Severe Airway Obstruction and Pleural Effusion After Arthroscopic Shoulder Surgery: a Case Report

http://dx.doi.org/10.14517/aosm14016 Case Report pISSN 2289-005X·eISSN 2289-0068

Severe airway obstruction and pleural effusion after arthroscopic shoulder surgery: a case report

Sang Hun Ko, Kwang Hwan Jung, Jae Ryong Cha, Min Chul Song, Chang-Gyu Choe

Department of Orthopedic Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea

Shoulder arthroscopy is used to treat a range of injuries of the shoulder and has many benefits, but it is also associated with undesirable complications. Even so, as the benefits by far surpass the risk, shoulder arthroscopy remains a common practice in orthopedics today. Here, we describe a previously unreported, potentially fatal complication, pleural effusion, after a shoulder arthroscopy. We removed the pleural effusion by thoracentesis with the patient in a beach-chair position.

Keywords: Arthroscopy; Pleural effusion; Extravasation; Airway obstruction

INTRODUCTION of height, 161 cm; weight, 74 kg; and body mass index (BMI), 28.5 kg/cm2 presented with airway obstruction Shoulder arthroscopy is used to treat a range of injuries of and pleural effusion after an arthroscopic surgery. the shoulder such as rotator cuff injuries, impingement Except for a high blood pressure, the patient did not syndromes, shoulder instability, and arthritis for its present with any particular conditions preoperatively. efficacy and minimally invasive procedures. However, it She was concomitantly referred to the Department is also associated with undesirable complications where of Cardiology to address her blood pressure, but was around 4.6% to 10.6% of arthroscopic surgeries of the simply placed under surveillance without drug therapy. shoulder are associated with at least one complication [1]. Preoperative range of motion tests showed a severely Commonly associated complications are vascular injuries, disabled forward elevation and pseudoparalysis with a nerve injuries, articular stiffness, infections, and systemic negative electromyogram. During forward elevation of absorption of irrigation fluid. In comparison, obstruction the patient’s arm, we measured an external rotation of of the airways as a complication associated with shoulder 40o, internal rotation at the third lumbar cord, and poor arthroscopy is rare, and one that is accompanied by muscle strength of grade 2. We carried out arthroscopic pleural effusion is even rarer. Here, we describe a rare repairs for the following shoulder lesions; degeneration complication of shoulder arthroscopy, severe airway of the subscapularis and the supraspinatus muscles and obstruction accompanied by pleural effusion that massive, complete tears of the subscapularis tendon, required a thoracentesis with the patient under general supraspinatus tendon, and biceps tendon. We carried anesthesia and in a beach-chair position. out the arthroscopic surgery with the patient in a lateral beach-chair position under general anesthesia. To obtain CASE REPORT a sufficient visual field, we maintained hypotensive conditions of less than a systolic blood pressure of 100 A 71-year-old woman with demographic characteristics mmHg. As the irrigation solution, we used epinephrine

Received November 7, 2014; Revised February 26, 2015; Accepted April 2, 2015 Correspondence to: Sang Hun Ko, Department of Orthopedic Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwan-doro, Dong-gu, Ulsan 682-714, Korea. Tel: +82-52-250-7129, Fax: +82-52-235-2823, E-mail: Arthroscopy and [email protected] Orthopedic Sports Medicine Copyright © 2015 Korean Arthroscopy Society and Korean Orthopedic Society for Sports Medicine. All rights reserved. CC This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ AOSM by-nc/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

124 Arthrosc Orthop Sports Med 2015;2(2):124-127 Sang Hun Ko, et al. Pleural effusion after arthroscopic shoulder surgery

solution diluted to 1:300,000 in saline. We used a Stryker cords through. The patient was under mechanical venti infusion pump (Stryker, Kalamazoo, MI, USA) at an initial lation at our intensive care unit until airway edema was pressure of 60 mmHg and assessed the glenohumeral resolved. Through thoracic plain radiography, we found joint and the subscapularis tear. Capsular release was severe edema of the subcutaneous tissue of the right performed for the treatment of the patient’s severe frozen thoracic region, discoid atelectasis, and pleural effusion. shoulder. When the arthroscope reached the acromial We carried out a thoracentesis during which 800 mL of space, the systolic blood pressure increased to 110 to serosanguineous exudate was drained. The patient was 120 mmHg making a hypotensive blood pressure near given antibiotics for pneumonia (2 g of ceftriaxone and impossible. Besides, hypotensive conditions would have 750 mg of levofloxacin, once per day). After a postoperative been unsupported anyway as systolic blood pressure had day, radiologic signs and clinical symptoms improved so to be increased to 150 mmHg to gain a better field of view. the endotracheal tube was extubated and the patient was We performed acromioplasty of the subacromion, repair transferred to general wards. On the 6th day of operation, of the 6-cm massive tear of the supraspinatus tendon, radiologic signs showed improved atelectasis, resolution and lastly, debridement and re-attachment of the biceps of pleural effusion, and normal arterial blood gas tendon to address its degenerative tear. composition. The patient was discharged from the hospital For this patient, we unwittingly ran over the predicted as we confirmed the remission of the initial symptoms (Fig. surgery time by 25 minutes because of reparative pro 1). cedures for unforeseen massive tears at the subacromial space, leading to a total surgery time of around 90 DISCUSSION minutes. During the thoracentesis, a total of 18 L of irri gation solution was used. During anesthesia, the patient Although a small degree of extravasation of the irrigation showed normal levels of arterial blood gas and SaO2, thus fluid into the deltoid muscle is inevitable during an no auscultation was performed. arthroscopic surgery of the shoulder, on the most part, Postoperatively, even though we stabilized the hemo most incidents of fluid accumulation remains harmless dynamic instability, we observed swelling on the cer [2]. In rare cases, excess accumulation of irrigation fluid in vical spine and on the right shoulder. However, after a patient’s body can lead to life-threatening airway edema. extubation of the endotracheal tube, we found loss of Examples of risk factors that increase the likelihood of the capnography waveform and SaO2 reduction (60%) pleural effusion are high infusion pump pressure, excess indicating obstruction of the airways. So we re-intu irrigation fluid, obesity, prolonged surgery time, lateral bated a laryngoscope for laryngoscopy and found severe decubitus position, shoulder acromioplasty, anterior airway edema with a severity that dislocated the vocal capsular resection of the glenohumeral joint, and

Fig. 1. (A) Simple chest radiography (chest anteroposterior), immediately after surgery. Pleural effusion associated with passive subsegmental atelectasis can be seen. (B) A B Six days after surgery, all radiologic findings are resolved (chest posteroanterior). www.e-aosm.org 125 Sang Hun Ko, et al. Pleural effusion after arthroscopic shoulder surgery

iatrongeic deltoid tears [1,3–8]. In addition, in elderly by thoracentesis to prevent further complications. patients, skin and soft tissues are more lax than in younger In this case report, not only did we have a patient patients, which facilitates effusion of the pleural fluid [9]. whose demography, age and BMI, predisposed her to To reduce the risk of severe airway obstruction, local surgery-related complications, but had one who was anesthesia is recommended over general anesthesia. met with risk-factors during surgery that contributed to Using local anesthesia helps keep the airways open and an increased risk. These high risk-factors were; capsular allows clinicians to carry out a hypotensive anesthesia release on her frozen shoulder, prolonged surgery time thereby allowing surgeons to maintain a low fluid pressure at the subacromial space due to a difficult repair of a full- and obtain an adequate visual field. Time otherwise spent thickness tear, and increase in fluid pressure in response on hemostatic issues can be saved as well. to an unstable blood pressure. These were detectable Unlike the glenohumeral joint for which a fluid pressure factors, symptoms, and radiologic signs that could have of 30 to 60 mmHg is sufficient to achieve a good visual been warned us in advance of a possible prolonged field, the subacromial space requires a greater fluid arthroscopic surgery. pressure to achieve the same level of vision. This is because Ways in which we may have prevented the occurrence the subacromial space is not a structure surrounded of this rare complication are as follows; preoperative by a joint capsule and but rather forms anatomical stabilization of blood pressure to minimize intraoperative interfaces with cervical and thoracic soft tissues. Thus, to peaks of blood pressure; intraoperative hypotensive achieve a clear view of the subacromial space, a higher anesthesia to reduce surgery time; postoperative measure pump pressure which unfavorably increases the risk of ment of the neck diameter; and prior to removal of the fluid extravasation to the cervical and thoracic spinal endotracheal tube, confirmation of leaks and normal air cord regions is required [10]. Extravasated fluid passes flow through the airways even when the endotracheal around the sides of the deltoid muscle and through the tube is not inflated [6]; lastly, assessment for a severe arthroscopic portal and accumulates at the layer of the cervical edema after extubation. subcutaneous fat above the pectoralis major muscle [11]. As such, elucidating such risk factors and preparing for Conversely, pleural effusion can also occur due to the potential adverse events are effective, prophylactic stalling of the lymph circulation induced by a pleural approaches against complications and their recurrence. membrane tear at the mediastinal surface or by severe edema of the axillary soft tissue. If severe, pleural effusion CONFLICT OF INTEREST based on this etiology can lead to a pneumothorax accompanied by pneumomediastinum [6,12]. Thus, No potential conflict of interest relevant to this article was when a large volume of pleural effusion is found, it is reported. important to remove the excess fluid as soon as possible

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