Difference between revisions of "Shoulder arthroplasty"

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| 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
| considerations_preoperative =  
| considerations_preoperative = Type and screen, airway and neurologic physical examination
| considerations_intraoperative = Optimal BP management for cerebral perfusion, VAE
| considerations_intraoperative = Optimal BP management for cerebral perfusion, VAE
| considerations_postoperative = Cerebrovascular accident
| considerations_postoperative = Cerebrovascular accident
}}
}}


Shoulder arthroplasty is a surgical procedure involved with removal of the head of the humerus and replacement with a prosthesis. Indication includes pain associated with severe osteoarthritis. Patients experiences diagnosis of avascular necrosis, rheumatoid arthritis, 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. 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>


== Preoperative management ==
== Preoperative management ==
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|-
|-
|Cardiovascular
|Cardiovascular
|
|Assess for valvular, conduction, and pericardial disease
|-
|-
|Respiratory
|Respiratory
|
|Assess for pleural effusions, pulmonary fibrosis, involvement of cricoarytenoids, andTMJ due to RA
|-
|Gastrointestinal
|
|-
|-
|Hematologic
|Hematologic
|
|Assess for chronic anemia
|-
|Renal
|
|-
|-
|Endocrine
|Endocrine
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* Type and screen  
* Type and screen  
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. 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. --> ===
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
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* 5-lead EKG  
* 5-lead EKG  
* PIV x 1-2 (opposite limb, large bore)
* 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  
* Consider precordial doppler given the risk of venous air embolism in the semi-sitting/beach chair position  


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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


=== 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. --> ===
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!
!
!Total shoulder arthroplasty
!Total shoulder arthroplasty
!Reverse Shoulder Arthroplasty
|-
|-
|Unique considerations
|Unique considerations
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* Sitting position  
* Sitting position  
* Methyl methacrylate cement can cause severe hypotension/VAE
* Methyl methacrylate cement can cause severe hypotension/VAE
|
|-
|-
|Position
|Position
|Semi-sitting/beach chair
|Semi-sitting/beach chair
|
|-
|-
|Surgical time
|Surgical time
|2-5 hours
|2-5 hours
|
|-
|-
|EBL
|EBL
|200-1000 mL
|200-1000 mL
|
|-
|-
|Postoperative disposition
|Postoperative disposition
|Floor
|Floor
|
|-
|-
|Pain management
|Pain management
|moderate-severe
|moderate-severe
|
|-
|-
|Potential complications
|Potential complications
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* VAE
* VAE
* brachial plexus injury
* brachial plexus injury
|
|}
|}


Revision as of 13:14, 21 January 2022

Shoulder arthroplasty
Anesthesia type

General

Airway

ETT

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. 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 [1]

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 a supplement to general

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

Positioning

  • Semi-sitting upright, beach chair
  • Table turned 90o

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 for hemodynamic changes associated with VAE especially during use 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. ↑ 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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