Bring Out Your Beach Chairs
Anesthesia For Shoulder Surgery: Perspective From The Literature
The first joint arthroscopy was performed by Dr Severin Nordentoft of Denmark in 1912.1 However, the ubiquity of arthroscopic surgery took off only after the 1970s with the help of Drs Masaki Watanabe and Richard O’Connor. Initially solely a diagnostic modality, arthroscopy has blossomed as one of the most frequently performed interventions thanks in large part to advances in techniques and technology making outcomes comparable to open procedures.2–5 According to the 2006 National Survey of Ambulatory Surgery, ambulatory surgery procedures increased from 380,000 to 57.1 million between 1983 to 2006; of those, 530,000 were shoulder arthroscopies with or without rotator cuff repair.6
For select patients, arthroscopy has hastened the diagnosis, treatment, and recovery from surgical interventions of both major and minor joints.7 Despite being more technically challenging, arthroscopic surgery versus traditional arthrotomy offers lower cost, quicker discharge,8 more patients reporting improved pain control,9 and higher satisfaction scores.10 Moreover, when polled, patients refuse to have surgery unless it will use an arthroscopic approach.11
Traditionally, arthroscopic shoulder surgery is performed under GA in either the lateral decubitus or beach chair position. The beach chair position came into vogue in the 1980s. The position maintains anatomic orientation; provides the surgeon with rotational control of the upper extremity; offers excellent visualization of surrounding anterior, inferior, and superior glenohumeral structures, and subacromial space; reduces injuries to the brachial plexus; and presents ease of setup when compared with the lateral decubitus positioning. In the United States, two-thirds of the 530,000 shoulder surgeries are performed in the beach chair position.6
However, concerns were raised about developing devastating neurologic complications including stroke, spinal cord ischemia, and transient vision loss while in the beach chair position.11–13 Although the exact mechanism is not known, many speculate that it relates to loss of cerebral autoregulation, leading to cerebral hypoperfusion and ischemia during general anesthesia (GA). In patients anesthetized with volatile anesthetics, the autoregulatory response is blunted in a dosedependent manner, with the exception with sevoflurane at relevant doses.14 By measuring regional cerebral oxygenation, multiple studies demonstrated a correlation relating diminished cerebral autoregulation during GA; nevertheless, there was little to no evidence of causation of neurologic injury.13,15–17 Despite the fact that the transient intraoperative cerebral desaturation events (CDE) have not been shown to be associated with either postoperative cognitive dysfunction or levels of biomarkers of neuronal injury, and the degree and duration of cerebral ischemia required to produce neurocognitive dysfunction in this patient population remain undefined; there is a need for strict hemodynamic management with higher blood pressure in the upright position during general anesthesia.16
Although GA with or without regional anesthesia (RA) has been the popular practice for shoulder arthroscopy, well-placed RA alone might be sufficient to provide surgical anesthesia. RA has numerous advantages to GA for arthroscopic procedures, including intraoperative analgesia and muscle relaxation without systemic paralysis, avoiding airway manipulation, less hemodynamic variation, preservation of cerebral autoregulation, decreased postoperative nausea and vomiting by reducing systemic opioid administration, superior pain control in the postanethesia care unit (PACU), shorter operating room times, expedited time to discharge, reduced admission rates, and reduction of overall cost.18,19 Recently, Ende et al analyzed 169,878 shoulder arthroscopy records from January 2010 to December 2014 documented in National Anesthesia Clinical Outcomes Registry and discovered that 105,666 cases (62%) were performed under GA, 60,765 (36 %) with GA+RA, and only 3447 (2.0 %) under RA alone.20 This suggests that RA alone is still underutilized despite the advantages mentioned above.
Application Of Ra At Our Institution
In our institution, we hypothesized that the frequency of CDE can be significantly reduced by risk stratification and implementation of an anesthesia protocol based on patients’ risk category. In 2014, we tested the rate of the CDE in patients undergoing shoulder arthroscopy in the sitting position in 100 consecutive patients. CDE were more frequent in patients who received GA when compared with those who received RA only despite strict hemodynamic control in the GA group. However, this difference was not statistically significant. The result of this quality improvement project was a proposal that patients with the highest risk for cerebral desaturation events (Framingham criteria >10 or previous cerebrovascular accident) should be offered RA with or without sedation for shoulder surgery in the beach chair position as the first option. If GA is chosen, invasive monitors and a strict hemodynamic management protocol should be deployed.
We believe the underutilization of RA for shoulder arthroscopy procedure is likely due to concerns over sufficient intraoperative sensory coverage and airway management. We worked closely with our shoulder surgeons to implement a pilot project aiming to use RA as an alternative to GA in select high-risk patients. Initially, RA was reserved for patients who were at risk for stroke or compromised cerebral perfusion. As our group (anesthesiologists and surgeons) became more comfortable with RA for intraoperative anesthesia, we started to offer this technique to healthy patients.
We created patient educational material to teach patients about RA options for shoulder surgery. These educational brochures were made available at the surgeon’s office and were part of the surgery packet when the patient is scheduled for surgery. An online version of the education material was made available to patients in the waiting room during their clinic visits as well.
During the preoperative visit, surgeons would address expectations of the surgery, provide an overview of the anesthetic options, and direct patients to the Penn Medicine website, which outlines the two techniques: general as well as RA for orthopedic surgery. On the day of surgery, the anesthesia team approaches well-informed patients to confirm their choice and answer any last-minute questions. All patients scheduled for a arthroscopic shoulder surgery expect to have RA but are also given the choice between being “awake” or “sleepy with sedation” for their surgery. An ultrasound-guided interscalene nerve block is performed in the holding area, 20 to 30 minutes before the scheduled surgery. Intraoperatively, the awake and cooperative patient is easily seated in the beach chair position, absolving problems such as postural hypotension and improperly padded pressure points. A separate monitor is placed under the drape for the patient to view the surgery (Figure 1). Once the surgical field is draped, the surgeon assesses the adequacy of the block. In our practice, placement of the posterior (viewing) portal between the inferior edge of the infraspinatus and teres minor may be spared after interscalene block. A separate axillary nerve block typically addresses this area of discomfort if performed preoperatively or can simply be infiltrated by the surgeon prior to portal placement. Placement of the anterior superior portal (working portal) is generally well tolerated.
In patients who opt to stay awake during surgery, the surgeon evaluates the shoulder and discusses findings with the patient, diagnoses and treats the existing abnormalities, and alludes to postoperative expectations (rehabilitation, recovery, and use). Patients actively participating in their surgery express higher levels of satisfaction, report a better understanding of their procedure, and rarely complain of discomfort.
Patients make a seamless transition from the operating room to the PACU with minimal to no cognitive impairment often bypassing phase I recovery. Moreover, most are ready for discharge upon arrival into the PACU as they have already discussed the goals of care, have adequate pain control, and have negligible residual anesthetic or nausea, all of which are deterrents to discharge. The overwhelming majority of patients who undergo shoulder arthroscopy with minimal sedation and interscalene nerve block report high levels of satisfaction and would repeat the procedure in a similar fashion.
Two and half years ago, we instituted a multimodal perioperative pain protocol for patients undergoing ambulatory shoulder surgery. The main elements of the protocol (in addition to RA) are acetaminophen, gabapentin, short course of nonsteroidal anti-inflammatory drugs, and opioids as needed. Implementation of this protocol resulted in overall reduction in opioid consumption over the first 3 days after surgery, better quality of recovery, and higher patient satisfaction with their pain management. The results of this work were presented at the ASRA spring meeting in San Francisco, 2017.21
Continuous ambulatory perineural catheters are offered to select patients. This portion of our practice represents only 20% of our ambulatory surgical volume. Selection criteria include, but are not limited to: patients with chronic pain syndromes or increased analgesic requirements, patients scheduled for arthroscopic capsular release for adhesive capsulitis, and patients who are very sensitive to oral opioids. Patients who are discharged home with an ambulatory catheters should have adequate home support, be reliable, be accessible, and be able to understand and follow instructions.
We believe that a team approach and communication between perioperative care management team members are the key elements to success for implementation of any new care protocols.
1. Kieser CW, Jackson RW. Severin Nordentoft: the first arthroscopist. Arthroscopy. 2001;17(5):532-5.
2. Fabbriciani C, Milano G, Demontis A, Fadda S, Ziranu F, Mulas PD. Arthroscopic versus open treatment of Bankart lesion of the shoulder: a prospective randomized study. Arthroscopy. 2004;20:456-62.
3. Husby T, Haugstvedt JR, Brandt M, Holm I, Steen H. Open versus arthroscopic subacromial decompression: a prospective, randomized study of 34 patients followed for 8 years. Acta Orthop Scand. 2003;74:408-14.
4. Sauerbrey AM, Getz CL, Piancastelli M, Iannotti JP, Ramsey ML, Williams GR Jr. Arthroscopic versus mini-open rotator cuff repair: a comparison of clinical outcome. Arthroscopy. 2005;21:1415-20.
5. Severud EL, Ruotolo C, Abbott DD, Nottage WM. All-arthroscopic versus mini-open rotator cuff repair: a long-term retrospective outcome comparison. Arthroscopy. 2003;19:234-8.
6. Jain N. Epidemiology of musculoskeletal upper extremity ambulatory surgery in the United States. BMC Musculoskeletal Disord. 2014;15:4.
7. Cullen DJ, Kirby RR. Beach chair position may decrease cerebral perfusion: catastrophic outcomes have occurred. APSF Newsletter. 2007;22(2):25.
8. Buess E. Open versus arthroscopic rotator cuff repair: a comparative view of 96 cases. Arthroscopy. 2005;21:597-604.
9. Wang C, Ghalambor N, Zarins B, Warner JJP. Arthroscopic versus open Bankart repair: analysis of patient subjective outcome and cost arthroscopy. 2005;21:1219-22.
10. Buess E, Steuber KU, Waibl B. Open versus arthroscopic rotator cuff repair: a comparative view of 96 cases. Arthroscopy. 2005;21:597-604.
11. Sperling JW. Patient perceptions of open and arthroscopic shoulder surgery. Arthroscopy. 2007;23(4):361-6.
12. Weber SC, Abrams JS, Nottage WM. Complications associated with arthroscopic shoulder surgery. Arthroscopy. 2002;18:88-95.
13. Pohl A, Cullen DJ. Cerebral ischemia during shoulder surgery in the upright position: a case series. J Clin Anesth. 2005;17:463-9.
14. Soeding PF. The effect of the sitting upright or “beachchair” position on cerebral blood flow during anaesthesia for shoulder surgery. Anaesth Intensive Care. 2011;39(3):440-8.
15. Dagal A, Lam AM. Cerebral autoregulation and anesthesia. Curr Opin Anaesthesiol. 2009;22(5):547-52.
16. Laflam A. Shoulder surgery in the beach chair position is associated with diminished cerebral autoregulation but no differences in postoperative cognition or brain injury biomarker levels compared with supine positioning: the anesthesia patient safety foundation beach chair study. Anesth Analg. 2015;120(1):176-85.
17. Yadeau JT, Casciano M, Liu SS, et al. Stroke, RA in the sitting position, and hypotension: a review of 4169 ambulatory surgery patients. Reg Anesth Pain Med. 2011;36:430-5.
18. Brown AR, Weiss R, Greenberg C, et al. Interscalene block for shoulder arthroscopy: comparison with general anesthesia. Arthroscopy. 1993;9:295-300.
19. Gonano C, Kettner SC, Ernstbrunner M, et al. Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery. Br J Anaesth. 2009;103:428-33.
20. Ende D, Gabriel RA, Vlassakov KV, Dutton RP, Urman RD. Epidemiologic data and trends concerning the use of regional anesthesia for shoulder arthroscopy in the United States of America. Int Orthop. 2016 Oct;40(10):2105-13.
21. Wang A, Kuntz A, Liu J, Mattera M, Elkassabany N. Improved quality of recovery from ambulatory shoulder surgery after implementation of a multimodal perioperative pain management protocol. Poster presented at the 42nd Annual Regional Anesthesiology and Acute Pain Medicine Meeting; April 6–8, 2017; San Francisco, CA.