller H, Brähler A, Gerlach I, Gerlach H, Becker W, Hempelmann G (1984) Diagnostische und prognostische Bedeutung hämodynamischer und respiratorischer Parameter bei venöser Luftembolie. Anaesthesist 33:493–498Google Scholar
  44. 44.
    Munson ES, Merrick HC (1966) Effect of nitrous oxide on venous air embolism. Anesthesiology 27:783–787Google Scholar
  45. 45.
    Oliver S, Cucchiara RF, Nishimura R, Michenfelder J (1987) Parameters affecting the occurrence of paradoxical air embolism. Anesthesiology 67:A435Google Scholar
  46. 46.
    Panning B (1987) Die sogenannte venöse Luftembolie. Anaesthesist 36:111–115Google Scholar
  47. 47.
    Panning B, Piepenbrock S, Nellessen U, Daniel WG (1985) Transösophageale Echokardiographie zur Erkennung der venösen Luftembolie bei neurochirurgischen Operationen in sitzender Position. Anaesthesist 34 [Suppl]:185Google Scholar
  48. 48.
    Paul WL, Munson ES (1981) Monitoring of end-tidal carbon dioxide to detect venous air embolism. Br J Anaesth 53:313P-314PGoogle Scholar
  49. 49.
    Pearl RG, Larson P (1986) Hemodynamic effects of positive end-expiratory pressure during continuous venous air embolism in the dog. Anesthesiology 64:724–729Google Scholar
  50. 50.
    Perkins NAK, Bedford RF (1983) Intravenous fluid loading: prophylaxis for paradoxical air embolism. Anesthesiology 59:A389Google Scholar
  51. 51.
    Perkins NAK, Bedford RF (1984) Hemodynamic consequences of PEEP in seated neurological patients — implications for paradoxical air embolism. Anesth Analg 63:429–432Google Scholar
  52. 52.
    Perkins-Pearson NAK, Marshall WK, Bedford RF (1982) Atrial pressures in the seated position. Anesthesiology 57:493–497Google Scholar
  53. 53.
    Samii M, Wild K von (1981) Operative treatment of lesions in the region of the tentorial notch. Neurosurg Rev 4:3–10Google Scholar
  54. 54.
    Samii M, Penkert G, Bini W (1988) Komplikationen bei Eingriffen im Kleinhirnbrückenwinkel. In: Bock WJ, Schirmer M (eds) Komplikationen bei neurochirurgischen Eingriffen. Zuckschwerdt, München Bern Wien, pp 49–57Google Scholar
  55. 55.
    Schalk H von (1987) Luftembolie. In: List WF, Osswald PM (eds) Komplikationen in der Anästhesie. Springer, Berlin Heidelberg New York, pp 447–454Google Scholar
  56. 56.
    Severinghaus JW (1982) Air embolism detected by mass spectrometry. In: Hershey SG (ed) The sitting position. Lippincott, Philadelphia, p 63Google Scholar
  57. 57.
    Standefer MW, Bay JW, Trusso R (1984) The sitting position in neurosurgery: a retrospective analysis of 488 cases. Neurosurgery 14:649–658Google Scholar
  58. 58.
    Toung T, Ngeow YK, Long DL, Rogers MC, Traystman RJ (1984) Comparison of the effects of positive end-expiratory pressure and jugular vein compression on canine cerebral venous pressure. Anesthesiology 61:169–172Google Scholar
  59. 59.
    Toung TJK, Miyabe M, McShane AJ, Rogers MC, Traystman RJ (1988) Effect of PEEP and jugular venous compression on canine cerebral blood flow and oxygen consumption in the head elevated position. Anesthesiology 68:53–58Google Scholar
  60. 60.
    Voorhies RM, Fraser RAR, Poznak A van (1983) Prevention of air embolism with positive end-expiratory pressure. Neurosurgery 12:503–506Google Scholar
  61. 61.
    Wiedemann K, Krier C (1983) Einleitung und Durchführung der Anästhesie bei Eingriffen in sitzender Position. In: Ahnefeld FW, Dick W, Schuster H-P (eds) Anästhesie in der Neurochirurgie. Springer, Berlin Heidelberg New York, pp 98–113Google Scholar
  62. 62.
    Young ML, Smith DS, Murtagh F, Vasquez A, Levitt J (1986) Comparison of surgical and anesthetic complications in neurosurgical patients experiencing venous air embolism in the sitting position. Neurosurgery 18:157–161Google Scholar
  63. 63.
    Zasslow MA, Pearl RG, Larson P, Silverberg G, Shuer LF (1988) PEEP does not affect left atrial-right atrial pressure difference in neurosurgical patients. Anesthesiology 68:760–763Google Scholar

Copyright information

© Springer-Verlag 1991

Authors and Affiliations

  • Hans-Henning von Gösseln
    • 1
  • Madjid Samii
    • 2
  • Dieter Suhr
    • 1
  • Walter Bini
    • 2
  1. 1.Anästhesie-AbteilungKrankenhaus NordstadtHannover 1Federal Republic of Germany
  2. 2.Neurochirurgische KlinikKrankenhaus NordstadtHannover 1Federal Republic of Germany

Personalised recommendations