Difference between revisions of "Shoulder arthroplasty"
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{{Infobox surgical procedure | {{Infobox surgical procedure | ||
| anesthesia_type = General | | anesthesia_type = General and/or regional | ||
| airway = ETT | | airway = ETT if GA | ||
| lines_access = PIV | | lines_access = PIV in opposite limb | ||
| monitors = Standard | | monitors = Standard | ||
| considerations_preoperative = Type and screen | 5-lead ECG | ||
| considerations_intraoperative = | Temperature | ||
| considerations_preoperative = Type and screen | |||
Airway and neurologic physical examination | |||
Note baseline MAPs | |||
| considerations_intraoperative = Maintain cerebral perfusion (MAP ±20% of baseline) | |||
VAE | |||
| considerations_postoperative = Cerebrovascular accident | | considerations_postoperative = Cerebrovascular accident | ||
}} | }}'''Shoulder arthroplasty''' is a surgical procedure which replaces the humeral head with a prosthesis. Indications include pain associated with severe osteoarthritis and restoration of mobility<ref name=":0">{{Cite journal|last=Ding|first=David Y.|last2=Mahure|first2=Siddharth A.|last3=Mollon|first3=Brent|last4=Shamah|first4=Steven D.|last5=Zuckerman|first5=Joseph D.|last6=Kwon|first6=Young W.|date=2017-12-01|title=Comparison of general versus isolated regional anesthesia in total shoulder arthroplasty: A retrospective propensity-matched cohort analysis|url=https://www.sciencedirect.com/science/article/pii/S0972978X17301071|journal=Journal of Orthopaedics|language=en|volume=14|issue=4|pages=417–424|doi=10.1016/j.jor.2017.07.002|issn=0972-978X|pmc=PMC5537444|pmid=28794581}}</ref>, and may be associated with avascular necrosis, rheumatoid arthritis (RA), trauma, or a rotator cuff tear<ref name=":0" /><ref name=":1" />. | ||
The procedure is typically performed using a deltopectoral incision. The head of the humerus is removed and a prosthesis is placed with or without cement. The glenoid's surface is smoothed and the glenoid prosthesis is placed. The humeral prothesis is fitted onto the glenoid prosthesis. After surgery, the patient is placed in a shoulder sling or immobilizer.<ref name=":1">{{Cite book|url=https://www.worldcat.org/oclc/1117874404|title=Anesthesiologist's manual of surgical procedures|date=2020|others=Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu|isbn=978-1-4698-2916-6|edition=6|location=Philadelphia|oclc=1117874404}}</ref> | |||
== Preoperative management == | ==Preoperative management== | ||
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> === | ===Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. -->=== | ||
{| class="wikitable" | {| class="wikitable" | ||
|+ | |+ | ||
| Line 20: | Line 25: | ||
|- | |- | ||
|Neurologic | |Neurologic | ||
| | |Baseline neurological exam | ||
* Preexisting neuropathy especially with regional technique | |||
* Increased risk of CVA if in beach chair position | |||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
| | |Baseline blood pressure especially important to note given upright position | ||
|- | |- | ||
|Respiratory | |Respiratory | ||
|Assess for pleural effusions, pulmonary fibrosis, involvement of cricoarytenoids, | |Assess for pleural effusions, pulmonary fibrosis, involvement of cricoarytenoids, and TMJ due to RA | ||
|- | |- | ||
|Hematologic | | Hematologic | ||
|Assess for chronic anemia | |Assess for chronic anemia | ||
|- | |- | ||
|Endocrine | |Endocrine | ||
| | |If arthritis is autoimmune-mediated, assess for chronic steroid use | ||
|- | |- | ||
|Other | | Other | ||
|Assess for cervical neck motion as some patients suffered rheumatoid arthritis or trauma | |Assess for cervical neck motion as some patients suffered rheumatoid arthritis or trauma | ||
|} | |} | ||
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | ===Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. -->=== | ||
* Type and screen | *Type and screen | ||
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | === Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->=== | ||
* | *Midazolam for anxiety | ||
* | *Consider initiating multimodal pain management preoperatively | ||
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ===Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. -->=== | ||
* Interscalene block as primary anesthetic or | *Interscalene block as primary anesthetic or supplement to general anesthesia | ||
*Can consider nerve catheter for intraop and postop pain management | |||
== Intraoperative management == | ==Intraoperative management== | ||
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | ===Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. -->=== | ||
* Standard ASA monitors | * Standard ASA monitors | ||
* 5-lead EKG | *5-lead EKG | ||
* PIV x 1-2 (opposite limb, large bore) | *PIV x 1-2 (opposite limb, large bore) | ||
* +/- arterial line | *+/- arterial line | ||
* Consider precordial doppler given | *Consider precordial doppler given increased risk of venous air embolism in the upright position | ||
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | ===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->=== | ||
* If general | * If using general anesthesia, ETT typically preferable for airway security given patient positioning and surgical manipulation | ||
*If regional is chosen, moderate to deep sedation is reasonable | |||
* If regional is chosen, moderate to deep sedation is reasonable | |||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->=== | ||
* Semi-sitting upright | *Semi-sitting upright (beach chair) | ||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | ===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->=== | ||
*Maintain MAP within 20% of baseline to ensure adequate cerebral perfusion in upright position | |||
*Maintenance of neuromuscular blockade may be helpful for surgeons | |||
* Maintain MAP within 20% of baseline to ensure adequate cerebral perfusion | * Monitor for venous air embolus, especially during placement of cement | ||
* Monitor | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->=== | ||
* PONV prophylaxis | * PONV prophylaxis | ||
* | *Consider cerebral infarction if delayed emergence | ||
== Postoperative management == | ==Postoperative management== | ||
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->=== | ||
* PACU | * PACU | ||
* Floor | *Floor | ||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->=== | ||
* Pain is usually moderate to severe | * Pain is usually moderate to severe | ||
* Multimodal management | |||
** | **Regional anesthesia | ||
** | **Acetaminophen | ||
** | **NSAIDs (verify with surgeons) | ||
** | **Gabapentin | ||
** | **Opioids | ||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->=== | ||
* CVA | * CVA | ||
* Bleeding | *Bleeding | ||
* Infection | *Infection | ||
* Brachial plexus nerve injury | *Brachial plexus nerve injury | ||
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> == | ==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->== | ||
{| class="wikitable wikitable-horizontal-scroll" | {| class="wikitable wikitable-horizontal-scroll" | ||
| Line 116: | Line 123: | ||
|Unique considerations | |Unique considerations | ||
| | | | ||
* Sitting position | *Sitting position | ||
* Methyl methacrylate cement can cause severe hypotension/VAE | *Methyl methacrylate cement can cause severe hypotension/VAE | ||
|- | |- | ||
|Position | |Position | ||
| Line 136: | Line 143: | ||
|Potential complications | |Potential complications | ||
| | | | ||
* CVA | *CVA | ||
* VAE | *VAE | ||
* brachial plexus injury | *brachial plexus injury | ||
|} | |} | ||
== References == | ==References== | ||
<references /> | |||
[[Category:Surgical procedures]] | [[Category:Surgical procedures]] | ||
[[Category:Orthopedic surgery]] | [[Category:Orthopedic surgery]] | ||
[[Category:Joint replacement surgery]] | [[Category:Joint replacement surgery]] | ||
[[Category:Shoulder surgery]] | |||
Latest revision as of 14:21, 13 June 2022
Shoulder arthroplasty
| Anesthesia type |
General and/or regional |
|---|---|
| Airway |
ETT if GA |
| Lines and access |
PIV in opposite limb |
| Monitors |
Standard 5-lead ECG Temperature |
| Primary anesthetic considerations | |
| Preoperative |
Type and screen Airway and neurologic physical examination Note baseline MAPs |
| Intraoperative |
Maintain cerebral perfusion (MAP ±20% of baseline) VAE |
| Postoperative |
Cerebrovascular accident |
| Article quality | |
| Editor rating | |
| User likes | 0 |
Shoulder arthroplasty is a surgical procedure which replaces the humeral head with a prosthesis. Indications include pain associated with severe osteoarthritis and restoration of mobility[1], and may be associated with avascular necrosis, rheumatoid arthritis (RA), trauma, or a rotator cuff tear[1][2].
The procedure is typically performed using a deltopectoral incision. The head of the humerus is removed and a prosthesis is placed with or without cement. The glenoid's surface is smoothed and the glenoid prosthesis is placed. The humeral prothesis is fitted onto the glenoid prosthesis. After surgery, the patient is placed in a shoulder sling or immobilizer.[2]
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Neurologic | Baseline neurological exam
|
| Cardiovascular | Baseline blood pressure especially important to note given upright position |
| Respiratory | Assess for pleural effusions, pulmonary fibrosis, involvement of cricoarytenoids, and TMJ due to RA |
| Hematologic | Assess for chronic anemia |
| Endocrine | If arthritis is autoimmune-mediated, assess for chronic steroid use |
| Other | Assess for cervical neck motion as some patients suffered rheumatoid arthritis or trauma |
Labs and studies
- Type and screen
Patient preparation and premedication
- Midazolam for anxiety
- Consider initiating multimodal pain management preoperatively
Regional and neuraxial techniques
- Interscalene block as primary anesthetic or supplement to general anesthesia
- Can consider nerve catheter for intraop and postop pain management
Intraoperative management
Monitoring and access
- Standard ASA monitors
- 5-lead EKG
- PIV x 1-2 (opposite limb, large bore)
- +/- arterial line
- Consider precordial doppler given increased risk of venous air embolism in the upright position
Induction and airway management
- If using general anesthesia, ETT typically preferable for airway security given patient positioning and surgical manipulation
- If regional is chosen, moderate to deep sedation is reasonable
Positioning
- Semi-sitting upright (beach chair)
Maintenance and surgical considerations
- Maintain MAP within 20% of baseline to ensure adequate cerebral perfusion in upright position
- Maintenance of neuromuscular blockade may be helpful for surgeons
- Monitor for venous air embolus, especially during placement of cement
Emergence
- PONV prophylaxis
- Consider cerebral infarction if delayed emergence
Postoperative management
Disposition
- PACU
- Floor
Pain management
- Pain is usually moderate to severe
- Multimodal management
- Regional anesthesia
- Acetaminophen
- NSAIDs (verify with surgeons)
- Gabapentin
- Opioids
Potential complications
- CVA
- Bleeding
- Infection
- Brachial plexus nerve injury
Procedure variants
| Total shoulder arthroplasty | |
|---|---|
| Unique considerations |
|
| Position | Semi-sitting/beach chair |
| Surgical time | 2-5 hours |
| EBL | 200-1000 mL |
| Postoperative disposition | Floor |
| Pain management | moderate-severe |
| Potential complications |
|
References
- ↑ 1.0 1.1 Ding, David Y.; Mahure, Siddharth A.; Mollon, Brent; Shamah, Steven D.; Zuckerman, Joseph D.; Kwon, Young W. (2017-12-01). "Comparison of general versus isolated regional anesthesia in total shoulder arthroplasty: A retrospective propensity-matched cohort analysis". Journal of Orthopaedics. 14 (4): 417–424. doi:10.1016/j.jor.2017.07.002. ISSN 0972-978X. PMC 5537444. PMID 28794581.CS1 maint: PMC format (link)
- ↑ 2.0 2.1 Anesthesiologist's manual of surgical procedures. Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu (6 ed.). Philadelphia. 2020. ISBN 978-1-4698-2916-6. OCLC 1117874404.CS1 maint: others (link)
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