J Shoulder Elbow Surg (2014) 23, e163-e165
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CASE REPORTS
Rapid tracheal deviation and airway compromise due to fluid extravasation during shoulder arthroscopy Dafydd S. Edwards, FRCS(Tr&Orth)*, Ian Davis, MBBS, Nick A. Jones, FRCA, Dominic W. Simon, FRCS(Tr&Orth) Department of Trauma and Orthopaedics, Basingstoke Hospitals, Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hampshire, UK Arthroscopic shoulder surgery has become commonplace in the management of shoulder pathology. Soft-tissue swelling around the shoulder due to fluid leaking into the tissue planes is well documented during shoulder arthroscopic procedures,2 rarely causes complications, and usually subsides within 12 hours.8 We report a case of rapid tracheal deviation and subsequent airway compromise in an otherwise healthy woman undergoing elective shoulder arthroscopy. The most likely cause was irrigation fluid passage from the glenohumeral joint through the tissue planes into the pharyngeal structures. It has been reported that airway compromise caused by softtissue swelling due to irrigation fluid can occur but after significantly longer periods of operative time have elapsed1,35,9,13 but never with such a rapid onset.
Case report A 53-year-old, 65-kg, 165-cm woman presented to the orthopaedic surgeons with a 6-month history of right shoulder pain and stiffness; she was diagnosed with right shoulder adhesive capsulitis and subsequently scheduled to undergo right shoulder arthroscopic capsule release. The only significant finding in the patient’s medical history was malignant melanoma of the right thumb, which was removed Authors and Institutions aforementioned state their compliance with ethical guidelines for publication. *Reprint requests: Dafydd S. Edwards, FRCS(Tr&Orth), 32 Brassey Road, Winchester, SO22 6SB, UK. E-mail address: [email protected] (D.S. Edwards).
by partial amputation, and right axillary sentinel node biopsy. The findings of the clinical examination of her neck were unremarkable, with good neck range of movement. The findings of the preoperative anesthetic review were unremarkable, and the patient was subsequently given an American Society of Anesthesiologists grade of 1. The patient received premedication on the ward of gabapentin, 600 mg; oxycodone, 20 mg, diclofenac, 75 mg slow-release; ranitidine, 150 mg; and metoclopramide, 10 mg. General anesthesia was induced with fentanyl, 250 mg, and propofol, 120 mg. After confirmation of easy facemask ventilation, a size 4 laryngeal mask airway was inserted, and the patient was stabilized on positive pressure ventilation by a circle system with maintenance of anesthesia with a mixture of sevoflurane, oxygen, and air. The patient was subsequently set up in the beach-chair position. The surgeon, having identified the midway point along the scapular spine, injected 15 mL of 0.375% bupivacaine into the supraspinous fossa to create a suprascapular block. A 5-mm stab incision was made in the skin in the position for the standard posterior portal for shoulder arthroscopy. A blunt arthroscope trocar was then used to gain access to the shoulder joint, which was achieved in a single pass. Saline solution, 0.9%, from a 3-L bag was passed through the port using an Arthrex arthroscopic pressure pump (AR-6480; Arthrex, Naples, FL, USA) at a flow rate of 2.5 L/min to achieve a pressure of 50 mm Hg. Initial images showed synovitis of the capsule and thickening of the superior glenoid humeral ligament within the rotator interval. Manipulation under anesthesia or capsular release/debridement had not been performed at this stage. Within 2 minutes, the surgeon noticed that the ipsilateral trapezius was swollen; the anesthetist confirmed that this was unilateral, and the airway pressures were becoming elevated. Clinical examination showed tracheal deviation to the left, and
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.03.006
e164
D.S. Edwards et al.
Figure 1 Anterior aspect of neck showing asymmetry of neck and shoulder soft tissues and tracheal deviation (dotted line). the procedure was stopped. The drapes were removed, and the patient was laid flat. The laryngeal mask was removed, and laryngoscopy was performed and showed a grossly deviated trachea to the left. A 7.5-mm cuffed endotracheal tube was successfully inserted on first pass, and hand ventilation was managed easily. Airway pressure was noted to increase from 11 cm H2O to 18 cm H2O but remained within normal limits (
www.elsevier.com/locate/ymse
CASE REPORTS
Rapid tracheal deviation and airway compromise due to fluid extravasation during shoulder arthroscopy Dafydd S. Edwards, FRCS(Tr&Orth)*, Ian Davis, MBBS, Nick A. Jones, FRCA, Dominic W. Simon, FRCS(Tr&Orth) Department of Trauma and Orthopaedics, Basingstoke Hospitals, Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hampshire, UK Arthroscopic shoulder surgery has become commonplace in the management of shoulder pathology. Soft-tissue swelling around the shoulder due to fluid leaking into the tissue planes is well documented during shoulder arthroscopic procedures,2 rarely causes complications, and usually subsides within 12 hours.8 We report a case of rapid tracheal deviation and subsequent airway compromise in an otherwise healthy woman undergoing elective shoulder arthroscopy. The most likely cause was irrigation fluid passage from the glenohumeral joint through the tissue planes into the pharyngeal structures. It has been reported that airway compromise caused by softtissue swelling due to irrigation fluid can occur but after significantly longer periods of operative time have elapsed1,35,9,13 but never with such a rapid onset.
Case report A 53-year-old, 65-kg, 165-cm woman presented to the orthopaedic surgeons with a 6-month history of right shoulder pain and stiffness; she was diagnosed with right shoulder adhesive capsulitis and subsequently scheduled to undergo right shoulder arthroscopic capsule release. The only significant finding in the patient’s medical history was malignant melanoma of the right thumb, which was removed Authors and Institutions aforementioned state their compliance with ethical guidelines for publication. *Reprint requests: Dafydd S. Edwards, FRCS(Tr&Orth), 32 Brassey Road, Winchester, SO22 6SB, UK. E-mail address: [email protected] (D.S. Edwards).
by partial amputation, and right axillary sentinel node biopsy. The findings of the clinical examination of her neck were unremarkable, with good neck range of movement. The findings of the preoperative anesthetic review were unremarkable, and the patient was subsequently given an American Society of Anesthesiologists grade of 1. The patient received premedication on the ward of gabapentin, 600 mg; oxycodone, 20 mg, diclofenac, 75 mg slow-release; ranitidine, 150 mg; and metoclopramide, 10 mg. General anesthesia was induced with fentanyl, 250 mg, and propofol, 120 mg. After confirmation of easy facemask ventilation, a size 4 laryngeal mask airway was inserted, and the patient was stabilized on positive pressure ventilation by a circle system with maintenance of anesthesia with a mixture of sevoflurane, oxygen, and air. The patient was subsequently set up in the beach-chair position. The surgeon, having identified the midway point along the scapular spine, injected 15 mL of 0.375% bupivacaine into the supraspinous fossa to create a suprascapular block. A 5-mm stab incision was made in the skin in the position for the standard posterior portal for shoulder arthroscopy. A blunt arthroscope trocar was then used to gain access to the shoulder joint, which was achieved in a single pass. Saline solution, 0.9%, from a 3-L bag was passed through the port using an Arthrex arthroscopic pressure pump (AR-6480; Arthrex, Naples, FL, USA) at a flow rate of 2.5 L/min to achieve a pressure of 50 mm Hg. Initial images showed synovitis of the capsule and thickening of the superior glenoid humeral ligament within the rotator interval. Manipulation under anesthesia or capsular release/debridement had not been performed at this stage. Within 2 minutes, the surgeon noticed that the ipsilateral trapezius was swollen; the anesthetist confirmed that this was unilateral, and the airway pressures were becoming elevated. Clinical examination showed tracheal deviation to the left, and
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.03.006
e164
D.S. Edwards et al.
Figure 1 Anterior aspect of neck showing asymmetry of neck and shoulder soft tissues and tracheal deviation (dotted line). the procedure was stopped. The drapes were removed, and the patient was laid flat. The laryngeal mask was removed, and laryngoscopy was performed and showed a grossly deviated trachea to the left. A 7.5-mm cuffed endotracheal tube was successfully inserted on first pass, and hand ventilation was managed easily. Airway pressure was noted to increase from 11 cm H2O to 18 cm H2O but remained within normal limits (
