Position: Lateral
Time: 1-2 hours (average)
Blood Loss: Low (10-50 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: Yes

Blocks: Interscalene, Supraclavicular

Lateral position vs Beach chair – The lateral position will have far less effect on hemodynamics vs positional hypotension seen with the beach chair position. However, keep in mind the general considerations of this position as mentioned below.

Interscalene block – Bradycardia and hypotension can be more pronounced with an interscalene block (particularly right-sided) and use of fentanyl. Many suggest the use of a short acting beta blocker such as esmolol prior to intubation. The short half life of esmolol will blunt the sympathetic response to intubation, while not having the chronic hypotensive effects of fentanyl.

Supraclavicular block – this is a possibility but may have “spotty” coverage of the proximal upper arm.

IV – One 20g IV in the contralateral arm is usually sufficient for this case.

Lateral position (general considerations): If an ETT has been placed, make sure ETT is secure with extra tape.  Unhook anesthesia circuit while turning lateral and be especially careful to keep patient’s head neutral and aligned with body to avoid neck injury. Once lateral, use pillows/blankets/foam headrest to keep the patient’s head in neutral position. The most common nerve injury for orthopedic lateral procedures are neurapraxias of the brachial plexus. These are motor and/or sensory loss for 6-8 weeks due to pressure on the contralateral (dependent) axilla. To prevent this, place an axillary roll under the patient (caudad to the axilla, on the rib cage, and NOT in the axilla). Check routinely to make sure the axillary roll does not migrate into the axilla. If the non-dependent arm is placed on a board, check padding and reposition regularly to avoid radial nerve compression. If a bean bag is employed, check the hard edges to ensure that unnecessary pressure isn’t being put on soft tissues. Pad all dependent bony prominences such as the fibular head (to prevent peroneal nerve injury), and place pillows between the knees and ankles (to prevent saphenous nerve injury). If anterior hip supports are in place, ensure they are properly padded or neuropraxias and/or occlusions of large blood vessels may result.

Lateral arthroscopic shoulder surgery is performed to diagnose and treat shoulder problems. Some procedures that can be performed under arthroscopy include rotator cuff repair, synovectomy, loose body removal, subacromial space decompression, distal clavichord resection, chondroplasty, or slap repair (torn labrum).