Salient points in the history in patients who are presumed to be healthy is to identify any as-yet undetected illnesses which could have an adverse affect on the forthcoming surgery and peri-operative care. The history should focus on the indication for surgical procedures, allergies, and undesirable side-effects to medications or other agents, known medical problems, surgical history, major trauma, and current medications.

Common conditions which can affect peri-operative care include ischaemic heart disease, congestive cardiac failure, chronic respiratory disease, diabetes mellitus and liver or renal dysfunction [3]. As anaesthetic drugs can have pronounced adverse effects on cardiovascular and respiratory systems, it is worthwhile enquiring about chest pain, dyspnoea, ankle swelling and palpitations. The presence of a cough, sputum production and any indication of airway obstruction will provide invaluable information. An excellent indicator of cardiorespiratory function is tolerance of exercise [4]. A smoking history should also be taken as smokers are difficult to anaesthetise due to their upper airways being sensitive to the dry gases used during anaesthesia, and their risk of hypoxia is greater. Assessment and documentation of alcohol intake is required, as induction of liver enzymes by alcohol may shorten the action of anaesthetic drugs and may identify the risk of potential alcohol withdrawal. The use of recreational drugs such as intravenous opiates should also be recognised, as such patients may have poor venous access, may be at risk of septicaemia, and may pose a risk to the surgical team. Patients on long term steroids require adequate cover intra-operatively in order to avoid a hypotensive crisis [4].

In elective shoulder surgery, a detailed history is important not only in arriving at the correct diagnosis, but also in decision-making between the clinician and patient. The history may be considered one of the most valuable yet least effectively used tools in clinical medicine [5]; and poor history taking and physical examination may lead to both inappropriate diagnostic testing and surgery. Patients with shoulder pathology usually present with pain and/or loss of function, which should be explored along with the patient’s premorbid status and demands, and the likely functional demands aimed for in the future. A comprehensive interview regarding the patient’s pain and functional deficit is required, exploring components such as site, onset, duration, character and radiation of the pain, including features of neural irritation. The degree of dysfunction should also be clarified and how this impacts on the patient and their activities of daily living (ADL), especially as lower pre-operative ADL measurements have been associated with higher post-operative mortality in patients undergoing elective orthopaedic surgery [6]. Table 1 below displays how shoulder function can be assessed [5].

A general systems examination is performed to identify abnormalities of the cardiorespiratory system which would require further assessment. In particular, cardiac murmurs, additional heart sounds, and abnormal chest signs in patients with no previously documented pathology require investigation and/or referral to an appropriate specialist. Review of the gastrointestinal (GI) system identifies any abdominal masses and previous surgical scars. Skeletal malformations such as kyphoscoliosis can be detected on examining the musculoskeletal system. Local skin abnormalities should be documented and any issues should be highlighted to the surgical team.

Observations including heart rate and blood pressure are recorded. Brief examination of the airway provides valuable information regarding the feasibility of intubation. Several factors must be considered when assessing the airway. These include whether the patient is obese, has a short neck and small mouth, or whether or not there is any soft tissue swelling at the back of the mouth or if there are any constraints to neck flexion or extension. Cervical spine stiffness should be followed up with a plain radiograph to aid the anaesthetic team in decision-making regarding intubation.

Specific examination of the shoulder involves inspection, palpation, movement and special tests which may be able to narrow down the diagnosis. Previous scars, skin abnormalities, erythema, bruising and shoulder symmetry are to be noted on inspection [5]. Palpation of the shoulder should reveal any specific tenderness around the joint, in addition to crepitus, especially with movement. Passive and active range of movement should then be assessed, comparing both sides.

Special tests of shoulder joint function involve Hawkins test for subacromial impingement, with the humerus abducted to 90 degrees and 30 degrees anteriorly in the line of the scapula. The elbow is then flexed to 90 degrees and the glenohumeral joint internally rotated. Pain constitutes a positive test. This test has a sensitivity of 91–92% and specificity of 25–43% [7]. The empty can test can also be used for detecting a torn rotator cuff, specifically for a supraspinatus tear. Pain and/or weakness signify a positive test when the patient resists a downward pressure with the arm in 90 degrees of abduction in the plane of the scapula. Sensitivity for this test is 18.7% with specificity being 100% [7]. The apprehension test can be used to test for anterior shoulder instability, following anterior shoulder dislocation and subluxation, with a sensitivity of 91.9% and specificity of 88.9%. The active compression test (O’Brien’s test) for acromioclavicular joint (ACJ) arthritis and labral pathology can also be utilised. With the arm flexed to 90 degrees and the elbow fully extended, the arm is then adducted about 15 degrees medially. The arm is internally rotated so that the thumb points to the floor, the patient then resists the downward force applied by the clinician. The arm is then supinated so the palm is facing upward and resisting another downward force. The test is positive and diagnostic of ACJ pathology if pain is elicited over the ACJ or on top of the shoulder in the thumb down position and reduced or eliminated in the palm up position. Sensitivity for this test is 100% with specificity of 96.6% [7].

Most patients admitted for elective surgery undergo a range of routine pre-operative tests. Some of these tests are guided by the patient’s clinical needs, whilst others are done as a matter of routine. The purposes of routine pre-operative tests are to assess whether the patient may have any pre-existing health problems, to identify any medical conditions unknown to the patient, the prediction of post-operative complications and the establishment of a reference for comparisons [8] if tests need to repeated at a later date.

Monitoring of patients allows routine data to be collated and trends established, therefore making it more straightforward to detect any clinical deterioration. It also allows a patient’s response to treatment to be evaluated. Common parameters include temperature, pulse rate, blood pressure, respiratory rate, urine output, peripheral oxygen saturation and pain scores [2].

These variables should be measured multiple times during the day, depending on the type of surgery involved. Other examples of monitoring include ECGs, arterial blood gas analysis (ABGs) and central venous pressure (CVP) monitoring [23]. In addition, assessment of drainage and bleeding should also be performed routinely [24].

As the main significant post-operative complications in general surgical patients are cardiovascular and respiratory in nature, it is sensible that cardiorespiratory monitoring be made a priority [25]. In general, maintaining a patient’s heart rate and blood pressure within normal limits will result in a satisfactory outcome. However, there are no clinical studies to indicate what is normal with respect to heart rate and blood pressure for individual patients in the post-operative period [2].

Hypertension is common post-operatively and can be due to various causes including pain, anxiety and discontinuing antihypertensive medication. Guidelines by The American College of Cardiology/American Heart Association [26] recommend deferring surgery if the diastolic pressure is above 110 mm Hg and systolic is above 180 mm Hg. No such guidelines exist in the UK however.

Hypotension is also common post-operatively and has been defined as a systolic blood pressure below 90 mmHg [27]. Causes include hypovolaemia due to bleeding or dehydration, or drug therapy.

Myocardial ischaemia in the first 48 hours after an operation is the single most important predictor of serious cardiac events, including cardiac death, myocardial infarction, unstable angina, congestive heart failure and serious arrhythmias [2]. High risk procedures with a risk of cardiac event greater than 5% include cardiac and vascular surgery, or major pelvic/GI surgery in the presence of pre-existing vascular disease. The majority of elective orthopaedic surgery is classed as intermediate risk, with a cardiac risk of less than 5% [28].

Pulmonary complications are an important and common cause of post-operative morbidity and mortality and are particularly common after major abdominal and thoracic surgery. Risk factors for the development of post-operative pulmonary complications include high body mass index (BMI), smoking status and the presence of COPD [29]. Others include pre-operative respiratory illnesses, Intensive Care Unit (ICU) stay and mechanical ventilation in the post-operative period [30]. In order to adequately observe respiratory function and to identify post-operative respiratory complications the respiratory rate, heart rate and conscious level should be monitored routinely. Indicators of respiratory complications include respiratory rate <10 or >25 breaths per minute; pulse rate >100 beats per minute and reduced conscious level.

Patients in whom there is a suspicion of post-operative pulmonary complications should have an arterial blood gas analysis, a sputum culture and ECG. A CXR should be performed on suspicion of major collapse, effusions, pneumothorax or haemothorax. Generally accepted diagnostic criteria for respiratory failure, pulmonary infections and acute respiratory distress syndrome (ARDS) are summarised in Table 3 [2].

Post-operative pulmonary complications can therefore be recognised early if vital signs are recorded accurately in the post-operative period. Any deterioration in these values should then necessitate the need for further investigations such as x-rays and ABGs.

The standard principles of fluid balance in the post-operative patient are to correct any pre-existing deficits, to replace unusual losses (e.g. from surgical drains, pyrexia) and to use the oral route wherever possible as there is not infrequently a delay in commencing oral intake after surgery. Particular patient groups susceptible to fluid or electrolyte disturbances include the elderly, those with pre-existing cardiovascular/cerebrovascular/renal disease and patients who have suffered a peri-operative myocardial ischaemic event [2].

In order to detect fluid and electrolyte abnormalities, patients must have their vital signs checked regularly. Hypotension, tachycardia, oliguria, confusion and tachypnoea may all be indications of hypovolaemia but also have other causes, including sepsis. Whenever a post-operative patient is hypovolaemic, it is important that haemorrhage be considered and to actively exclude this before attributing hypovolaemia to another cause [31].

Potential causes of hypovolaemia include haemorrhage, diarrhoea and vomiting, polyuria and fluid losses via drains. On the other hand, causes of fluid overload include excessive intravenous fluid administration and poor renal or cardiac function [32]. This should be avoided as consequences may include pulmonary oedema. It is thus important to regularly check patients’ vital signs when administering intravenous fluids, so that it can be recognised early if the patient is getting too much or too little.

Sepsis is the systemic inflammatory response to infection and represents a progressive response to infection leading to a generalised inflammatory reaction and eventually end-organ dysfunction and/or failure [2]. The development of systemic sepsis in a post-operative patient marks a serious decline in their condition. Therefore, early identification of patients at risk of developing sepsis and subsequent management is paramount [2] (see Table 4). Matot et al. [33] explain that some of the clinical features to look out when identifying sepsis include fever, signs of peripheral vasodilation, altered mental state, leucocytosis/neutropenia and unexplained tachycardia, tachypnoea or hypotension. Early identification and appropriate treatment of sepsis improves outcome [34]. Without prompt intervention, severe sepsis may ensue, which has a mortality rate of 20-50% [35].

Following shoulder surgery, particularly highly invasive procedures such as total shoulder arthroplasty, reverse shoulder arthroplasty, or hemiarthroplasty, a thorough neurovascular assessment should be conducted. Circulation, sensation and movement (CSM) are evaluated by assessing the shoulder, elbow and wrist [20]. Motor and sensory examination findings may be difficult to determine in the immediate post-operative period however, as regional blocks are frequently used. As a result, regular assessments are encouraged to demonstrate return of function. Assessment of all major nerves of the upper limb should be conducted, including the axillary nerve which is the most common nerve to be injured during shoulder surgery [36].

Post-operative pain can have a significant effect on patient recovery. Since the introduction of Patient-Controlled Analgesia (PCA) in the early 1980s, the daily management of post-operative pain has been enhanced. Patients using PCAs administer and titrate the dose to their own needs using a small microprocessor-controlled pump. Morphine is the most commonly used intravenous drug for PCA, however other opioids have been used. The most frequently observed adverse effects of opioid-based PCA are nausea and vomiting, pruritus, respiratory depression, sedation, confusion and urinary retention [37].

Other options available for post-operative analgesia include intrathecal and epidural analgesia. These may be provided either by using opioids, local anaesthetics or a combination of both. Intrathecal opioids are relatively straightforward to administer and can provide pain relief for twenty four hours or more after a single injection of intrathecal morphine. Epidural analgesia has been shown to be more effective than parenteral opioid administration and intravenous PCA for major surgery [38]. However, this route of administration increases the risk for complications related to the indwelling epidural catheter, including dislodging, kinking or migration within the epidural space.

Opioids are commonly used in the post-operative period. Commonly used agents include morphine, fentanyl and pethidine. Intravenous infusion administration results in a more constant blood level however [39]. Oral opioids can be very effective and can be used to rapidly wean a patient off parenteral therapy, thereby allowing earlier discharge from the hospital. Oxycodone as a controlled-release tablet can provide good pain control for up to 12 hours.

Other methods of providing analgesia also exist. A Cochrane review in 1998 concluded that paracetamol can be used for post-operative pain relief. Several reviews have since supported this, suggesting that paracetamol can provide effective pain relief for up to four hours post-operatively with few adverse side effects [40, 41]. Non-steroidal anti-inflammatory drugs (NSAIDs) can also be added to opioid treatment post-operatively as this can reduce morphine requirements and opioid-related side effects in the early post-operative period [42].

Wound infiltration with a local anaesthetic is a simple, safe, and attractive technique in the control of post-operative pain. Several randomised, controlled studies involving minor surgical procedures have discovered that wound infiltration with local anaesthetic provides superior analgesia, better pain scores, and superior reduction in opioid consumption compared with placebo [43, 44]. Long-acting local anaesthetics such as ropivacaine or bupivacaine are preferred as the analgesic effect is longer.

Interscalene brachial plexus blocks, either alone or combined with a general anaesthetic, are also a useful technique which can be employed to provide excellent post-operative analgesia for patients undergoing shoulder surgery [45]. Fredrickson et al. in 2010 [46] discovered during their review that continuous interscalene block incorporating a local anaesthetic infusion combined with PCA is the most effective analgesic technique following both major and minor shoulder surgery.

Thromboprophylaxis after elective shoulder surgery is a debatable issue as venous thromboembolic events (VTE) are so rare. There are no large-scale randomised trials published on rates of VTEs, although these are thought to be very low. The risk of a pulmonary embolism (PE) ranges from 0.2% to 2% in the literature with mortality rates of 1% [47]. Jameson et al. [47] discovered that since the introduction of NICE guidelines in 2007 recommending the use of chemical agents in shoulder surgery, rates of VTE events did not change. As such, chemical VTE prophylaxis may not be required in shoulder surgery. Despite this, NICE continues to recommend thromboprophylaxis for high-risk shoulder surgery, extrapolating data from hip and knee replacements.