University of Maryland School of Medicine, Department of Orthopaedics, Shoulder and Elbow Service, Baltimore, Maryland, U.S.A..
University of Maryland School of Medicine, Department of Orthopaedics, Shoulder and Elbow Service, Baltimore, Maryland, U.S.A.
Arthroscopy. 2019 Mar;35(3):725-730. doi: 10.1016/j.arthro.2018.10.123. Epub 2019 Feb 4.
The goals of this study were 2-fold: (1) to determine the risk factors for cerebral desaturation events (CDEs) after implementation of a comprehensive surgical and anesthetic protocol consisting of patient risk stratification, maintenance of normotensive anesthesia, and patient positioning in a staged fashion, and (2) to assess for subclinical neurologic decline associated with intraoperative ischemic events through cognitive testing.
One hundred patients undergoing shoulder surgery in the beach chair position were stratified for risk of CDE based on Framingham stroke criteria, body mass index (BMI), and history of cerebrovascular accidents. Cerebral oxygen saturation was monitored with near-infrared spectroscopy. As per a standardized protocol, mean arterial pressure was maintained between 70 and 90 mm Hg. The head was raised in 2 stages separated by 3 minutes. CDE were defined as >20% drop from baseline or <55% O absolute threshold. Patients completed a Mini-Mental State Examination during preoperative examination and at the first postoperative visit.
The CDE rate was 4% overall and 4.3% in patients undergoing general anesthesia. Forty-five patients were in the higher risk category, and all CDEs occurred in that group. Patients with a Framingham score ≥ 10 or BMI ≥ 35 who underwent general anesthesia had an increased risk of CDE (P = .04). No significant change was noted in Mini-Mental State Examination scores between pre- and postoperative visits. No correlation was shown between CDE and history of diabetes, smoking, cardiovascular disease, or left ventricular hypertrophy.
Our observed CDE rate was lower than previously reported rates, likely because of risk stratification, staged positioning, and normotensive anesthesia. Framingham score ≥ 10 and BMI ≥ 35 are risk factors for CDE in the beach chair position.
Level II, prospective observational study with >80% follow-up.
本研究的目的有两个：（1）确定在实施综合手术和麻醉方案后发生脑缺氧事件（CDE）的风险因素，该方案包括患者风险分层、维持正常血压的麻醉和分期患者定位；（2）通过认知测试评估与术中缺血事件相关的亚临床神经功能下降。
根据弗莱明汉卒中标准、体重指数（BMI）和脑血管意外史，对 100 例在沙滩椅位行肩部手术的患者进行 CDE 风险分层。使用近红外光谱监测脑氧饱和度。根据标准化方案，将平均动脉压维持在 70 至 90mmHg 之间。头抬高分为 2 个阶段，间隔 3 分钟。CDE 定义为与基线相比下降>20%或绝对阈值<55%O。患者在术前检查和第一次术后就诊时完成简易精神状态检查。
总体 CDE 发生率为 4%，全身麻醉患者发生率为 4.3%。45 例患者处于高风险类别，所有 CDE 均发生在该组。Framingham 评分≥10 或 BMI≥35 且行全身麻醉的患者发生 CDE 的风险增加（P=0.04）。简易精神状态检查评分在术前和术后就诊时无显著变化。CDE 与糖尿病、吸烟、心血管疾病或左心室肥厚病史之间未显示出相关性。
我们观察到的 CDE 发生率低于先前报道的发生率，可能是因为进行了风险分层、分期定位和正常血压麻醉。Framingham 评分≥10 和 BMI≥35 是沙滩椅位发生 CDE 的危险因素。
II 级，前瞻性观察研究，随访率>80%。
