Shoulder arthroplasty

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
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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, and may be associated with avascular necrosis, rheumatoid arthritis (RA), trauma, or a rotator cuff tear.

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.

Preoperative management

Patient evaluation

System	Considerations
Neurologic	Baseline neurological exam Preexisting neuropathy especially with regional technique Increased risk of CVA if in beach chair position
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

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	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