Position: Sitting / Beach Chair, Operative arm will be suspended and the non-operative arm will be secured to an arm-rest
Time: 1-2 hours (average)
Blood Loss: Moderate (50 – 200 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: Yes

Blocks: Interscalene

Positioning – In some cases, the surgeon will opt to do the case in the lateral position. See the post “Arthroscopy – Shoulder (Lateral)”.

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 chronic 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.

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.

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).