Beach chair position

 

Contraindications:

Absolute

·     Intracardiac communication: PFO/ASD/VSD

*Hence must have pre-op TTE*

Relative

·     CVS: uncontrolled HTN, poor LV function

·     Resp: severe COPD (why?)

·     Extremes of age (why?)

 

Problems:

Remote airway

·     Reinforced ETT

·     Well-secured to face

·     Connections jammed in

Cerebral hypoperfusion

·     Hips flexed

·     Start supine and raise slowly

·     Metaraminol infusion

·     Arterial line with transducer at brainstem level

Venous embolism

Cause:

·     Surgical field above the heart

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

Identification:

·     Gas analysis: ↑etN2, ↓etCO2

·     Pressure transduction: ↑mPAP

·     Imaging: TOE

Treatment:

·     Stop entrainment: flood + flatten + falsalva

·     Stop transit: left lateral + head down (often impossible)

·     Remove the air: aspirate via CVC (often impossible)

·     Support: FiO2 1.0, fluid, pressors, CPR

Paradoxical embolism

·     Pathophys: venous embolism -> arterial embolism -> stroke

Positioning injury

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

·     Common peroneal nerve (compression)

·     Cervical spine fracture-dislocation: body pulling on pins

 

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