Shoulder surgery

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Shoulder Surgery

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Introduction

  • Arthroscopic or open shoulder procedures generate some of the highest early postoperative pain scores in orthopaedics; pain is greatest in the first 24–48 h but may persist for several days.
  • Patient positioning (beach-chair or lateral decubitus) places the head away from the anaesthetist and necessitates meticulous airway security, long breathing circuits and extended IV tubing.

Pre-operative Assessment

Issue Relevance Actions
Comorbidities Rheumatoid arthritis (cervical instability), COPD/OSA, obesity, cardiac disease Optimise cardio-respiratory status; discuss phrenic-sparing block if limited reserve
Antithrombotics Regional anaesthesia & postoperative VTE prophylaxis planning Follow latest ASRA 5th-edition antiplatelet/anticoagulant guidelines
Regional consent Explain expected arm weakness, potential diaphragmatic paresis & rebound pain Provide written information; outline rescue analgesia plan
Beach-chair risks Cerebral desaturation, hypotensive-bradycardic events (HBEs) Advise arterial line transduction at external auditory meatus for high-risk cases

Conduct of Anaesthesia

Airway & Vascular Access

  • Secure airway before positioning; south-facing armoured tube preferred for prolonged cases.
  • Place wide-bore IV (contralateral arm) with 100 cm extension; consider second IV or arterial line for steep head-up tilt.

Anaesthetic Technique

Component Recommendation
GA TIVA with propofol–remifentanil minimises cerebral autoregulatory impairment; remimazolam reduces hypotension on transition to beach-chair.
Regional See below; combine with light GA or sedation for patient comfort and airway control.
Haemodynamics Maintain brain-level MAP ≥ 70 mmHg (transducer at tragus); treat HBEs promptly with ephedrine/atropine.
Venous air embolism (VAE) Rare but catastrophic; keep irrigation pumps < 50 mmHg, avoid air insufflation and monitor EtCO₂ for sudden drops.]

Beach-chair Physiology

  • CNS: 1 cm elevation of the head ≈ 0.75 mmHg fall in MAP; near-infrared spectroscopy (NIRS) detects cerebral desaturation events (CDEs) that occur in up to 56 % of cases under GA but seldom translate into stroke when MAP targets are respected.
  • CVS: Venous pooling → ↓ preload, CO and CPP; mitigate with leg compression, slight hip-knee flexion, judicious fluids and vasopressors.
  • Respiratory: FRC rises, but airway displacement risk increases—confirm tube position after final head-neck adjustment.

Regional Anaesthesia

Technique Analgesia Quality Diaphragm Involvement Key Evidence
Interscalene block (ISB) 15–20 mL 0.5 % ropivacaine Gold-standard analgesia; lowest PACU opioid use 70–100 % hemidiaphragmatic paresis Urmey 1991; many RCTs
Superior trunk block (STB) 5–10 mL around C5-C6 trunk Non-inferior pain scores & opioid consumption 0–15 % paresis 2023 meta-analysis of 4 RCTs (RR 0.07 for paresis)
Suprascapular + axillary (SSNB + ANB) 8–10 mL + 5 mL Equivalent 24 h pain, higher intra-op opioid than ISB < 5 % paresis 2023 3-arm RCT (n = 118)
Continuous interscalene catheter Longer analgesia (48 h); ↓ sleep disturbance Same diaphragmatic effect as single-shot 2019 review
  • Block selection guidance
    • Normal pulmonary reserve: ultrasound-guided ISB (15 mL).
    • Limited reserve (COPD, obesity, contralateral phrenic palsy): STB (8 mL 0.5 % ropivacaine) or combined SSNB + ANB.
    • Anticoagulated patients: consider landmark-guided surgeon-delivered SSNB + ANB intra-articularly.

Post-operative Analgesia

Time-frame Recommended Regimen
PACU (0–6 h) Paracetamol 1 g IV; dexamethasone 8 mg IV; ondansetron 4 mg IV; ketorolac 0.5 mg kg⁻¹ IV if not contra-indicated
24 h Continue paracetamol 1 g 6-hourly; NSAID 8-hourly; rescue oral oxycodone 0.05 mg kg⁻¹; consider gabapentin 300 mg nocte for high opioid tolerance
Catheter techniques Continuous ISB: ropivacaine 0.2 % 5 mL h⁻¹ with 5 mL bolus q30 min; Subacromial catheter: 10 mL 0.25 % bupivacaine q4 h equally effective in rotator cuff repair

Early mobilisation with the elbow supported reduces swelling and improves analgesia. Educate patients about block resolution and rebound pain; supply rescue analgesics before discharge.

Complications & Prevention

Complication Prevention
Cerebral desaturation / stroke Maintain brain-level MAP ≥ 70 mmHg; NIRS monitoring; avoid excessive head flexion
Hypotensive-bradycardic events Adequate preload; avoid large propofol/dexmedetomidine boluses; atropine/ephedrine ready
Hemidiaphragmatic paresis Use STB or SSNB + ANB in high-risk lungs
VAE Limit arthroscopic pump pressures; avoid air; monitor EtCO₂
Nerve & pressure injuries Pad head, arms, ischial tuberosities; minimise neck rotation; arms in padded gutters

Links

References:

  1. Hewson, D. W., Oldman, M., & Bedforth, N. (2019). Regional anaesthesia for shoulder surgery. BJA Education, 19(4), 98-104. https://doi.org/10.1016/j.bjae.2018.12.004
  2. Beecroft, C. and Coventry, D. (2008). Anaesthesia for shoulder surgery. Continuing Education in Anaesthesia Critical Care &Amp; Pain, 8(6), 193-198. https://doi.org/10.1093/bjaceaccp/mkn040
  3. Amaral S, Lombardi RA, Medeiros H, et al. Superior trunk block as a phrenic-sparing alternative to interscalene block: systematic review and meta-analysis. Cureus. 2023;15:e48217. pubmed.ncbi.nlm.nih.gov
  4. Kim DH, Lin Y, Beathe JC, et al. Superior trunk block versus interscalene block for shoulder surgery: randomised trial. Anesthesiology. 2019;131:521-533. pubmed.ncbi.nlm.nih.gov
  5. Boekel P, Brereton SG, Doma K, et al. Surgeon-directed suprascapular + axillary nerve blocks versus interscalene block: 3-arm RCT. JSES Int. 2023;7:307-315. pubmed.ncbi.nlm.nih.gov
  6. O’Neill CN, McFarland K, Bowyer A, et al. No increased risk of cerebrovascular accident with beach-chair versus lateral positioning for shoulder arthroscopy. Arthrosc Sports Med Rehabil. 2023;5:100826. pmc.ncbi.nlm.nih.gov
  7. Gould HP, Yadeau JT, Fields KG, et al. Risk of intra-operative cerebral oxygen desaturation in beach-chair shoulder surgery. Clin Orthop Relat Res. 2021;479:2680-2694. pubmed.ncbi.nlm.nih.gov
  8. Hong JY, Choi SJ, Park K, et al. Risk factors for hypotensive-bradycardic events during shoulder arthroscopy in sitting position. Korean J Anesthesiol. 2020;73:201-208. ekja.org
  9. ee MG, Shin YJ, You HS, et al. Effects of low-volume superior trunk block on diaphragmatic function. Anesth Analg. 2021;133:1303-1310. pubmed.ncbi.nlm.nih.gov
  10. Urmey WF, Talts KH, Sharrock NE. Hemidiaphragmatic paresis after interscalene block diagnosed by ultrasound. Anesth Analg. 1991;72:498-503. (Historical reference for 100 % paresis with ISB).

Summaries:

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© 2025 Francois Uys. All Rights Reserved.

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