Case 16: Shoulder Surgery – Watch Out!

Abstract

Today you are anesthetizing a 38 year old man (90 kg and 185 cm) for shoulder reconstruction. The patient is otherwise healthy and does not take any medication regularly. He has not had any surgery in the past. A surgeon, you have never worked with, is going to do the surgery. The patient is anesthetized in a routine manner with fentanyl, propofol, and rocuronium. The trachea is intubated using a #9 endotracheal tube (ETT). The ETT is secured at 22 cm. The patient receives positive-pressure ventilation. Anesthesia is maintained with sevoflurane in oxygen. The patient is placed in a beach chair position and his left arm is placed on a McConnell armholder (Greenville, TX 75401) and secured. You have not seen anyone use this armholder before. The surgery commences. Two hours later there is a sudden drop in systolic pressure to 60 mmHg, measured at the right ankle. The heart rate goes from 60 to 110 bpm and the end-tidal CO₂ decreases from 30 to 15 mmHg. The oxygen saturation decreases from 100 to 85%. The ventilator parameters all remain the same. You cannot see any obvious blood loss nor have you given any medications for over 1.5 h.