Difference between revisions of "Shoulder arthroplasty"

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{{Infobox surgical procedure
{{Infobox surgical procedure
| anesthesia_type = General
| anesthesia_type = General vs regional
| airway = ETT
| airway = ETT vs non-invasive O2
| lines_access = PIV x 1-2 (opposite limb, large bore)
| lines_access = PIV x 1-2 (opposite limb, large bore)
| monitors = Standard, 5-lead EKG, temperature
| monitors = Standard, 5-lead EKG, temperature
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}}
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Shoulder arthroplasty is a surgical procedure involved with removal of the humeral head and replacement with a prosthesis. Indication includes pain associated with severe osteoarthritis. Patients experiences diagnosis of avascular necrosis, rheumatoid arthritis (RA), trauma, and rotator cuff tear. The procedure begins with a deltopectoral incision. The humerus head 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's prosthesis. Skin is closed and patient is placed in a shoulder sling or immobilizer <ref>{{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=Sixth edition|location=Philadelphia|oclc=1117874404}}</ref>
Shoulder arthroplasty is a surgical procedure involved with removal of the humeral head and replacement 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>. Patients experiences diagnosis of avascular necrosis, rheumatoid arthritis (RA), trauma, and rotator cuff tear<ref name=":0" /><ref name=":1" />. The procedure begins with a deltopectoral incision. The humerus head 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's prosthesis. Skin is closed and 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=Sixth edition|location=Philadelphia|oclc=1117874404}}</ref>


== Preoperative management ==
== Preoperative management ==
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=== 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 a supplement to general
* Interscalene block as primary anesthetic or supplemented with GA


== Intraoperative management ==
== Intraoperative management ==
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* If general is chosen, standard induction  
* If general is chosen, standard induction  
** ETT  
** ETT  
* 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, beach chair  
* Semi-sitting upright, beach chair  
* Table turned 90<sup>o</sup>


=== 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. --> ===
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** Maintenance of neuromuscular blockade
** Maintenance of neuromuscular blockade
* Maintain MAP within 20% of baseline to ensure adequate cerebral perfusion due to sitting position
* Maintain MAP within 20% of baseline to ensure adequate cerebral perfusion due to sitting position
* Monitor for hemodynamic changes associated with VAE especially during use of cement  
* Monitor hemodynamic changes or precordial doppler if used for VAE especially during placement of cement


=== 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. --> ===

Revision as of 19:21, 21 January 2022

Shoulder arthroplasty
Anesthesia type

General vs regional

Airway

ETT vs non-invasive O2

Lines and access

PIV x 1-2 (opposite limb, large bore)

Monitors

Standard, 5-lead EKG, temperature

Primary anesthetic considerations
Preoperative

Type and screen, airway and neurologic physical examination

Intraoperative

Optimal BP management for cerebral perfusion, VAE

Postoperative

Cerebrovascular accident

Article quality
Editor rating
Comprehensive
User likes
0

Shoulder arthroplasty is a surgical procedure involved with removal of the humeral head and replacement with a prosthesis. Indications include pain associated with severe osteoarthritis and restoration of mobility [1]. Patients experiences diagnosis of avascular necrosis, rheumatoid arthritis (RA), trauma, and rotator cuff tear[1][2]. The procedure begins with a deltopectoral incision. The humerus head 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's prosthesis. Skin is closed and patient is placed in a shoulder sling or immobilizer [2]

Preoperative management

Patient evaluation

System Considerations
Neurologic Assess for baseline neurological exam for pre-existing neuropathy especially with regional technique and risk of CVA
Cardiovascular Assess for valvular, conduction, and pericardial disease
Respiratory Assess for pleural effusions, pulmonary fibrosis, involvement of cricoarytenoids, andTMJ due to RA
Hematologic Assess for chronic anemia
Endocrine Assess for adrenal insufficiency in patients with rheumatoid arthritis on chronic steroids
Other Assess for cervical neck motion as some patients suffered rheumatoid arthritis or trauma

Labs and studies

  • Type and screen

Patient preparation and premedication

  • IV midazolam for anxiety
  • PO acetaminophen for pain

Regional and neuraxial techniques

  • Interscalene block as primary anesthetic or supplemented with GA

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 the risk of venous air embolism in the semi-sitting/beach chair position

Induction and airway management

  • If general is chosen, standard induction
    • ETT
  • If regional is chosen, moderate to deep sedation is reasonable

Positioning

  • Semi-sitting upright, beach chair

Maintenance and surgical considerations

  • Maintainanence with volatile anesthetic supplemented with either regional or IV anesthetics/opioids
    • Maintenance of neuromuscular blockade
  • Maintain MAP within 20% of baseline to ensure adequate cerebral perfusion due to sitting position
  • Monitor hemodynamic changes or precordial doppler if used for VAE especially during placement of cement

Emergence

  • PONV prophylaxis
  • Possible delayed emergence if patient experienced CVA

Postoperative management

Disposition

  • PACU
  • Floor

Pain management

  • Pain is usually moderate to severe
    • Multimodal
      • PO/IV acetaminophen
      • PO/IV NSAIDs
      • PO gabapentin
      • PO/IV opioids
      • Regional

Potential complications

  • CVA
  • Bleeding
  • Infection
  • Brachial plexus nerve injury

Procedure variants

Total shoulder arthroplasty
Unique considerations
  • Sitting position
  • Methyl methacrylate cement can cause severe hypotension/VAE
Position Semi-sitting/beach chair
Surgical time 2-5 hours
EBL 200-1000 mL
Postoperative disposition Floor
Pain management moderate-severe
Potential complications
  • CVA
  • VAE
  • brachial plexus injury

References

  1. ↑ 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. ↑ 2.0 2.1 Anesthesiologist's manual of surgical procedures. Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu (Sixth edition ed.). Philadelphia. 2020. ISBN 978-1-4698-2916-6. OCLC 1117874404. |edition= has extra text (help)CS1 maint: others (link)

Top contributors: Cornel Chiu, Chris Rishel and Tony Wang

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