Available Guidelines and Research for Anesthetic Management of Proximal Humerus Sarcoma Resection
Primary Guideline Resources
The Association of Anaesthetists of Great Britain and Ireland (AAGBI) 2014 guideline on "Peri-operative Care of the Elderly" provides the most directly applicable framework for this 56-year-old patient undergoing major oncologic surgery. 1, 2
Key Guideline Components
Pharmacological dosing adjustments: The AAGBI recommends reducing all induction doses by 30-50% from standard adult dosing due to age-related alterations in pharmacokinetics and pharmacodynamics 2
Depth of anesthesia monitoring: BIS or entropy monitors should be used to guide depth of anesthesia and prevent relative overdose, which commonly results in prolonged hypotension and delayed recovery 1, 2
Neuromuscular monitoring: Peripheral nerve stimulation should be used routinely for patients administered neuromuscular blocking agents, as pharmacokinetic and pharmacodynamic changes can result in unpredictably prolonged neuromuscular blockade 1
Hemodynamic monitoring: Intra-arterial blood pressure monitoring should be considered earlier in elderly unwell patients, particularly for major surgery like wide tumor resection 1
Positioning and nerve injury prevention: The AAGBI specifically recommends comprehensively padding all probable sites of nerve injury before surgery starts and reassessing every 30 minutes throughout the procedure, as older patients are at higher risk of preventable peripheral nerve injuries during prolonged surgery 1, 2
Fluid management: High-risk patients undergoing major surgery benefit from "restrictive" fluid therapy that replaces pre-operative plus intra-operative losses without causing fluid overload 1, 2
Postoperative delirium prevention: Multimodal intervention strategies are recommended for preventing postoperative delirium, which is common but underdiagnosed in elderly surgical patients 1
Pain management: Opioid-sparing analgesia should be administered where possible, following published guidance on pain management in older people 1
Surgical Reconstruction Literature
Proximal humerus reconstruction options are comprehensively reviewed in a 2021 overview published in Advances in Orthopedics, which summarizes biological reconstructions (allografts and autografts), prosthetic reconstructions (anatomic endoprostheses, total reverse shoulder prostheses), and graft-prosthetic composite reconstructions 3
Functional outcomes and complications of modern anatomic and reverse endoprostheses are detailed in a 2025 review in Current Reviews in Musculoskeletal Medicine, noting that reverse endoprostheses provide improved motion, patient-reported outcome scores, and revision-free implant survivorship 4
Comparative reconstruction outcomes from a 2008 study in the Journal of the Egyptian National Cancer Institute compared free vascularized fibular graft, pedicled lateral scapular crest graft, and proximal humerus prosthesis, finding similar functional scores across techniques but different operative times and complication profiles 5
Anesthetic Considerations for Cancer Surgery
- Perioperative anesthetic technique and cancer recurrence is reviewed in a 2016 narrative review in the Canadian Journal of Anaesthesia, which discusses how volatile agents, local anesthetics, NSAIDs, and opioids may affect cancer cell proliferation and metastasis, though the authors note that evidence is conflicting and primarily from in vitro studies 6
Evidence Gaps
No specific guidelines exist for anesthetic management of sarcoma resection surgery 7
The AAGBI guideline acknowledges that the evidence base informing peri-operative care for the elderly remains poor, and strongly encourages involvement in national audit projects and outcomes research specifically involving elderly surgical patients 1
No randomized controlled trials specifically address anesthetic management for proximal humerus tumor resection in the available literature