American Society of Regional Anesthesia and Pain Medicine May 2017 - 32
Bring Out Your Beach Chairs
The beach-chair position accounts for two thirds of shoulder
surgeries performed in the United States. Traditionally, patients
receive general anesthesia (GA) to facilitate positioning,
provide analgesia, and offer an adequate surgical field.
For the surgeon, it awards numerous advantages whereas
anesthesiologists are tasked with rectifying additional
physiological derangements. Nationally, only 2% of shoulder
arthroscopies are reported to be performed solely under
regional anesthesia (RA).
ANESTHESIA FOR SHOULDER SURGERY: PERSPECTIVE FROM THE
LITERATURE
The first joint arthroscopy was performed by Dr Severin Nordentoft
of Denmark in 1912.1 However, the ubiquity of arthroscopic
surgery took off only after the 1970s with the help of Drs Masaki
Watanabe and Richard O'Connor. Initially solely a diagnostic
modality, arthroscopy has blossomed as one of the most frequently
performed interventions thanks in large part to advances in
techniques and technology making outcomes comparable to open
procedures.2-5 According to the 2006 National Survey of Ambulatory
Surgery, ambulatory surgery procedures increased from 380,000
to 57.1 million between 1983 to 2006; of those, 530,000 were
shoulder arthroscopies with or without rotator cuff repair.6
For select patients, arthroscopy has hastened the diagnosis,
treatment, and recovery from surgical interventions of both major
and minor joints.7 Despite being more technically challenging,
arthroscopic surgery versus traditional arthrotomy offers lower
cost, quicker discharge,8 more patients reporting improved pain
control,9 and higher satisfaction scores.10 Moreover, when polled,
patients refuse to have surgery unless it will use an arthroscopic
approach.11
Traditionally, arthroscopic shoulder surgery is performed under GA
in either the lateral decubitus or beach chair position. The beach
chair position came into vogue in the 1980s. The position maintains
anatomic orientation; provides the surgeon with rotational control
of the upper extremity; offers excellent visualization of surrounding
anterior, inferior, and superior glenohumeral structures, and
subacromial space; reduces injuries to the brachial plexus; and
presents ease of setup when compared with the lateral decubitus
positioning. In the United
States, two-thirds of the
530,000 shoulder surgeries are
performed in the beach chair
position.6
However, concerns were raised
about developing devastating
neurologic complications
32
2
Taras Grosh, MD
Instructor
Department of Anesthesiology
and Critical Care
Nabil Elkassabany, MD, MSCE
Assistant Professor
Department of Anesthesiology
and Critical Care
Jiabin Liu, MD, PhD
Assistant Professor
Department of Anesthesiology
and Critical Care
David Glaser, MD
Associate Professor
Department of Orthopaedic Surgery
University of Pennsylvania
Philadelphia, PA
Section Editor: Melanie Donnelly
including stroke, spinal cord ischemia, and transient vision
loss while in the beach chair position.11-13 Although the exact
mechanism is not known, many speculate that it relates to loss
of cerebral autoregulation, leading to cerebral hypoperfusion
and ischemia during general anesthesia (GA). In patients
anesthetized with volatile anesthetics, the autoregulatory response
is blunted in a dosedependent manner, with the
exception with sevoflurane
at relevant doses.14 By
measuring regional cerebral
oxygenation, multiple studies
demonstrated a correlation
relating diminished cerebral
autoregulation during
"A team approach and communication
between perioperative care
management team members are the
key elements to success."
American Society of Regional Anesthesia and Pain Medicine
2017
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