The sitting position in neurosurgical anaesthesia: a survey of French practice

INTRODUCTION: It remains a French and international controversy about the use of the sitting position in neurosurgery. The aim of this study was to evaluate the frequency of sitting position use, perioperative monitoring and procedures for air embolism detection and treatment. STUDY DESIGN: National postal survey. PATIENTS AND METHODS: The survey was sent in may 2000 to the anaesthesiologists in 53 french public neurosurgical centers. Responses were collected during 9 months. RESULTS: Among the 44 centers (83%), 33 (75%) used the sitting position. In 20 centers (61%) it was limited for the surgical procedures for which the surgeon was unable to operate in other position. Perioperative monitoring for air embolism was: capnography (100%), Swan-Ganz catheter (21%), precordial Doppler ultrasonography (15%) and transoesophageal echocardiography (6%). Only 12 centers (36%) used 2 or more techniques of detection for perioperative air embolism. In the 25 centers (76%) of those, which used the sitting position systematic pre-operative identification of patent foramen ovale by contrast echocardiography was performed. Prevention procedures of air embolism were: plasma volume expansion (94%), antigravity suit (61%), mechanical ventilation with positive end-expiratory pressure (42%), and abdominal compression (24%). No protocol of air embolism prophylaxis was used in 18 centers. CONCLUSION: The survey concerned 83% of the centers. The number of centers using the sitting position was larger than in other countries like United Kingdom, Germany and Japan. Despite its lack of sensitivity capnography was universally practised. Preoperative contrast echocardiography for patent foramen ovale detection was not considered as necessary in all centers. Expert recommendations may be required.     

The sitting position in neurosurgical anaesthesia: a survey of British practice in 1991

A postal survey of 160 members of the Neurosurgical Anaesthetists'Travelling Club was conducted in 1991 to investigate the currentuse of the sitting position in neurosurgery. There was a 78%response rate; at least one reply was received from every neurosurgicalcentre in the UK. Patients were placed normally in the sittingposition for posterior fossa surgery in eight (20%) of the centres,compared with 19 (53%) in 1981. For posterior cervical spinalsurgery, only three (7%) centres routinely used the sittingposition, compared with 11(31%) in 1981. Thus in the period1981%1991, the number of neurosurgical centres using the sittingposition routinely, decreased by more than 50%. Current techniquesof ventilation and monitoring for the sitting position are discussedbriefly.      

Pre-operative non-shaving for neurosurgical operations (author's transl)

The authors report their pre-operative technique for scalp attendance according to which they operated on more than 1000 cranial neurosurgical patients in three years without the classical complete hair shave. Major psychological advantages are obvious. Principle technical details are: as complete cleaning of scalp-grease as possible by repeated shampoos; in the operating room: shaving only a thin pathway along the skin incision drawn by the surgeon himself, and disinfection with tincture of iodine exclusively. During the same time, they observed a fall to 0,6% of surgical infections needing bone flap removal because of osteitis. Secondary but always transitory partial alopecia has been observed in three patients.     

Postoperative systemic candidiasis in neurosurgical patients (author's transl)

Two cases of postoperative systemic candidiasis in neurosurgical practice are reported. Postoperatively these patients showed signs and symptoms of systemic infection and unfortunately died in spite of intensive chemotherapy. In both cases systemic candidiasis became evident by histological examinations at autopsy. Long use of antibiotics and aggressive nosocomy were supposed to be the cause of the systemic candidiasis. The authors emphasized a high possibility of opportunistic fungal infection in neurosurgical practice. The symptomatology, treatment and prevention of this disease are also discussed.     

Provocation of an epileptic seizure during induction of NLA (author's transl)]

We report about a case in which the induction of NLA produced an epileptic seizure. The seizure was checked by relaxation, intubation and controlled ventilation. During the following anaesthesia the EEG-monitoring did not show any increased disposition to cramps. The operation was finished without complications.     

Haemodilution in neurosurgical operations (author's transl)]

The subject of this paper is an investigation of the usefulness of haemodilution in neurosurgical operations. The studies were carried out on 30 patients undergoing operations for intracranial aneurysms (17 patients) or intracranial tumours (13 patients). The control group consisted of 50 patients undergoing operations for intracranial tumours (25 patients) or cerebral aneurysms (25 patients). It was found that during haemodilution cerebral oedema did not occur during the operation, while in the control group cerebral oedema was observed in 28% operations of the cerebral aneurysms and in 56%-- of the cerebral tumors. The amount of transfused blood in the group with intracranial tumors was diminished by ca 150 ml and in the group with cerebral aneurysms blood transfusion was not necessary at all (in the control group the average transfusion was 310 ml). Described method in correlation with the controlled hypotension should be more widely used in the neurosurgical operations.