ARTHROSCOPY- SHOULDER

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Shoulder arthroscopy is a minimally invasive surgical procedure used to examine, diagnose, and treat various conditions within the shoulder joint. An arthroscope, a small camera attached to a thin, flexible tube, is inserted through a small incision in the skin, allowing the surgeon to visualize the joint and surrounding structures on a monitor. This procedure is performed under general or regional anesthesia, depending on the patient and the specific condition being treated.

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The recovery process after shoulder arthroscopy varies depending on the specific procedure performed and the patient's individual condition. Generally, patients can expect to wear a sling for a few weeks, followed by a gradual return to normal activities. Physical therapy is often recommended to help restore strength, flexibility, and range of motion.

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Some common reasons for shoulder arthroscopy include:

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1. Rotator cuff repair: Tears in the rotator cuff can be repaired using arthroscopic techniques, which are less invasive and have shorter recovery times compared to open surgery.

2. Labral repair: The labrum is a ring of cartilage that surrounds the shoulder socket, providing stability to the joint. Labral tears can cause pain and instability and can be repaired using arthroscopy.

3. Bone spur removal: Bone spurs, or osteophytes, can develop around the shoulder joint and cause pain and inflammation. They can be removed arthroscopically.

4. Debridement: This involves the removal of damaged tissue, such as loose cartilage or inflamed synovium, to alleviate pain and improve joint function.

5. Frozen shoulder (adhesive capsulitis) treatment: In some cases, arthroscopy can be used to release tight or scarred joint capsule tissue, improving shoulder mobility.

6. Stabilization: For patients with shoulder instability or recurrent dislocations, arthroscopic surgery can be used to tighten or repair damaged ligaments.

                                                                                                 

                                                                Anesthetic Implications for Shoulder Arthroscopy

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Anesthesia type: General ETT, LMA, or peripheral nerve block 

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Airway: Endotracheal tube or LMA

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Preoperative:

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• Patients may have osteoarthritis or rheumatoid arthritis

• Shoulder conditions may result from either arthritis or trauma

• Arthritic patients may have pleural effusion or pulmonary fibrosis

• Arthritic patients may have valvular heart disease and cardiac conduction defects

• Arthritic patients may have cervical or lumbar radiculopathies

• Arthritic patients may have limited neck and jaw range of motion

• Rheumatoid arthritis can be associated with cervical nerve root compression and/or atlantooccipital instability

• Check neck X-ray for subluxation of the cervical spine

• Shoulder dislocations can be accompanied by axillary nerve palsy

• Combined regional-general anesthetic techniques are commonly used

• An interscalene block is commonly performed 

• Assess the quality of the block by asking the patient to lift the arm

• Place IVs and the blood pressure cuff on the nonoperative arm

• During positioning, careful attention during the stabilization of the patient's head

• It may be difficult to access the patient's face after the drapes are up. Tape ETT securely

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Intraoperative:

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• Interscaleene block may be associated with phrenic nerve palsy and ipsilateral hemidiaphragmatic paresis

• Postural hypotension is a common complication of the sitting position

• Position: beach-chair position or lateral decubitus position is used 

• The bed is positioned 45-90 degrees away from the anesthetist

• Keep MAP within 20% of the patient's baseline

• The blood pressure (BP) measured in the arm will be higher than the BP in the brain

• Beach chair position may decrease cerebral perfusion

• Hydrostatic gradient: There is a 0.77 mmHg decrease for every centimeter gradient (1 mmHg for each 1.25 cm change in height between heart and head)

• Duration: 1-3 hours

• EBL: 50-100 ml

• The Bezold-Jarisch reflex (profound bradycardia and hypotension) may be activated during shoulder surgery in the beach-chair position

 

Postoperative:

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• Multimodal analgesia

• Patients should remain anesthetized until the shoulder is immobilized (sling placement)

• Pain following shoulder surgery may be severe

• Interscalene brachial plexus block may be used to reduce postoperative pain

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Complications:

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• Infection

• Bleeding

• Nerve or blood vessel damage

• Venous air embolism (VAE)

• Stroke

• Hypotension

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Sources:

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Christina L. Beecroft, FRCA, FDS RCS, David M. Coventry, FRCA, Anaesthesia for shoulder surgery, Continuing Education in Anaesthesia Critical Care & Pain, Volume 8, Issue 6, December 2008, Pages 193–198, https://doi.org/10.1093/bjaceaccp/mkn040

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David J. Cullen, MD; Robert R. Kirby, MD. Beach chair position may decrease cerebral perfusion. Anesthesia Patient Safety Foundation. Retrieved from https://www.apsf.org/article/beach-chair-position-may-decrease-cerebral-perfusion/

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Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. 

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Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). 

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Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.

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