Objective To investigate the effect of hydromorphone preemptive analgesia on perioperative pain, hemodynamics and stress response in elderly patients undergoing shoulder arthroscopic surgery. Methods A total of 90 patients undergoing unilateral shoulder arthroscopic surgery under general anesthesia in Taizhou People's Hospital from January to December 2022 were selected as subjects. According to the random number table method were divided into observation group and control group, with 45 cases in each group. The observation group was intravenously injected with hydromorphone 10 min before anesthesia induction, and the control group was intravenously injected with an equal volume of normal saline. After that, all patients underwent routine tracheal intubation general anesthesia. After the operation, they were sent to PACU for resuscitation and unified postoperative analgesia. The perioperative hemodynamics [mean arterial pressure (MAP), heart rate (HR)], VAS score and stress index [norepinephrine (NE), epinephrine (E), cortisol (Cor), blood glucose (Glu)] were compared between the two groups at different time points [before anesthesia induction (T0), immediately after intubation (T1), at the time of skin incision (T2), at the end of operation (T3), at the time of tracheal extubation (T4), at the time of leaving the anesthesia recovery room (T5), 4 h after operation (T6), 8 h after operation (T7), 24 h after operation (T8)]. Results MAP and HR at T1-T5 time points in the observation group were lower than those in the control group, VAS score at T5-T8 time points was lower than that in the control group, Glu and serum NE, E and Cor contents at T2 and T3 time points were lower than those in the control group (P<0.05). Conclusion Hydromorphone preemptive analgesia can effectively reduce perioperative pain, perioperative stress response and hemodynamic fluctuations in elderly patients undergoing shoulder arthroscopic surgery, which is worthy of clinical application.