Al-Afif Shadi, Elkayekh Hesham, Omer Mazin, Heissler Hans E, Scheinichen Dirk, Palmaers Thomas, Nakamura Makoto, Hermann Elvis J, Samii Madjid, Krauss Joachim K
1Department of Neurosurgery, Medical School Hannover, Germany.
3Department of Anesthesiology and Intensive Care, Medical School Hannover, Germany; and.
J Neurosurg. 2021 Nov 5;137(1):258-265. doi: 10.3171/2021.7.JNS211107. Print 2022 Jul 1.
Routine use of the semisitting position, which offers several advantages, remains a matter of debate. Venous air embolism (VAE) is a potentially serious complication associated with the semisitting position. In this study, the authors aimed to investigate the safety of the semisitting position by analyzing data over a 20-year period.
The incidence of VAE and its perioperative management were analyzed retrospectively in a consecutive series of 740 patients who underwent surgery between 1996 and 2016. The occurrence of VAE was defined by detection of bubbles on transthoracic Doppler echocardiography (TTDE) or transesophageal echocardiography (TEE) studies, a decrease of end-tidal CO2 (ETCO2) by 4 mm Hg or more, and/or an unexplained drop in systolic arterial blood pressure (≥ 10 mm Hg). From 1996 until 2013 TTDE was used, and from 2013 on TEE was used. The possible risk factors for VAE and its impact on surgical performance were analyzed.
There were 404 women and 336 men with a mean age at surgery of 49 years (range 1-87 years). Surgery was performed for infratentorial lesions in 709 patients (95.8%), supratentorial lesions in 17 (2.3%), and cervical lesions in 14 (1.9%). The most frequent pathology was vestibular schwannoma. TEE had a higher sensitivity than TTDE. While TEE detected VAE in 40.5% of patients, TTDE had a detection rate of 11.8%. Overall, VAE was detected in 119 patients (16.1%) intraoperatively. In all of these patients, VAE was apparent on TTDE or TEE. Of those, 23 patients also had a decrease of ETCO2, 18 had a drop in blood pressure, and 23 had combined decreases in ETCO2 and blood pressure. VAE was detected in 24% of patients during craniotomy before opening the dura mater, in 67% during tumor resection, and in 9% during wound closure. No risk factors were identified for the occurrence of VAE. Two patients had serious complications due to VAE. Surgical performance in vestibular schwannoma surgery was not affected by the presence of VAE.
This study shows that the semisitting position is overall safe and that VAE can be managed effectively. Persistent morbidity is very rare. The authors suggest that the semisitting position should continue to have a place in the standard armamentarium of neurological surgery.
常规使用具有多种优势的半坐位仍存在争议。静脉空气栓塞（VAE）是与半坐位相关的一种潜在严重并发症。在本研究中，作者旨在通过分析20年期间的数据来调查半坐位的安全性。
回顾性分析1996年至2016年间连续接受手术的740例患者中VAE的发生率及其围手术期管理情况。VAE的发生定义为经胸多普勒超声心动图（TTDE）或经食管超声心动图（TEE）检查发现气泡、呼气末二氧化碳（ETCO2）下降4 mmHg或更多，和/或收缩动脉血压 unexplained 下降（≥10 mmHg）。1996年至2013年使用TTDE，2013年起使用TEE。分析了VAE的可能危险因素及其对手术操作的影响。
有404名女性和336名男性，手术时平均年龄为49岁（范围1 - 87岁）。709例患者（95.8%）因幕下病变进行手术，17例（2.3%）因幕上病变进行手术，14例（1.9%）因颈部病变进行手术。最常见的病理类型是前庭神经鞘瘤。TEE的敏感性高于TTDE。TEE在40.5%的患者中检测到VAE，而TTDE的检测率为11.8%。总体而言，术中119例患者（16.1%）检测到VAE。在所有这些患者中，TTDE或TEE上VAE均明显。其中，23例患者还出现ETCO2下降，18例血压下降，23例同时出现ETCO2和血压下降。在打开硬脑膜前的开颅手术期间，24%的患者检测到VAE，肿瘤切除期间为67%，伤口缝合期间为9%。未发现VAE发生的危险因素。两名患者因VAE出现严重并发症。前庭神经鞘瘤手术的手术操作不受VAE存在的影响。
本研究表明半坐位总体安全，VAE可得到有效管理。持续性发病非常罕见。作者建议半坐位应继续在神经外科的标准器械库中占有一席之地。
