Compression Stocking Use in Shoulder Arthroscopy in Beach Chair
| Status: | Completed |
|---|---|
| Conditions: | Obesity Weight Loss, Orthopedic |
| Therapuetic Areas: | Endocrinology, Orthopedics / Podiatry |
| Healthy: | No |
| Age Range: | 18 - Any |
| Updated: | 9/2/2018 |
| Start Date: | March 28, 2013 |
| End Date: | July 27, 2015 |
The Effect of Compression Stockings on Cerebral Desaturation Events in Obese Patients Undergoing Shoulder Arthroscopy in the Beach Chair Position
Shoulder arthroscopy is one of the most commonly performed orthopaedic procedures and it is
often done with the patient in the upright, or beach chair position (BCP). There have been
multiple reported complications associated with the BCP, including cerebral ischemia, loss of
vision, ophthalmoplegia, stroke, and even death. It has been reported that patients with a
body mass index (BMI) of 34 or greater are as much as 12 times more likely to experience
cerebral desaturation events (CDEs) compared to non-obese controls. CDEs in the upright
position are hypothesized to be partially related to reduced cardiac preload due to venous
pooling in the lower extremities which is exaggerated in obese patients. This prospective
observational study aims to determine if the use of compression stockings in obese patients
undergoing shoulder arthroscopy in the BCP can reduce the incidence, frequency, or magnitude
of CDEs experienced by the patient
often done with the patient in the upright, or beach chair position (BCP). There have been
multiple reported complications associated with the BCP, including cerebral ischemia, loss of
vision, ophthalmoplegia, stroke, and even death. It has been reported that patients with a
body mass index (BMI) of 34 or greater are as much as 12 times more likely to experience
cerebral desaturation events (CDEs) compared to non-obese controls. CDEs in the upright
position are hypothesized to be partially related to reduced cardiac preload due to venous
pooling in the lower extremities which is exaggerated in obese patients. This prospective
observational study aims to determine if the use of compression stockings in obese patients
undergoing shoulder arthroscopy in the BCP can reduce the incidence, frequency, or magnitude
of CDEs experienced by the patient
There have been numerous studies recently in the orthopaedic surgery and anesthesia
literature related to both complications associated with arthroscopy in the BCP and ongoing
efforts to improve patient safety. Advantages of this position when compared with the lateral
decubitus position include easier anatomic orientation, lack of traction on the brachial
plexus, ease of exam under anesthesia, and easier conversion to an open approach if needed.
While extremely uncommon, complications such as ischemic brain and spinal cord injury as well
as visual loss and ophthalmoplegia have been reported. A recent study reported that obesity
increases the likelihood of having a CDE by as many as 12 times. CDEs were defined as
intra-operative decreases in regional cerebral tissue oxygen saturation (rSO2) of 20% or
greater from baseline as measured by near-infrared spectroscopy (NIRS). Since obesity is so
common, it was decided to investigate a measure to potentially help decrease CDEs in this
population.
The exact etiology of CDEs has not been definitively demonstrated and it is felt to be
multifactorial. The sympathetic nervous system normally increases systemic vascular
resistance and heart rate to maintain mean arterial blood pressure (MAP) when a person sits
up or stands upright. This response is blunted by the vasodilatory effects of intravenous and
inhaled anesthetics used in patients undergoing shoulder arthroscopy in the BCP. The result
is decreased MAP and cerebral perfusion pressure that can contribute to hypoxic brain injury.
The use of sequential compression devices placed on the legs of patients undergoing shoulder
arthroscopy in the BCP has been shown to reduce the incidence of hypotension by increasing
cardiac preload. This study excluded obese patients (BMI > 30) and did not directly monitor
rSO2, but rather only monitored hemodynamic variables.
Compression stockings are often used in patients with venous insufficiency to help with pain
and to control edema. The stockings compress the soft tissues and veins, and in conjunction
with sequential compression devices (SCDs), may help to increase preload in an anesthetized
patient in the BCP. To our knowledge, the effect of compression stockings on cerebral
perfusion has not been studied. This study aims to determine if the use of compression
stockings in obese patients undergoing shoulder arthroscopy in the BCP can decrease the
incidence, frequency or magnitude of CDEs as measured by NIRS. We hypothesize that the use of
compression stockings will result in decreased incidence and frequency of CDEs in our
population.
literature related to both complications associated with arthroscopy in the BCP and ongoing
efforts to improve patient safety. Advantages of this position when compared with the lateral
decubitus position include easier anatomic orientation, lack of traction on the brachial
plexus, ease of exam under anesthesia, and easier conversion to an open approach if needed.
While extremely uncommon, complications such as ischemic brain and spinal cord injury as well
as visual loss and ophthalmoplegia have been reported. A recent study reported that obesity
increases the likelihood of having a CDE by as many as 12 times. CDEs were defined as
intra-operative decreases in regional cerebral tissue oxygen saturation (rSO2) of 20% or
greater from baseline as measured by near-infrared spectroscopy (NIRS). Since obesity is so
common, it was decided to investigate a measure to potentially help decrease CDEs in this
population.
The exact etiology of CDEs has not been definitively demonstrated and it is felt to be
multifactorial. The sympathetic nervous system normally increases systemic vascular
resistance and heart rate to maintain mean arterial blood pressure (MAP) when a person sits
up or stands upright. This response is blunted by the vasodilatory effects of intravenous and
inhaled anesthetics used in patients undergoing shoulder arthroscopy in the BCP. The result
is decreased MAP and cerebral perfusion pressure that can contribute to hypoxic brain injury.
The use of sequential compression devices placed on the legs of patients undergoing shoulder
arthroscopy in the BCP has been shown to reduce the incidence of hypotension by increasing
cardiac preload. This study excluded obese patients (BMI > 30) and did not directly monitor
rSO2, but rather only monitored hemodynamic variables.
Compression stockings are often used in patients with venous insufficiency to help with pain
and to control edema. The stockings compress the soft tissues and veins, and in conjunction
with sequential compression devices (SCDs), may help to increase preload in an anesthetized
patient in the BCP. To our knowledge, the effect of compression stockings on cerebral
perfusion has not been studied. This study aims to determine if the use of compression
stockings in obese patients undergoing shoulder arthroscopy in the BCP can decrease the
incidence, frequency or magnitude of CDEs as measured by NIRS. We hypothesize that the use of
compression stockings will result in decreased incidence and frequency of CDEs in our
population.
Inclusion Criteria:
- Age 18 years or older
- BMI greater than or equal to 30 kg/m^2
- Capable of receiving an interscalene nerve block.
Exclusion Criteria:
- Age < 18
- History of carotid artery stenosis equal to or greater than 90%
- History of stroke
- History of transient ischemic attack
- History of syncope
- History of vision loss
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