Skip to main content
  • Letter to the Editor
  • Open access
  • Published:

Fast-track management of airway complications following shoulder arthroscopy

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 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 (Antonucci et al. 2006; Manjuladevi et al. 2013; Khan et al. 2013).

Monitoring of neck circumference postoperatively, a positive cuff leak test with endotracheal cuff deflation at the end of the procedure, and checking for airway edema on direct laryngoscopy can help to detect the risk of airway obstruction (Antonucci et al. 2006; Manjuladevi et al. 2013; No et al. 2013). Bronchoscopy and ultrasound observation of fluid infiltration are other techniques which can detect tracheal compression (Manjuladevi et al. 2013; Gupta et al. 2016). In patients with clinical suspicion of airway edema, it is advocated to delay extubation as extensive cervicothoracic edema can limit neck mobility and impair visualization of the glottis, making reintubation difficult leading to overnight admission in ICU (Antonucci et al. 2006; Manjuladevi et al. 2013; Ko et al. 2015). In our patient, intraoperative monitoring of increased airway pressure and compliance and serial monitoring of neck circumference in the postoperative period along with the cuff leak test helped us to fast-track extubation with good recovery. We advocate routine use of these tests serially in the postoperative period in the operating theatre itself before extubation in centers performing shoulder arthroscopy to reduce the ICU occupancy rate in patients with suspected airway edema due to irrigated fluids.

Availability of data and materials

Not applicable









Intensive care unit


  • Antonucci S, Orlandi P, Mattei PA, Amato F (2006) Airway obstruction during arthroscopic shoulder surgery: anesthesia for the patient or for the surgeon? Minerva Anestesiol 72:995–1000

    CAS  PubMed  Google Scholar 

  • Chellam S, Chiplonkar S, Pathak K (2015) Change in neckcircumference after shoulder arthroscopy: an observational study. Indian J Anaesth 59:365–368

    Article  Google Scholar 

  • Gupta S, Manjuladevi M, Upadhyaya KS, Kutappa AM, Amaravathi R, Arpana J (2016) Effects of irrigation fluid in shoulder arthroscopy. Indian J Anaesth 60:194–198

    Article  Google Scholar 

  • Khan F, Padmanabha S, Shantaram M, Aravind M (2013) Airway compromise due to irrigation fluid extravasation following shoulder arthroscopy. J Anaesthesiol Clin Pharmacol 29:578–579

    Article  Google Scholar 

  • Ko SH, Jung KH, Cha JR, Song MC, Choe C-G (2015) Severe airway obstruction and pleural effusion after arthroscopic shoulder surgery: a case report. Arthrosc Orthop Sports Med 2:124–127

    Article  Google Scholar 

  • Manjuladevi M, Gupta S, Upadhyaya KV, Kutappa AM (2013) Postoperative airway compromise in shoulder arthroscopy: a case series. Indian J Anaesth 57:52–55

    Article  CAS  Google Scholar 

  • No MY, Kim PO, Choi WJ (2013) Airway compression after arthroscopic shoulder surgery under general anesthesia. Korean J Anesthesiol 65:S121–S122

    Article  Google Scholar 

Download references




No funding received.

Author information

Authors and Affiliations



VS participated in the intellectual content, review of the literature, and writing of the manuscript and has read and approved the final manuscript. RG participated in the intellectual content, conception, and design of this work as well as reviewing and editing the manuscript. She has read and approved the final manuscript and to take public responsibility for it and has agreed to be the corresponding author.

Corresponding author

Correspondence to Ranju Gandhi.

Ethics declarations

Ethics approval and consent to participate

Not applicable

Consent for publication

Written and informed consent of the patient for publication was obtained.

Competing interests

The authors have no competing interests to declare.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Sharma, V., Gandhi, R. Fast-track management of airway complications following shoulder arthroscopy. Ain-Shams J Anesthesiol 12, 49 (2020).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: