Shoulder arthroplasty

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
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Editor rating	Comprehensive
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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 . 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

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