. 2019 Oct 11;7(2):46–55. doi: 10.1055/s-0039-1697606

Table 5. Pitfall and pearls of the beach chair position.

Pitfall	Pearls
Cerebrovascular events	• Stratify patients for the risk of cerebral desaturation events in the BC position. ○ High risk: obese patients (BMI > 34). 45 ○ Possible risk: diabetes mellitus, obstructive sleep apnea, hypertension, older patients with more medical comorbidities, and history of stroke. 7 45 61 • Consider the use of isolated regional anesthesia. The use of regional anesthesia under an interscalene block and sedation may be the most effective strategy to decrease the risk of CDE and ischemic neurological injury in the BC position. 40 41 • When general anesthesia is preferable or unavoidable, noninvasive monitoring of regional cerebral oxygenation with near-infrared spectroscopy is recommended. 40 • Consider the use of a less upright position (30 degree to 45 degree) for patients with a high or probable risk of CDE ( Fig. 4 ). A linear relationship between the angle of the BC position and an increase of cerebral deoxygenation has been demonstrated. 61 • If a vasopressor agent is planned to be used in the irrigation fluid to decrease the intraoperative bleeding, consider the use of norepinephrine (0.66 mg/L) rather than epinephrine. 46 • Keep an open communication with the anesthesia team of cardiovascular changes and cerebral oxygenation during patient positioning and during the procedure.
Peripheral neurological injuries	• Head and neck should be neutral. Avoid flexion, hyperextension, or lateral flexion. • Head position should be checked frequently during shoulder surgery especially if the angle of the operating table is changed. 48 • Protect the auricle against compression with extra padding of the headrest to minimize pressure. • Careful attention to placing the security belt across the thighs, rather than higher up around the waist, may avoid compression of the lateral femoral cutaneous nerve (LFCN). 62 • Limiting hip flexion by using reverse Trendelenburg to maintain a modified beach chair position may minimize compression of the LFCN from the belt. 62 • Proper preoperative counseling to obese patients with a BMI > 34 of possible LFCN neurapraxia. 47

Pitfall

Pearls

Cerebrovascular events

• Stratify patients for the risk of cerebral desaturation events in the BC position.
○ High risk: obese patients (BMI > 34). 45
○ Possible risk: diabetes mellitus, obstructive sleep apnea, hypertension, older patients with more medical comorbidities, and history of stroke. 7 45 61
• Consider the use of isolated regional anesthesia. The use of regional anesthesia under an interscalene block and sedation may be the most effective strategy to decrease the risk of CDE and ischemic neurological injury in the BC position. 40 41
• When general anesthesia is preferable or unavoidable, noninvasive monitoring of regional cerebral oxygenation with near-infrared spectroscopy is recommended. 40
• Consider the use of a less upright position (30 degree to 45 degree) for patients with a high or probable risk of CDE ( Fig. 4 ). A linear relationship between the angle of the BC position and an increase of cerebral deoxygenation has been demonstrated. 61
• If a vasopressor agent is planned to be used in the irrigation fluid to decrease the intraoperative bleeding, consider the use of norepinephrine (0.66 mg/L) rather than epinephrine. 46
• Keep an open communication with the anesthesia team of cardiovascular changes and cerebral oxygenation during patient positioning and during the procedure.

Peripheral neurological injuries

• Head and neck should be neutral. Avoid flexion, hyperextension, or lateral flexion.
• Head position should be checked frequently during shoulder surgery especially if the angle of the operating table is changed. 48
• Protect the auricle against compression with extra padding of the headrest to minimize pressure.
• Careful attention to placing the security belt across the thighs, rather than higher up around the waist, may avoid compression of the lateral femoral cutaneous nerve (LFCN). 62
• Limiting hip flexion by using reverse Trendelenburg to maintain a modified beach chair position may minimize compression of the LFCN from the belt. 62
• Proper preoperative counseling to obese patients with a BMI > 34 of possible LFCN neurapraxia. 47

Abbreviations: BC, beach chair; CDE, cerebral desaturation events.