British Journal of Anaesthesia, Vol 82, Issue 1 117-128, Copyright © 1999 by The Board of Management and Trustees of the British Journal of Anaesthesia
J. M. Porter, C. Pidgeon and A. J. Cunningham
The potential for serious complications after venous air embolism and
successful malpractice liability claims are the principle reasons for the
dramatic decline in the use of the sitting position in neurosurgical
practice. Although there have been several studies substantiating the
relative safety compared with the prone or park bench positions, its use
will continue to decline as neurosurgeons abandon its application and
trainees in neurosurgery are not exposed to its relative merits. How can
individual surgeons continue to use this position? Will individual,
difficult surgical access cases be denied the obvious technical advantages
of the sitting position? Limited use of the sitting position should remain
in the neurosurgeon's armamentarium. However, several caveats must be
emphasized. Assessment of the relative risk-benefit, based on the
individual patient's physical status and surgical implications for the
particular intracranial pathology, is of paramount importance. The patient
should be informed of the specific risks of venous air embolism,
quadriparesis and peripheral nerve palsies. Appropriate charting of patient
information provided and special consent issues are essential. An
anaesthetic input into the decision to use the sitting position is a sine
qua non. The presence of a patient foramen ovale is an absolute
contraindication. Preoperative contrast echocardiography should be used as
a screening technique to detect the population at risk of paradoxical air
embolism caused by the presence of a patent foramen ovale. The technique
involves i.v. injection of saline agitated with air and a Valsalva
manoeuvre is applied and released. Use of this position necessitates
supplementary monitoring to promptly detect and treat venous air embolism.
Doppler ultrasonography is the most sensitive of the generally available
monitors to detect intracardiac air. The use of a central venous catheter
is recommended, with the tip positioned close to the superior vena cava
junction with the right atrium, to aspirate intravascular gas. Measures to
minimize hypotension associated with the sitting position include a slow,
staged positioning over 5-10 min and use of the 'G suit' inflated with
compressed air applied to the lower extremities and pelvis. Use of the
sitting or upright position for patients undergoing posterior fossa and
cervical spine surgery presents unique challenges for the anaesthetist.
With appropriate patient selection and preparation, and using prudent
intraoperative monitoring and anaesthetic techniques, selected patients
should still benefit from the optimum access to mid-line lesions, improved
cerebral venous decompression, lower intracranial pressure and enhanced
gravity drainage of blood and CSF associated with the sitting position.
REVIEW ARTICLE
The sitting position in neurosurgery: a critical appraisal
Department of Anaesthesia and Neurosurgery, Royal College of Surgeons in Ireland/Beaumont Hospital, Dublin 9, Ireland
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