Analysis of risk factors for venous air embolism in the semisitting position and its impact on outcome in a consecutive series of 740 patients

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  • 1 Department of Neurosurgery, Medical School Hannover, Germany;
  • | 2 Department of Neurosurgery, University of Witten/Herdecke, Cologne Merheim Medical Center, Cologne, Germany;
  • | 3 Department of Anesthesiology and Intensive Care, Medical School Hannover, Germany; and
  • | 4 International Neuroscience Institute, Hannover, Germany
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OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

ABBREVIATIONS

ETCO2 = end-tidal CO2; PEEP = positive end-expiratory pressure; PFO = patent foramen ovale; TEE = transesophageal echocardiography; TTDE = transthoracic Doppler echocardiography; TTE = transthoracic echocardiography; VAE = venous air embolism.

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  • 1

    Himes BT, Abcejo AS, Kerezoudis P, Bhargav AG, Trelstad-Andrist K, Maloney PR, et al. Outcomes in single-level posterior cervical spine surgeries performed in the sitting and prone positions. J Neurosurg Spine. 2020;33:667673.

    • Search Google Scholar
    • Export Citation
  • 2

    Matjasko J, Petrozza P, Cohen M, Steinberg P. Anesthesia and surgery in the seated position: analysis of 554 cases. Neurosurgery. 1985;17(5):695702.

    • Search Google Scholar
    • Export Citation
  • 3

    Lobato EB, Black S, De Soto H. Venous air embolism and selective denervation for torticollis. Anesth Analg. 1997;84(3):551553.

  • 4

    Spektor S, Fraifeld S, Margolin E, Saseedharan S, Eimerl D, Umansky F. Comparison of outcomes following complex posterior fossa surgery performed in the sitting versus lateral position. J Clin Neurosci. 2015;22(4):705712.

    • Search Google Scholar
    • Export Citation
  • 5

    Hernesniemi J, Romani R, Albayrak BS, Lehto H, Dashti R, Ramsey C III, et al. Microsurgical management of pineal region lesions: personal experience with 119 patients. Surg Neurol. 2008;70(6):576583.

    • Search Google Scholar
    • Export Citation
  • 6

    Ganslandt O, Merkel A, Schmitt H, Tzabazis A, Buchfelder M, Eyupoglu I, Muenster T. The sitting position in neurosurgery: indications, complications and results. A single institution experience of 600 cases. Acta Neurochir (Wien). 2013;155(10):18871893.

    • Search Google Scholar
    • Export Citation
  • 7

    Orliaguet GA, Hanafi M, Meyer PG, Blanot S, Jarreau MM, Bresson D, et al. Is the sitting or the prone position best for surgery for posterior fossa tumours in children?. Paediatr Anaesth. 2001;11(5):541547.

    • Search Google Scholar
    • Export Citation
  • 8

    Porter JM, Pidgeon C, Cunningham AJ. The sitting position in neurosurgery: a critical appraisal. Br J Anaesth. 1999;82(1):117128.

  • 9

    Elton RJ, Howell RS. The sitting position in neurosurgical anaesthesia: a survey of British practice in 1991. Br J Anaesth. 1994;73(2):247248.

    • Search Google Scholar
    • Export Citation
  • 10

    Schaffranietz L, Günther L. The sitting position in neurosurgical operations. Results of a survey. Article in German. Anaesthesist. 1997;46(2):9195.

    • Search Google Scholar
    • Export Citation
  • 11

    Schaffranietz L, Grothe A, Olthoff D. Use of the sitting position in neurosurgery. Results of a 1998 survey in Germany. Article in German. Anaesthesist. 2000;49(4):269274.

    • Search Google Scholar
    • Export Citation
  • 12

    Leonard IE, Cunningham AJ. The sitting position in neurosurgery—not yet obsolete! Br J Anaesth. 2002;88(1):13.

  • 13

    Jadik S, Wissing H, Friedrich K, Beck J, Seifert V, Raabe A. A standardized protocol for the prevention of clinically relevant venous air embolism during neurosurgical interventions in the semisitting position. Neurosurgery. 2009;64(3):533539.

    • Search Google Scholar
    • Export Citation
  • 14

    Breun M, Nickl R, Perez J, Hagen R, Löhr M, Vince G, et al. Vestibular schwannoma resection in a consecutive series of 502 cases via the retrosigmoid approach: technical aspects, complications, and functional outcome. World Neurosurg. 2019;129:e114e127.

    • Search Google Scholar
    • Export Citation
  • 15

    Himes BT, Mallory GW, Abcejo AS, Pasternak J, Atkinson JLD, Meyer FB, et al. Contemporary analysis of the intraoperative and perioperative complications of neurosurgical procedures performed in the sitting position. J Neurosurg. 2017;127(1):182188.

    • Search Google Scholar
    • Export Citation
  • 16

    Feigl GC, Decker K, Wurms M, Krischek B, Ritz R, Unertl K, Tatagiba M. Neurosurgical procedures in the semisitting position: evaluation of the risk of paradoxical venous air embolism in patients with a patent foramen ovale. World Neurosurg. 2014;81(1):159164.

    • Search Google Scholar
    • Export Citation
  • 17

    Fathi AR, Eshtehardi P, Meier B. Patent foramen ovale and neurosurgery in sitting position: a systematic review. Br J Anaesth. 2009;102(5):588596.

    • Search Google Scholar
    • Export Citation
  • 18

    Cucchiara RF, Bowers B. Air embolism in children undergoing suboccipital craniotomy. Anesthesiology. 1982;57(4):338339.

  • 19

    Safdarian M, Safdarian M, Chou R, Hashemi SMR, Rahimi-Movaghar V. A systematic review about the position-related complications of acoustic neuroma surgery via suboccipital retrosigmoid approach: sitting versus lateral. Asian J Neurosurg. 2017;12(3):365373.

    • Search Google Scholar
    • Export Citation
  • 20

    Günther F, Frank P, Nakamura M, Hermann EJ, Palmaers T. Venous air embolism in the sitting position in cranial neurosurgery: incidence and severity according to the used monitoring. Acta Neurochir (Wien). 2017;159(2):339346.

    • Search Google Scholar
    • Export Citation
  • 21

    House JW, Brackmann DE. Facial nerve grading system. Otolaryngol Head Neck Surg. 1985;93(2):146147.

  • 22

    Hatipoglu Majernik G, Al-Afif S, Heissler HE, Cassini Ascencao L, Krauss JK. Microvascular decompression: is routine postoperative CT imaging necessary?. Acta Neurochir (Wien). 2020;162(5):10951099.

    • Search Google Scholar
    • Export Citation
  • 23

    Matthies C, Samii M. Management of vestibular schwannomas (acoustic neuromas): the value of neurophysiology for intraoperative monitoring of auditory function in 200 cases. Neurosurgery. 1997;40(3):459468.

    • Search Google Scholar
    • Export Citation
  • 24

    Matthies C, Samii M. Direct brainstem recording of auditory evoked potentials during vestibular schwannoma resection: nuclear BAEP recording. Technical note and preliminary results. J Neurosurg. 1997;86(6):10571062.

    • Search Google Scholar
    • Export Citation
  • 25

    Samii M, Matthies C. Management of 1000 vestibular schwannomas (acoustic neuromas): surgical management and results with an emphasis on complications and how to avoid them. Neurosurgery. 1997;40(1):1123.

    • Search Google Scholar
    • Export Citation
  • 26

    Hermann EJ, Rittierodt M, Krauss JK. Combined transventricular and supracerebellar infratentorial approach preserving the vermis in giant pediatric posterior fossa midline tumors. Neurosurgery. 2008;63(1)(suppl 1):ONS30ONS37.

    • Search Google Scholar
    • Export Citation
  • 27

    Hong B, Biertz F, Raab P, et al. Normobaric hyperoxia for treatment of pneumocephalus after posterior fossa surgery in the semisitting position: a prospective randomized controlled trial. PLoS One. 2015;10(5):e0125710.

    • Search Google Scholar
    • Export Citation
  • 28

    Hermann EJ, Petrakakis I, Polemikos M, Raab P, Cinibulak Z, Nakamura M, et al. Electromagnetic navigation-guided surgery in the semi-sitting position for posterior fossa tumours: a safety and feasibility study. Acta Neurochir (Wien). 2015;157(7):12291237.

    • Search Google Scholar
    • Export Citation
  • 29

    Scheller C, Rampp S, Tatagiba M, Gharabaghi A, Ramina KF, Ganslandt O, et al. A critical comparison between the semisitting and the supine positioning in vestibular schwannoma surgery: subgroup analysis of a randomized, multicenter trial. J Neurosurg. 2020;133(1):249256.

    • Search Google Scholar
    • Export Citation
  • 30

    Saladino A, Lamperti M, Mangraviti A, Legnani FG, Prada FU, Casali C, et al. The semisitting position: analysis of the risks and surgical outcomes in a contemporary series of 425 adult patients undergoing cranial surgery. J Neurosurg. 2017;127(4):867876.

    • Search Google Scholar
    • Export Citation
  • 31

    Schackert G, Ralle S, Martin KD, Reiss G, Kowalski M, Sobottka SB, et al. vestibular schwannoma surgery: outcome and complications in lateral decubitus position versus semi-sitting position-a personal learning curve in a series of 544 cases over 3 decades. World Neurosurg. 2021;148:e182e191.

    • Search Google Scholar
    • Export Citation
  • 32

    Roessler K, Krawagna M, Bischoff B, Rampp S, Ganslandt O, Iro H, et al. Improved postoperative facial nerve and hearing function in retrosigmoid vestibular schwannoma surgery significantly associated with semisitting position. World Neurosurg. 2016;87:290297.

    • Search Google Scholar
    • Export Citation
  • 33

    Ammirati M, Lamki TT, Shaw AB, Forde B, Nakano I, Mani M. A streamlined protocol for the use of the semi-sitting position in neurosurgery: a report on 48 consecutive procedures. J Clin Neurosci. 2013;20(1):3234.

    • Search Google Scholar
    • Export Citation
  • 34

    Luostarinen T, Lindroos AC, Niiya T, Silvasti-Lundell M, Schramko A, Hernesniemi J, et al. prone versus sitting position in neurosurgery-differences in patients’ hemodynamic management. World Neurosurg. 2017;97:261266.

    • Search Google Scholar
    • Export Citation
  • 35

    Pandia MP, Bithal PK, Dash HH, Chaturvedi A. Comparative incidence of cardiovascular changes during venous air embolism as detected by transesophageal echocardiography alone or in combination with end tidal carbon dioxide tension monitoring. J Clin Neurosci. 2011;18(9):12061209.

    • Search Google Scholar
    • Export Citation
  • 36

    Papadopoulos G, Kuhly P, Brock M, Rudolph KH, Link J, Eyrich K. Venous and paradoxical air embolism in the sitting position. A prospective study with transoesophageal echocardiography. Acta Neurochir (Wien). 1994;126(2-4):140143.

    • Search Google Scholar
    • Export Citation
  • 37

    Pearson AC, Labovitz AJ, Tatineni S, Gomez CR. Superiority of transesophageal echocardiography in detecting cardiac source of embolism in patients with cerebral ischemia of uncertain etiology. J Am Coll Cardiol. 1991;17(1):6672.

    • Search Google Scholar
    • Export Citation
  • 38

    Klein J, Juratli TA, Weise M, Schackert G. A systematic review of the semi-sitting position in neurosurgical patients with patent foramen ovale: how frequent is paradoxical embolism? World Neurosurg. 2018;115:196200.

    • Search Google Scholar
    • Export Citation
  • 39

    Yonekawa Y. Operative neurosurgery: personal view and historical backgrounds (8) suboccipital craniotomy-sitting position-linear incision. Article in Japanese. No Shinkei Geka. 2011;39(8):789809.

    • Search Google Scholar
    • Export Citation
  • 40

    Türe H, Harput MV, Bekiroğlu N, Keskin Ö, Köner Ö, Türe U. Effect of the degree of head elevation on the incidence and severity of venous air embolism in cranial neurosurgical procedures with patients in the semisitting position. J Neurosurg. 2018;128(5):15601569.

    • Search Google Scholar
    • Export Citation
  • 41

    Bithal PK, Pandia MP, Dash HH, Chouhan RS, Mohanty B, Padhy N. Comparative incidence of venous air embolism and associated hypotension in adults and children operated for neurosurgery in the sitting position. Eur J Anaesthesiol. 2004;21(7):517522.

    • Search Google Scholar
    • Export Citation
  • 42

    Baro V, Lavezzo R, Marton E, Longatti P, Landi A, Denaro L, d’Avella D. Prone versus sitting position in pediatric low-grade posterior fossa tumors. Childs Nerv Syst. 2019;35(3):421428.

    • Search Google Scholar
    • Export Citation
  • 43

    Hitselberger WE, House WF. A warning regarding the sitting position for acoustic tumor surgery. Arch Otolaryngol. 1980;106(2):69.

  • 44

    Voorhies RM, Fraser RAR, Van Poznak A. Prevention of air embolism with positive end expiratory pressure. Neurosurgery. 1983;12(5):503506.

    • Search Google Scholar
    • Export Citation
  • 45

    Abcejo AS, Pasternak JJ, Perkins WJ. Urgent repositioning after venous air embolism during intracranial surgery in the seated position: a case series. J Neurosurg Anesthesiol. 2019;31(4):413421.

    • Search Google Scholar
    • Export Citation

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