Shoulder arthroplasty
Anesthesia type

General and/or regional



Lines and access

PIV in opposite limb


Standard 5-lead ECG Temperature

Primary anesthetic considerations

Type and screen Airway and neurologic physical examination Note baseline MAPs


Maintain cerebral perfusion (MAP ±20% of baseline) VAE


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[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
  • 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
  • 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


  • 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


  • PONV prophylaxis
  • Consider cerebral infarction if delayed emergence

Postoperative management


  • 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


  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 (6 ed.). Philadelphia. 2020. ISBN 978-1-4698-2916-6. OCLC 1117874404.CS1 maint: others (link)