Severe Airway Obstruction during Arthroscopic Shoulder Surgery

A 55-yr old man with a history of a painful rotator cuff rupture and American Society of Anesthesiology physical status II was scheduled for left shoulder arthroscopy. Except for obesity (body mass index, 31), preoperative physical examination and laboratory findings were normal. After premedication with 7.5 mg midazolam, an interscalene catheter (Polymedic® 22 gauge; Te Me Na, Bondi, France) was placed according to the modified lateral approach. 3The procedure was uneventful, and 50 ml ropivacaine, 0.5% (250 mg), was administered through the catheter, with a surgical block achieved within 20 min. After 25 min, the patient was placed in the right lateral decubitus with the left shoulder up. Monitoring included pulse oximetry, electrocardiography, and noninvasive blood pressure determination. Supplemental analgesia (for pain in the right hip) was achieved with a remifentanil-controlled infusion (target concentration, 2.0 ng/ml). The patient remained awake with a respiratory rate of 14 breaths/min. After insertion of the arthroscope, the subacromial space was inflated by infusion with lactated Ringer's solution, and his blood pressure was maintained between 80 and 100 mmHg.

The surgical procedure was uneventful during the first 110 min. Suddenly, the patient started to complain about breathing difficulties and a feeling of pressure on the throat. Within minutes, the patient became restless and developed severe dyspnea; the drapes were quickly removed, and the patient was placed in a supine position. Massive swelling of the left side of the chest and of the anterior portion of the neck extending to the face was noted. Oxygen saturation decreased quickly below 50%, and the patient became bradycardiac (heart rate, 38 beats/min). Emergency intubation was unsuccessful because the laryngeal structures could not be identified. Prednisone (200 mg) was given intravenously, and an incision was made by the surgeon at the level of the cricothyroid membrane to perform a tracheotomy. Immediately after the skin incision, manual ventilation became possible, and oxygen saturation steadily increased to 80% by relief of pressure on the trachea through mere distention of the tissue. The heart rate returned to normal. The tracheotomy procedure was stopped, and a second attempt at orotracheal intubation was now successful despite massive swelling of the tissue surrounding the airways. The patient's blood pressure remained stable. The incisions at the neck and shoulder were closed, and the patient was transferred to the intensive care unit, where he remained intubated for another 24 h. The patient was extubated the next day with no problems, and no sequelae were observed.

We report another case of a severe airway problem during arthroscopic shoulder surgery performed during interscalene brachial plexus blockade and sedation. To our knowledge, only two cases have been reported before with extraarticular spread of arthroscopic irrigation fluid compromising the airway. 4,5The extraarticular leakage of fluid is a well-recognized complication of shoulder arthroscopy 6; extravasation into the deltoid muscle and the chest frequently occurs, but usually it is without clinically significant symptoms and most often is reabsorbed within 12 h. 7,8Risk factors for an extended loss of irrigation fluid into soft tissue are increased pump pressure, 4obesity, duration of arthroscopic procedure, and arthroscopy within the subacromial space, because this space is not enclosed within a capsule. 2 

The worldwide use of regional anesthetic techniques is increasing; in parallel, an increasing number of patients are sedated during placement of the block and during surgery. Brown et al.  9demonstrated that the interscalene block compared with general anesthesia for shoulder arthroscopy was associated postoperatively with fewer side effects, shorter hospital stay, and higher patient satisfaction. In this context, sedation is likely to be increasingly used. This case emphasizes the need for sedation that must be predictable, rapidly reversible, and easily monitored. As shown here, the patient's ability to communicate with the anesthetist and to complain about discomfort and airway problems during shoulder arthroscopy are crucial to a well-managed sedation. Direct communication with the patient permits early recognition of complications, such as any difficulty in swallowing or throat sensation, which are ominous signs of airway swelling.