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Beach chair (shoulder sx) (Advantage over supine of L lateral (Improved…
Beach chair (shoulder sx)
Haemodynamic issues
Orthostatic hypotension and risk of hypoperfusion injury and infarction in cerebral, opthalmic, spinal cord and coronary circulations
Risk of hypotensive, bradycardic event (idiosyncratic) - potential for permanent cerebral damage if >3 mins
May increase risk of VAE (not usually a prob in arthroscopic sx)
Mitigation
Careful patient selection - consider surgical approach, consider ISB to avoid GA and IPPV
Frequent and accurate BP monitoring (consider IABP)
Measure/estimate BP at circle of willis (need to correct for height of arm to brain - up to 20mmHg)
Maintain MAP (>70 when using NIBP at arm)
Good hydration pre op
IV fluid loading with pressors as req
Consider stockings
Avoid hypothermia, hypocapnia and anaemia
Emerging role of neuro monitoring (TCD, cerebral oximetry)
Pressure injuries
Nerves: brachial plexus and ulnar, auricular, occipital and sciatic nerves
Sacral, eyes and vascular compression
Mitigation
Positioning patient is a team responsibility: roles must be designated
Avoid stretching
Provide some knee flexion
Appropriate padding and protection
Ensure neutral head position
Continued surveillance for pressure points and head position
Remote anaesthesia
Poor access to patient, airway, monitoring and ART/venous lines
Mitigate
Attention to a secure ETT and support for the circuit
Extra secure IV
Advantage over supine of L lateral
Improved surgical access
Improved operating arm mobility and ease of examination
Reduced bleeding as a result of increased venous drainage
Easier conversion from arthroscopic to open procedure
Avoidance of brachial plexus traction injury