Fluid Extravasation in Shoulder Arthroscopic Surgery: A Systematic Review

Abstract

Background:Arthroscopic surgery of the shoulder joint has become increasingly more common given its advantages over open surgery; however, one rare but potentially life-threatening complication is fluid extravasation into the surrounding tissues, causing edema, respiratory compromise, abnormal results on laboratory blood tests, and possibly death. Currently, no systematic review exists that summarizes the existing clinical research on this topic.Purpose:To perform a systematic review on fluid extravasation as a complication of shoulder arthroscopic surgery, specifically assessing clinical presentation, risk factors, management, and outcomes.Study Design:Systematic review; Level of evidence, 4.Methods:Two reviewers independently searched 3 databases (PubMed, Ovid [MEDLINE], and Embase) from database inception until July 1, 2017. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist guided the reporting and data abstraction. The methodological quality of these studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) checklist. The results are presented in a narrative summary fashion using descriptive statistics including ranges and agreement statistics.Results:A total of 26 studies (20 case reports, 4 case series, and 2 prospective comparative studies) encompassing 205 patients (mean age, 50.8 years [range, 15-83 years]) were included. The most common signs of fluid extravasation included chest wall swelling (n = 86) and neck swelling (n = 116). In 32 patients, observation alone was sufficient. Other patients required airway intubation (n = 16), diuretics (n = 7), steroids (n = 1), and percutaneous drainage of fluid (n = 1). Clinical edema resolved after 2 to 48 hours, and patients were discharged 1 to 20 days postoperatively. Serious complications included transfer to the intensive care unit (n = 14), anterior interosseous nerve palsy (n = 4), rhabdomyolysis (n = 1), and death (n = 1).Conclusion:Fluid extravasation has the potential to be a life-threatening complication of shoulder arthroscopic surgery; however, it is most commonly managed nonoperatively, and symptoms typically resolve with no evidence of long-term complications. Intraoperative surgical decisions, such as minimizing the surgical time and volume of irrigation fluid used, may limit fluid extravasation, while careful intraoperative monitoring may facilitate prompt diagnosis and management to optimize patient outcomes.

Extravasation of fluid in arthroscopic shoulder surgery requiring prolonged intubation: a case report

“…The authors also suggest limiting the pump pressures to less than 150 mmHg. Utilizing a gravity feed irrigation setup may be a safer alternative to pump systems which result in higher intra-articular pressures [16–18]. Their literature review also found that symptomatic patients had irrigation volumes of between 20 and 36 L and suggest limiting the total irrigation volume to 20 L. [16]…”

“…Total operative time is directly proportional to the volume of irrigation fluid used and subsequent weight gain by the patient, presumably from absorption of the irrigation fluid [19]. Although there is no clear safe upper limit for operative times, some authors suggest limiting surgical time to between 90 and 120 min to reduce this risk [16, 20] .…”

“…Ichai et al demonstrated that there is systemic absorption of glycine irrigation fluid during shoulder arthroscsopy. Although the absorption of glycine may be different than that of other irrigation fluids including normal saline or Ringer’s lactate, the authors suggest that the risk of significant systemic absorption can be mitigated with lower pump pressures and a lower volume of irrigation fluid used during arthroscopy [16, 21].…”

Pulmonary edema following shoulder arthroscopy under general anesthesia with nerve block

“…For swelling of adjacent neck, chest, and facial tissues, most patients will be lack of obvious syndrome within 2 days after surgery. [ 2 ] However, in severe cases, excessive irrigation will flow into the pharyngolaryngeal and paratracheal space, which can lead upper respiratory obstruction [ 3 , 4 ] and even pulmonary edema. [ 5 ]…”

Pulmonary edema lead by circulation overload following shoulder arthroscopy under general anesthesia with nerve block: an observational study

“…As a result, it may lead the occurrence of signi cant edema of face, neck and chest tissues, tracheal compression, upper respiratory tract obstruction, and pulmonary edema. For swelling of adjacent neck, chest, and facial tissues, most patients will be lack of obvious syndrome within 2 days after surgery [2]. However, in severe cases, excessive irrigation will ow into the pharyngolaryngeal and paratracheal space, which can lead upper respiratory obstruction [3,4] and even pulmonary edema [5].…”