Fast-track management of airway complications following shoulder arthroscopy
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(2020) 12:49
LETTER TO THE EDITOR
Ain-Shams Journal of Anesthesiology
Open Access
Fast-track management of airway complications following shoulder arthroscopy Vibhuti Sharma and Ranju Gandhi* To the Editor, A 56-year-old female, controlled hypertensive with right shoulder rotator cuff tear, was planned for arthroscopic repair. Her preoperative investigations and general physical and airway examination were normal. In the operating theatre, standard general anesthesia care with ultrasound-guided right brachial plexus block by interscalene approach was performed. The patient was placed in the left lateral decubitus position. Nitroglycerine infusion was started to provide a bloodless surgical field. Peak airway pressure showed an increasing trend with a baseline value of 18 cm H2O prior to the start of surgery and gradually increasing to 30 cm H2O by the end. Fifty-four liters of normal saline was infused into the surgical space at the pressure of 70 mm Hg over 85 min. Postoperatively, when the patient was positioned supine and surgical drapes removed, widespread edema involving the lower face, tongue, neck, and chest was noted extending till the left shoulder but significantly more on the right side with neck circumference increased from a baseline of 32 to 41 cm. Due to the risk of airway compromise and difficult laryngoscopy, extubation was deferred. She was given iv fentanyl 25 μg, morphine 3 mg, and frusemide 5 mg and ventilated. Neck circumference was 36 cm, 35 cm, and 33 cm after 60, 90, and 120 min of postoperative ventilation, respectively, with a visible decrease in swelling and induration of the tongue, face, and chest. After she became fully awake with return of motor power, a cuff leak test was done and it was negative. Direct laryngoscopy was possible, and the patient’s trachea was extubated. The
* Correspondence: [email protected] Department of Anaesthesia & Intensive Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi 110029, India
patient was stable with no respiratory distress during postoperative recovery. Shoulder arthroscopy is a minimally invasive technique which in comparison to open technique causes less postoperative pain and earlier rehabilitation. However, airway complications resulting from the use of irrigated fluid though rare can occur and can be life threatening if not recognized early and managed effectively. Risk is increased with long duration of surgery, sub-acromial pathology (sub-acromial space is unencapsulated), large volume of irrigation fluids, increased pump pressures, lateral decubitus position (due to the effect of gravity), obesity, and intraoperative hypertension (Antonucci et al. 2006; Manjuladevi et al. 2013; Khan et al. 2013; Chellam et al. 2015; Ko et al. 2015). Use of controlled pump pressures (40–80 mm Hg) and controlled flow rate of irrigation fluids (50–150 ml/min) with continuous outflow conduit, surgery duration limited to 90 to 120 min, and providing general anesthesia with secured airway have been shown to reduce complications (An
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