Upper Airway Compromise by Extravasated Fluid: A Rare Complication After Arthroscopic Repair of Atrophic Cuff Tear

Posted on October 11, 2009

by Gorthi Venkat, MS; Young Lae Moon, MD; Woong Chae Na, MD; Keum Young So, MD

Abstract

During arthroscopic procedures, leakage of irrigation fluid into surrounding tissue planes is a frequently noticed phenomenon usually clinically asymptomatic and resolving within 12 hours postoperatively. Although rare, this fluid may produce life-threatening complications such as airway compromise. This article describes a case of upper airway obstruction in a 60-year-old man undergoing arthroscopic repair for an atrophic rotator cuff tear.

The patient presented with a 6-month history of pain and weakness in the left shoulder. Magnetic resonance imaging studies revealed a massive rotator cuff tear with significant retraction and fatty degeneration of cuff musculature. Perioperatively, all vital cardiorespiratory parameters were within normal limits. Postoperatively, immediately on extubation, he was dyspneic, and examination revealed a diffuse swelling extending from the left shoulder up to the neck and face. He was reintubated and sent to the recovery room, where he recovered 12 hours later.

This article highlights the possibility of respiratory compromise due to the extravasation of irrigation fluid into the neck and chest during arthroscopic repair of massive and atrophied cuff tears, even with shorter surgical time as is this case. The widened suprascapular space will offer less resistance to the spread of fluid into the neck and chest from the shoulder. We advocate monitoring the patient continuously to prevent this serious complication from becoming life-threatening.

Arthroscopic shoulder surgery is an accepted and preferred technique for managing rotator cuff tears, recurrent joint instability, and subacromial pathology. Shoulder arthroscopy has several important advantages over open techniques, including less postoperative pain and more rapid rehabilitation.1,2 However, shoulder arthroscopy is not without complications.3 The rate of possible complications ranges from 2% to 5% depending on several factors.4 Leakage of the irrigation fluid into the surrounding tissue planes is a frequently noticed phenomenon that is usually clinically asymptomatic and resolves within 12 hours after the procedure.5 Although rare, the leaked irrigation fluid may produce severe life-threatening complications such as pulmonary edema, airway obstruction, and tracheal compression.

Case Report

A 60-year-old man presented with pain and weakness in the left shoulder of 6 months’ duration. There was no recent history of trauma to the shoulder region. On examination, his active range of motion was considerably decreased with preservation of the passive range of motion. Simple radiographs revealed the superior migration of the humeral head and early osteoarthritic changes. Magnetic resonance imaging studies revealed a massive rotator cuff tear with significant retraction and fatty degeneration of the cuff musculature (Figure 1).

Prior to the arthroscopic procedure, the regional brachial plexus block was administered using a nerve stimulator, followed by general anesthesia and mechanical ventilation. The patient was placed in the right lateral decubitus with the left shoulder up. Monitoring included pulse oximetry, electrocardiography, and noninvasive blood pressure determination.

Arthroscopic repair of the massive tear was undertaken by using the posterior viewing portal and the lateral working portals. The shoulder joint was irrigated with 0.9% normal saline mixed with adrenaline in 1:300,000 dilutions, using a pressure pump at an intra-articular pressure of 100 mm Hg throughout the procedure. The tear was repaired using 2 5-mm suture anchors, and the superficial wounds were closed with 2-0 nylon. The operative time was 45 minutes, and the anesthesia time was 70 minutes. During the peroperative period all the vital cardiorespiratory parameters were within the normal limits.

After the completion of the procedure the patient was extubated. Immediately on extubation the patient was found to be dyspneic, and a diffuse swelling was noticed extending from the left shoulder up to the neck and face (Figure 2). The swelling was noticed only on the operated side. Auscultation of the chest revealed stridor and diminished air entry into the left side of the chest. The patient was drowsy and unable to maintain saturation because of the airway compromise secondary to the huge neck swelling. The patient was reintubated and spontaneous respiration with 5l/minute O2 was provided through the endotracheal tube. With the saturations and vital signs returning to normalcy within a few minutes after the reintubation, the patient was moved to the recovery room and then to intensive care for further monitoring. Twelve hours after the procedure, the patient’s ability to maintain saturation had improved significantly, and swelling had decreased remarkably on clinical examination. The remaining postoperative hospital stay was uneventful and followed the routine rotator cuff repair protocol.

Discussion

This case report highlights the rare complication of airway compromise occurring after shoulder arthroscopy. Complications related to shoulder arthroscopy are not uncommon. The rate of possible complications ranges from 2% to 5% depending on factors such as the nature of the procedure and experience of the surgeon.4

Complications include extravasation of fluid producing respiratory compromise and other local compressive effects, traction neuropraxias, intraoperative hemorrhage, infections, and cartilage injury.

However, respiratory compromise related to shoulder arthroscopy procedures is rare and can be produced by air embolism, pneumothorax, tracheal compression, and complete airway obstruction from edema.6,7

To date, several anesthesiologists and orthopedic surgeons have described airway obstruction during shoulder arthroscopic procedures; the majority of these airway complications occurred while patients were awake or lightly sedated under interscalene brachial plexus block,2,8,9 with only 1 report of airway obstruction occurring in a patient under general anesthesia using a laryngeal mask airway.5 In previously reported cases of airway compromise, the complication was noticed during the procedure and was seen mainly with the subacromial decompressions. However, no reports exist in the literature on airway compromise noticed after the procedure and in a patient who underwent arthroscopic repair of an atrophied cuff tear under the combined regional and general anesthesia.

Although arthroscopic procedures are minimally invasive, the extra-articular leakage of fluid used for continuous flushing of the articular space is a complication of shoulder arthroscopy, extravasation into the deltoid muscle and the chest frequently occurs3 but usually is clinically asymptomatic and reabsorbed within 12 hours.5 Airway compromise related to arthroscopic shoulder surgery is uncommon but can be life threatening.2,9

Several risk factors are associated with extensive loss of irrigation fluid into the subcutaneous soft tissues, including high pump pressure,4 obesity, and a prolonged arthroscopic procedure.8 A subacromial arthroscopy is another associated risk factor, as this space is not capsulated and the fluid can escape easily into the surrounding areas.7 Lateral positioning may also contribute to the movement of subcutaneous fluid from the shoulder to the neck by gravity.8

References

  1. Gartsman GM. Arthroscopic rotator cuff repair. Clin Orthop Related Res. 2001; (390):95-106.
  2. Orebaugh SL. Life-threatening airway edema resulting from prolonged shoulder arthroscopy. Anesthesiology. 2003; 99(6):1456-1458.
  3. Berjano P, Gonzalez BG, Olmedo JF, Perez-Espana LA, Munilla MG. Complications in arthroscopic shoulder surgery. Arthroscopy. 1998; 14(8):785-788.
  4. Bigliani LU, Flatow EL, Deliz ED. Complications of shoulder arthroscopy. Orthop Rev. 1991; 20(9):743-751.
  5. Yoshimura E, Yano T, Ichinose K, Ushijima K. Airway obstruction involving a laryngeal mask airway during arthroscopic shoulder surgery. J Anesth. 2005; 19(4):325-327.
  6. Lee HC, Dewan N, Crosby L. Subcutaneous emphysema, pneumomediastinum, and potentially life-threatening tension pneumothorax. Pulmonary complications from arthroscopic shoulder decompression. Chest. 1992; 101(5):1265-1267.
  7. Borgeat A, Bird P, Ekatodramis G, Dumont C. Tracheal compression caused by periarticular fluid accumulation: a rare complication of shoulder surgery. J Shoulder Elbow Surg. 2000; 9(5):443-445.
  8. Hynson JM, Tung A, Guevara JE, Katz JA, Glick JM, Shapiro WA. Complete airway obstruction during arthroscopic shoulder surgery. Anesth Analg. 1993; 76(4):875-878.
  9. Blumenthal S, Nadig M, Gerber C, Borgeat A. Severe airway obstruction during arthroscopic shoulder surgery. Anesthesiology. 2003; 99(6):1455-1456.

Authors

Mr Venkat and Drs Moon, Na, and So are from Chosun University Hospital, Gwangju, South Korea.

Mr Venkat and Drs Moon, Na, and So have no relevant financial relationships to disclose.

Correspondence should be addressed to: Young Lae Moon, MD, Orthopedic Department, Chosun University Hospital, 588 Seoseok-dong, Dong-ku, Gwangju 501-717, South Korea.

doi: 10.3928/01477447-20090818-32

Posted in Shoulder/Elbow