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

Blocks: Interscalene, Supraclavicular

Bradycardia and Hypotension – 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 ongoing hypotensive effects of fentanyl.

Non-operative side – Pulse oximeter and blood pressure cuff should be positioned on the non-operative side. Recommended to tape the tube on the non-operative side to keep it out of the surgical field and avoid accidental disconnection during the case.

Blocks – Interscalene is the most common. Supraclavicular block is possible but the coverage of the proximal upper arm will be weak/spotty.

Non-operative side – Pulse oximeter and blood pressure cuff should be positioned on the non-operative side. Recommended to tape the tube on the non-operative side to keep it out of the surgical field and avoid accidental disconnection during the case.

Blood loss – No tourniquet will be used. Blood loss is typically not a big concern for these cases, but it is something to be aware of.

IV placement – a single 20g IV in the opposite arm is typically 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.

Beach Chair/sitting position (general considerations): When putting the patient in this position, the staff will typically help lift the patient and exchange the head rest after intubation. Once the headrest is secured, the patient will be lifted to the sitting position. At this junction, make sure the circuit is disconnected and the ETT is free – this could easily extubate the patient if the ETT is still attached when lifting the patient. The degree of hemodynamic changes depends on the angle. If sitting at 45 degrees there will be minimal changes, whereas 90 degrees will reduce cardiac output by 20% (due to venous pooling in the legs). SVR will be 15-20 mm Hg lower at the circle of willis than at the cuff, which may compromise cerebral perfusion. Consider having ready ephedrine and phenylephrine to support blood pressures. For higher risk patients requiring an A-line, it is recommended to place the transducer at the level of the brain (level the transducer at the tragus). Make sure the head is in a neutral position (looking straight ahead and void of flexion/extension).

Rotator cuff repair is typically performed 3 ways: open, mini-open, or by arthroscopy. In all methods the goal is to reattach the tendon to where it originally tore from the bone. This is done by suturing the tendon and inserting anchors into the bone to re-secure the tendon.