Beach chair position

 

Contraindications:

Absolute

·     Intracardiac communication: PFO/ASD/VSD

o  Consider pre-op TTE (?)

·     RAP > LAP

o  Just in case invisible communication (?)

Relative

·     CVS: uncontrolled HTN, poor LV function

·     Resp: severe COPD (why?)

·     Extremes of age (why?)

 

Venous air embolism:

Cause

·     Surgical field above the heart

·     If neuro: non-collapsible veins
(incidence 25-50% in neuro, mostly insignificant)

Anticipation

·     Discuss contingency plan with surgeon, nurses, tech

·     Set etCO2 alarm at 5mmHg below steady state

·     Consider CVC

·     Consider praecordial doppler in the room

Diagnosis

·     Gas analysis: ↓mAP, ↓etCO2

·     Ultrasound: praecordial doppler, TOE

·     Pressure transduction: ↑mPAP

Treatment

·     Support: FiO2 1.0, fluid, pressors, CPR

·     Stop entrainment: flood, flatten, Valsalva, compress the jugulars

·     Stop transit: left lateral + head down

·     Remove the air: aspirate via CVC

 

Problems:

Remote airway

·     Reinforced ETT

·     Well-secured to face

·     Connections jammed in

Remote lines

·     IVC and A-line: long, visible, same side as anaesthetist

·     Fluid warmer: connected pre-op

·     Drug-line connections: secure

Cerebral hypoperfusion

·     Metaraminol infusion

·     Arterial line with transducer at brainstem level

·     Raise slowly

·     Flex hips

Positioning injury

·     Sciatic nerve (stretch from if thigh flexion + knee extension)

·     Common peroneal nerve (compression)

·     Cervical spine fracture-dislocation: body pulling on pins

Air embolism

·     Venous

·     Arterial (paradoxical embolus)

 

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