Concise Review Avoiding Catastrophic Complications of Stroke and Death Related to Shoulder Surgery in the Sitting Position Anastasios Papadonikolakis, M.D., Ethan R. Wiesler, M.D., Michael A. Olympio, M.D., and Gary G. Poehling, M.D. Abstract: The beach-chair position in shoulder surgery provides advantages to the surgeon and anes- thesiologist. However, cautious interpretation of the patient’s blood pressure is essential, especially when the blood pressure cuff is placed at the calf. The calf pressure should be interpreted relative to the heart-level pressure to avoid iatrogenic cerebral hypoperfusion related to hypotensive anesthesia. Possible complications of cerebral hypoperfusion are permanent neurologic impairment, stroke, and death. Key Words: Beach-chair position—Shoulder surgery—Complications—Stroke—Death T he beach-chair position for arthroscopic or open shoulder surgery has gained wide acceptance among orthopaedic surgeons. 1 Advantages include easier airway access, placing the anatomy in the stan- dard upright position, and less bleeding in the upright position; it also facilitates checking the effect of dif- ferent positions of the arm on the involved anatomy and enables use of the weight of the arm for traction. However, complications have been reported in Ar- throscopy. 2 Recently, Pohl and Cullen 3 reported on 4 cases of shoulder surgery in the beach-chair position that resulted in death in 1 patient and severe brain damage in 3 patients. Stroke and brain death, loss of vision, and ophthalmoplegia have also been de- scribed. 4,5 Such complications are presumed to be attributable to errors in blood pressure reference points. 5 The purpose of this article is to point out the potential catastrophic complications associated with shoulder surgery in the beach-chair position and to describe methods of prevention. Arthroscopic shoulder surgery can be performed with the patient in the beach-chair or lateral decubitus position. These 2 different positions have significant physiologic effects on the mechanisms of blood pres- sure regulation. In addition, the method of monitoring the blood pressure in these positions plays a major role in avoiding potential permanent or lethal iatrogenic complications. In the sitting position the blood pres- sure at the calf is significantly higher than it is at the head or arm. The blood pressure readings differ from calf to head primarily and fundamentally because of the hydrostatic gradients from calf to heart to head. This hydrostatic difference alone could be approxi- mately 50 inches, or equivalent to a 94 –mm Hg pres- sure variation from calf to head. To achieve better visualization during shoulder ar- throscopy, it is common to ask for hypotensive anes- thesia to decrease intra-articular bleeding. 6 With the patient in the beach-chair position, the anesthesia team will frequently measure the blood pressure at the calf because the intravenous line is in the arm; therefore, there is a false assumption that the calf pressure should be reduced to what would have been measured From the Departments of Orthopaedic Surgery (A.P., E.R.W., G.G.P.) and Anesthesiology (M.A.O.), Wake Forest University Medical Center, Winston-Salem, North Carolina, U.S.A. The authors report no conflict of interest. Address correspondence and reprints requests to Ethan R. Wiesler, M.D., Department of Orthopaedic Surgery, Wake Forest University Health Sciences, Medical Center Boulevard, Winston- Salem, NC 27157-1070, U.S.A. E-mail: ewiesler@wfubmc.edu © 2008 by the Arthroscopy Association of North America 0749-8063/08/2404-0876$34.00/0 doi:10.1016/j.arthro.2008.02.005 481 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 24, No 4 (April), 2008: pp 481-482