Patterns of intra-arterial blood pressure monitoring for patients undergoing total shoulder arthroplasty under general anesthesia: a retrospective analysis of 23,073 patients


Total shoulder arthroplasty (TSA) is typically performed in the beach-chair position. Maintenance of adequate mean arterial pressure is required to provide appropriate cerebral perfusion pressure and prevent cerebral ischemia. Placement of an arterial line to facilitate invasive monitoring is discretionary, based on clinical judgment. We aimed to describe patient, surgical and institutional factors associated with the current use of blood pressure monitoring via an arterial line for TSA. We used de-identified patient data from the National Anesthesia Clinical Outcomes Registry between 2010 and 2015 to identify patients undergoing TSA under general anesthesia. We conducted a multivariable logistic regression model to demonstrate factors significantly associated with arterial line placement. We report results as odds ratios (OR) with their associated 95 % confidence intervals (CI). Of 23,073 patients undergoing TSA under general anesthesia, 443 (1.92 %) had intra-arterial blood pressure monitoring. Patient age over 65 years old (OR 1.74, CI 1.37–2.21), congestive heart failure (OR 7.09, CI 2.63–19.14) and surgery lasting at least 180 min (OR 4.10, CI 3.33–5.05) were all associated with increased odds for arterial line placement. Compared to university hospitals, arterial line placement was more likely in attached or freestanding surgical centers (OR 2.01, CI 1.37–2.96) and less likely in medium sized community hospitals (OR 0.62, CI 0.42–0.93), small community hospitals (OR 0.11, CI 0.03–0.34) and facilities performing less than 100 TSAs per year (OR 0.19, CI 0.12–0.31). Utilization of arterial line monitoring for TSA has associations with both institutional and patient factors. This study demonstrates the national patterns for the use of arterial lines for TSA and may serve as a resource to aid in clinical judgment.

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  1. 1.

    Scheer B, Perel A, Pfeiffer UJ. Clinical review: complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care. 2002;6(3):199–204.

    Article  PubMed Central  PubMed  Google Scholar 

  2. 2.

    Milzma DJT. Arterial puncture and cannulation. Clinical procedures in emergency medicine. Philidelphia: W.B. Saunders; 2004.

    Google Scholar 

  3. 3.

    Larsen SL, Lyngeraa TS, Maschmann CP, Van LieshoutJJ, Pott FC. Cardiovascular consequence of reclining versus sitting beach-chair body position for induction of anesthesia. Front Physiol. 2014;5:187. doi:10.3389/fphys.2014.00187.

    Article  PubMed Central  PubMed  Google Scholar 

  4. 4.

    Pant S, Bokor DJ, Low AK. Cerebral oxygenation using near-infrared spectroscopy in the beach-chair position during shoulder arthroscopy under general anesthesia. Arthroscopy. 2014;30(11):1520–7. doi:10.1016/j.arthro.2014.05.042.

    Article  PubMed  Google Scholar 

  5. 5.

    Laflam A, Joshi B, Brady K, Yenokyan G, Brown C, Everett A, Selnes O, McFarland E, Hogue CW. 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. doi:10.1213/ane.0000000000000455.

    Article  PubMed Central  PubMed  Google Scholar 

  6. 6.

    Lapage KG, Wouters PF. The patient with hypertension undergoing surgery. Curr Opin Anaesthesiol. 2016. doi:10.1097/aco.0000000000000343.

    PubMed  Google Scholar 

  7. 7.

    Salazar D, Sears B, Acosta A, Aghdasi B, Francois A, Tonino P, Marra G. Effect of head and neck positioning on cerebral perfusion during shoulder arthroscopy in beach chair position. J Surg Orthop Adv. 2014;23(2):83–9.

    Article  PubMed  Google Scholar 

  8. 8.

    Pin-on P, Schroeder D, Munis J. The hemodynamic management of 5177 neurosurgical and orthopedic patients who underwent surgery in the sitting or “beach chair” position without incidence of adverse neurologic events. Anesth Analg. 2013;116(6):1317–24. doi:10.1213/ANE.0b013e31828446bb.

    Article  PubMed  Google Scholar 

  9. 9.

    Pohl A, Cullen DJ. Cerebral ischemia during shoulder surgery in the upright position: a case series. J Clin Anesth. 2005;17(6):463–9. doi:10.1016/j.jclinane.2004.09.012.

    Article  PubMed  Google Scholar 

  10. 10.

    So J, Shin WJ, Shim JH. A cardiovascular collapse occurred in the beach chair position for shoulder arthroscopy under general anesthesia -A case report. Korean J Anesthesiol. 2013;64(3):265–7. doi:10.4097/kjae.2013.64.3.265.

    Article  PubMed Central  PubMed  Google Scholar 

  11. 11.

    Liau A, Havidich JE, Onega T, Dutton RP. The national anesthesia clinical outcomes registry. Anesth Analg. 2015;121(6):1604–10. doi:10.1213/ANE.0000000000000895.

    Article  PubMed  Google Scholar 

  12. 12.

    Yadeau JT, Casciano M, Liu SS, Edmonds CR, Gordon M, Stanton J, John R, Shaw PM, Wilfred SE, Stanton M. Stroke, regional anesthesia in the sitting position, and hypotension: a review of 4169 ambulatory surgery patients. Reg Anesth Pain Med. 2011;36(5):430–5. doi:10.1097/AAP.0b013e318228d54e.

    Article  PubMed  Google Scholar 

  13. 13.

    Janssen H, Stosch R, Poschl R, Buttner B, Bauer M, Hinz JM, Bergmann I. Blood pressure response to combined general anaesthesia/interscalene brachial plexus block for outpatient shoulder arthroscopy. BMC Anesthesiol. 2014;14:50. doi:10.1186/1471-2253-14-50.

    Article  PubMed Central  PubMed  Google Scholar 

  14. 14.

    Cunningham AJ. Controlled hypotension to minimize blood loss of anaemic Jehovah’s witness patient undergoing total hip and shoulder replacement. Br J Anaesth. 1982;54(8):895–8.

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    Nielsen HB. Systematic review of near-infrared spectroscopy determined cerebral oxygenation during non-cardiac surgery. Front Physiol. 2014;5:93. doi:10.3389/fphys.2014.00093.

    Article  PubMed Central  PubMed  Google Scholar 

  16. 16.

    Rooke GA. Autonomic and cardiovascular function in the geriatric patient. Anesthesiol Clin North Am. 2000;18(1):31–46.

    CAS  Article  Google Scholar 

  17. 17.

    El Beheiry H, Mak P. Effects of aging and propofol on the cardiovascular component of the autonomic nervous system. J Clin Anesth. 2013;25(8):637–43. doi:10.1016/j.jclinane.2013.07.004.

    Article  PubMed  Google Scholar 

  18. 18.

    Hammill BG, Curtis LH, Bennett-Guerrero E, O’Connor CM, Jollis JG, Schulman KA, Hernandez AF. Impact of heart failure on patients undergoing major noncardiac surgery. Anesthesiology. 2008;108(4):559–67. doi:10.1097/ALN.0b013e31816725ef.

    Article  PubMed  Google Scholar 

  19. 19.

    Fonseca-Reyes S, de Alba-Garcia JG, Parra-Carrillo JZ, Paczka-Zapata JA. Effect of standard cuff on blood pressure readings in patients with obese arms. How frequent are arms of a ‘large circumference’? Blood Press Monit. 2003;8(3):101–6. doi:10.1097/01.mbp.0000085763.28312.03.

    Article  PubMed  Google Scholar 

  20. 20.

    Marks LA, Groch A. Optimizing cuff width for noninvasive measurement of blood pressure. Blood Press Monit. 2000;5(3):153–8.

    CAS  Article  PubMed  Google Scholar 

  21. 21.

    Prineas RJ. Measurement of blood pressure in the obese. Ann Epidemiol. 1991;1(4):321–36.

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Jo YY, Jung WS, Kim HS, Chang YJ, Kwak HJ. Prediction of hypotension in the beach chair position during shoulder arthroscopy using pre-operative hemodynamic variables. J Clin Monit Comput. 2014;28(2):173–8. doi:10.1007/s10877-013-9512-z.

    Article  PubMed  Google Scholar 

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Rodney A. Gabriel has funding support from National Library of Medicine (NLM), Training Grant Number T15LM011271.

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Correspondence to Richard D. Urman.

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Institutional Review Board approval was obtained for analysis of the data and was exempted from the consent requirement due to the de-identified nature of the data. The authors do not know of any ethical issues to declare.

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The authors declare that they have no conflicts of interest.

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Gabriel, R.A., Beverly, A., Dutton, R.P. et al. Patterns of intra-arterial blood pressure monitoring for patients undergoing total shoulder arthroplasty under general anesthesia: a retrospective analysis of 23,073 patients. J Clin Monit Comput 31, 877–884 (2017).

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  • Total shoulder arthroplasty
  • Beach chair
  • Arterial line
  • Invasive blood pressure monitoring
  • Non-invasive blood pressure monitoring