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Reg Anesth Pain Med · Sep 2011
Review Case Reports Comparative StudyStroke, regional anesthesia in the sitting position, and hypotension: a review of 4169 ambulatory surgery patients.
Despite frequent incidence of hypotension, no cases of stroke were observed in this audit of 4,169 shoulder surgeries performed in the beach-chair position. Notably though, 97% of the cases were performed under brachial plexus block with intravenous sedation rather than a general or relaxant technique.
The authors estimate the upper limit incidence of stroke in the sitting position under regional anaesthesia as 1 in 1,429 (0.07%).
summary- Jacques T Yadeau, Mary Casciano, Spencer S Liu, Chris R Edmonds, Michael Gordon, Jennifer Stanton, Raymond John, Pamela M Shaw, Sarah E Wilfred, and Maureen Stanton.
- Department of Anesthesiology, Weill Cornell Medical Center, New York, NY, USA. yadeauj@hss.edu
- Reg Anesth Pain Med. 2011 Sep 1;36(5):430-5.
Background And ObjectiveIntraoperative hypotension is used to reduce surgical bleeding. Case reports of stroke after general anesthesia in the sitting position led us to collect data (patient demographics, medical risk factors for stroke, intraoperative hemodynamics) about the incidence of stroke after surgery in the sitting position.MethodsThis study reviewed 4169 (3000 retrospective, 1169 prospective) ambulatory shoulder surgeries in the sitting position. For the prospective cohort, patients were queried postoperatively regarding stroke, with corroboration from 4 databases (anesthesia department quality assurance, hospital case management, state-reportable events, and hospital information system diagnostic code databases). For the retrospective cohort, rate of stroke was determined via the same 4 databases.ResultsNo patient had a stroke (95% confidence interval, 0%-0.07%). Risk factors for perioperative stroke were present in 40% of patients. Brachial plexus nerve block with intravenous sedation was used for 95.7% (retrospective) and 99.8% (prospective) of the cohorts. Many patients (47%) experienced intraoperative hypotension by at least one definition: 40% (retrospective) and 30% (prospective) had at least a 30% decrease in mean arterial pressure; 27% (retrospective) and 24% (prospective) had a mean pressure less than 66 mm Hg; and 13% (retrospective) and 12% (prospective) had a systolic blood pressure of less than 90 mm Hg.ConclusionsNo strokes were observed in 4169 patients. The estimated upper limit of the 95% confidence interval for stroke after regional anesthesia for shoulder surgery in the seated position is 0.07%, despite frequent incidence of hypotension.
This article appears in the collections: Does beach-chair positioning increase the risk of stroke? and Regional anaesthesia .
Notes
Brachial plexus block with sedation for shoulder surgery is not a technique I employ. It would be interesting to see a direct comparison between stroke rates between this technique and one using block plus GA. Though, it is comforting to know that stroke risk is incredibly low, in spite the considerable number of intraoperative hypotensive events.
Chris Tan
Despite frequent incidence of hypotension, no cases of stroke were observed in this audit of 4,169 shoulder surgeries performed in the beach-chair position. Notably though, 97% of the cases were performed under brachial plexus block with intravenous sedation rather than a general or relaxant technique.
The authors estimate the upper limit incidence of stroke in the sitting position under regional anaesthesia as 1 in 1,429 (0.07%).
Daniel Jolley
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