Marina Nikolic, C Eisner, J O Neumann, D Haux, S M Krieg, M O Wielpütz, M A Weigand, U Tochtermann, Dania Fischer
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引用次数: 0
Abstract
Background: Neurosurgery performed in the semi-sitting position provides advantages for certain procedures. However, this approach is associated with potential complications, particularly venous air embolism. Due to typically negative venous pressure at the wound site, air can be drawn into the veins. This risk is especially high in patients presenting with an intra- or extracardiac right-to-left-shunt. Transoesophageal echocardiography can be used to detect a patent foramen ovale or other possible pulmonary-systemic shunt before placing the patient in the sitting position.
Case presentation: In this report, we present two young patients undergoing scheduled microsurgical vestibular schwannoma removal in a semi-sitting position who were diagnosed with congenital heart defects during routine perioperative assessment to detect possible intracardiac right-to-left shunts, using pre- and intraoperative transesophageal echocardiography (TEE) and additionally conducting an agitated saline bubble study under Valsalva manoeuvre. Patient A was diagnosed with a persistent left superior vena cava and Patient B with an unroofed coronary sinus (UCS). These findings confronted the anesthesiological and surgical teams with difficult individual decisions regarding further perioperative management.
Conclusions: Perioperative transesophageal echocardiography is a diagnostic tool to both detect intraoperative position-related air embolisms and to rule out intracardiac right-to-left shunts, e.g. a patent foramen ovale, in order to decide for or against a (semi-)sitting position. Depending on the surgical circumstances a semi-sitting positioning of patients presenting with an intracardiac right-to-left-shunt, e.g. a PFO, can be feasible in individual cases if there is an implemented therapeutic algorithm to immediately terminate significant venous air entry. However, since certain other intra- or extracardiac right-to-left-shunts, such as here presented PLSVC or UCS, are rare, there is no definitive way of estimating the amount of entered air through detected shunts or anomalous vessels. Therefore, it is recommended to avoid a (semi-)sitting position in favour of a lateral or prone position for a patient undergoing intracranial surgery, once the perioperative TEE shows air bubbles in the left atrium or ventricle whose origins cannot be defined solely through TEE for certain in order to ensure patient safety by minimizing the risk of intraoperative paradoxical air embolisms.
背景:采用半坐卧位进行神经外科手术在某些手术中具有优势。然而,这种方法也有潜在的并发症,尤其是静脉空气栓塞。由于伤口部位通常为静脉负压,空气会被吸入静脉。对于患有心内或心外右向左分流的患者,这种风险尤其高。在让患者取坐位之前,可以使用经食道超声心动图检测卵圆孔或其他可能的肺-系统分流:在本报告中,我们介绍了两名在半坐位下接受显微外科前庭裂孔瘤切除术的年轻患者,他们在常规围手术期评估中被诊断出患有先天性心脏缺陷,以便使用术前和术中经食道超声心动图(TEE)检测可能存在的心内右向左分流,并在瓦尔萨尔瓦体位法下进行搅拌生理盐水气泡研究。患者 A 被诊断为左上腔静脉持续存在,患者 B 被诊断为冠状动脉窦(UCS)未封堵。这些发现使麻醉团队和手术团队在围手术期的进一步处理上面临着各自的艰难抉择:围手术期经食道超声心动图是一种诊断工具,既能检测术中与体位相关的空气栓塞,又能排除心内右向左分流,如卵圆孔,从而决定是否采取(半)坐位。根据手术的具体情况,如果实施了立即终止大量静脉空气进入的治疗算法,那么在个别病例中,对出现心内右向左分流(如 PFO)的患者采取半坐卧位是可行的。然而,由于某些其他心内或心外的右向左分流(如此处出现的 PLSVC 或 UCS)非常罕见,因此没有明确的方法来估计通过检测到的分流或异常血管进入的空气量。因此,一旦围术期 TEE 显示左心房或左心室有气泡,且仅通过 TEE 无法确定气泡的来源,建议接受颅内手术的患者避免采取(半)坐位,而采取侧卧位或俯卧位,以通过最大限度地降低术中发生矛盾性空气栓塞的风险来确保患者的安全。
期刊介绍:
BMC Anesthesiology is an open access, peer-reviewed journal that considers articles on all aspects of anesthesiology, critical care, perioperative care and pain management, including clinical and experimental research into anesthetic mechanisms, administration and efficacy, technology and monitoring, and associated economic issues.