I read with interest the case presentation in the APSF Newsletter concerning the intraoperative stroke of a patient undergoing a shoulder procedure in the beach chair position. I wonder if the 50 mg dose of labetalol prior to induction is accurate? If so, I believe that we need to reevaluate how aggressive we should be with blood pressure control just prior to the induction of anesthesia. Many uncontrolled hypertensive patients present with dehydration and an elevated vascular resistance and become relatively hypotensive following induction.

I understand that the focus of this article was not the use of perioperative beta-blockers, but it highlights the push for more aggressive use of perioperative beta blockade and the potential negative effects. I am not blaming the outcome of this case on the beta-blocker use, but I do believe it was a contributing factor. Labetalol, besides lowering the blood pressure, will lower the cardiac output. What is good for the heart may not necessarily be good for the brain. Of late, there has been a push for indiscriminate perioperative beta-blocker use; it has almost been presented as a “magic bullet” to improve patient outcomes. To my knowledge there is no literature showing aggressive blood pressure control just prior to induction improves outcomes, especially in “healthy” patients. I am somewhat reassured that in the recent literature there has been information presented directing us to a more judicious use of perioperative beta-blockers. I do think there should be a greater dialogue between the cardiologist and anesthesiologist prior to the initiation of perioperative beta blockade, because when there is a disagreement about their appropriate use, the patient is frequently left confused and concerned about the judgement of his or her physicians. If anything, it may be wise to start with shorter-acting agents, assess the patient’s response to induction, and proceed from that point.

Sam Budnyk
Destin, FL

To the Editor

My compliments to Drs. Cullen and Kirby for their lead article in the summer 2007 issue of the APSF Newsletter highlighting the risk of cerebral ischemic damage with the “beach chair” position for shoulder surgery. They clearly documented the devastating injury that can occur and the “ball-park” calculations for compensation of blood pressure that are required.

I suggest every one of those patients get an arterial line zeroed to the head. Neuroanesthesiologists have been doing sitting cases for decades, and I have never heard of a patient being brain injured from unrealized low cerebral perfusion. I don’t think any bona fide neuroanesthesiologist would consider doing a sitting position case without this safety monitoring. Our orthopedic patients deserve the same level of diligence. If I try to balance the risk and cost of an arterial line against the terrible outcomes of the 2 cases in their report, it seems clear to me how we should proceed. I suggest we don’t calculate, estimate, or extrapolate the blood pressure from a cuff to the top of the head. Just measure the pressure with an arterial transducer zeroed to the head and get it right each and every time. Our specialty really tries to have a zero tolerance for avoidable brain injury at surgery. A change of our practice seems in order to achieve this highest quality.

Roy F. Cucchiara, MD
Jacksonville, FL