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Arthroscopic shoulder surgery under general anesthesia with brachial plexus block

Postoperative respiratory dysfunction of combined obstructive and restrictive pathology

Arthroskopische Schulteroperation in Allgemeinanästhesie mit Plexus-brachialis-Blockade

Postoperative Atemdysfunktion mit kombinierter obstruktiver und restriktiver Störung

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Abstract

Objective

Changes in respiratory parameters and pulmonary function tests were evaluated after shoulder arthroscopic surgery with brachial plexus block (BPB). The purpose of this study was to identify the mechanism of respiratory dysfunction after this type of surgery.

Methods

Patients undergoing arthroscopic rotator cuff repair under general anesthesia (GA) with BPB were enrolled in the arthroscopy group (n = 30) while those undergoing open reduction of a clavicle or humerus fracture under GA were enrolled in the control group (n = 30). Forced vital capacity (FVC) and forced expiratory volume 1 s (FEV1) were measured at the outpatient clinic stage (#1) before (#2) and 20 min after BPB (#3) and 1 h after extubation (#4). Respiratory variable measurements along with the cuff leak test were performed 5 min after surgical positioning (T1) and at the start of skin closure (T2). Respiratory discomfort was evaluated after extubation. The upper airway diameters and soft tissue depth of chest wall were also measured by ultrasonography at stages #3 and #4.

Results

Static compliance decreased significantly at T2 in the arthroscopy group (50 ± 11 at T1 vs. 44 ± 9 ml/cm H2O at T2, p =0.035) but not in the control group. The incidence of positive cuff leak tests at T2 was significantly higher in the arthroscopy group than in the control group (47% in the arthroscopy group vs. 17% in controls, p =0.010). While FEV1 and FVC remained stable at stages #1 and #2, FVC and FEV1 decreased at stages #3 and #4 only in the arthroscopy group (FVC in arthroscopy group, #2: 3.26 ± 0.77 l; #3: 2.55 ± 0.63 l, p =0.015 vs. #2; #4: 2.66 ± 0.41 l, p =0.040 vs. #2). The subglottic diameter decreased at #4 in the arthroscopy group, while no changes occurred in the control group (0.70 ± 0.21 cm vs. 0.85 ± 0.23 cm in the arthroscopy and control groups, respectively, p =0.011). Depth of skin to pleura increased at both intercostal spaces 1–2 and 3–4 in the arthroscopy group. There were three cases of hypoxia (SpO2 < 95%) with room air in the arthroscopy group while none occurred in the controls.

Conclusion

Shoulder arthroscopic surgery under GA with BPB induced both restrictive and obstructive pathologies. It is important to maintain a high level of awareness for the potential negative respiratory effects of this surgery especially for subjects with pre-existing cardiopulmonary disease. The measurements in this study would be useful to monitor the risk of respiratory dysfunction in these patients.

Zusammenfassung

Ziel

Evaluiert wurden die Veränderungen von atemwegsbezogenen Parametern und Lungenfunktionsuntersuchungen nach unter Plexus-brachialis-Blockade (PBB) durchgeführten arthroskopischen Operationen an der Schulter. Ziel war die Identifizierung der Mechanismen, die postoperativen Atemdysfunktionen zugrunde liegen.

Methoden

Patienten mit arthroskopischer Rotatorenmanschettenrevision in Allgemeinanästhesie (GA) und PBB wurden in die Arthroskopiegruppe (n=30) aufgenommen, Patienten mit offen behandelter Klavikula- oder Humerusfraktur in die Kontrollgruppe (n=30). Die forcierte Vitalkapazität (FVC) und das forcierte exspiratorische Einsekundenvolumen (FEV1) wurden präoperativ im ambulanten Setting (#1), vor (#2) und 20 min nach der PBB (#3) sowie 1 h nach Extubation (#4) bestimmt. Die Messung atemwegsbezogener Variablen sowie der „Cuff-leak“-Test wurden 5 min nach Lagerung (T1) und zu Beginn des Hautverschlusses (T2) durchgeführt. Atemwegsbezogene Beschwerden wurden nach der Extubation bewertet, ferner wurden zu den Messzeitpunkten #3 und #4 die Durchmesser der oberen Atemwege sowie die Weichgewebetiefe des Brustkorbs sonographisch bestimmt.

Ergebnisse

Die statische Compliance verringerte sich signifikant zum Zeitpunkt T2 in der Arthroskopiegruppe (50±11 bei T1 vs. 44±9 ml/cm H2O bei T2, p=0,035), nicht jedoch in der Kontrollgruppe. Die Inzidenz eines positiven Cuff-leak-Tests zum Zeitpunkt T2 war in der Arthroskopiegruppe signifikant höher als in der Kontrollgruppe (47 vs. 17%; p=0,010). Während FEV1/FVC erhalten blieb, verringerten sich FVC und FEV1 zu den Zeitpunkten #3 and #4 nur in der Arthroskopiegruppe [FVC in der Arthroskopiegruppe, #2: 3,26±0,77 l; #3: 2,55±0,63 l (p=0,015 vs. #2); #4: 2,66±0,41 l (p=0,040 vs. #2)]. Der subglottische Durchmesser war zum Zeitpunkt #4 in der Arthroskopiegruppe verringert, in der Kontrollgruppe dagegen unverändert (0,70±0,21 vs. 0,85±0,23 cm; p=0,011). Die Distanz zwischen Haut und Pleura, gemessen in den Interkostalräumen 1–2 und 3–4, erhöhte sich in der Arthroskopiegruppe. Anders als in der Kontrollgruppe kam es in der Arthroskopiegruppe in 3 Fällen zu einer Hypoxie [pulsoxymetrisch gemessene Sauerstoffsättigung (SpO2) <95%] unter Raumluft.

Schlussfolgerung

Bei arthroskopischen Schulteroperationen unter GA mit PBB wurden restriktive und obstruktive pathologische Veränderungen induziert. Wichtig ist ein kontinuierliches, ausgeprägtes Bewusstsein für potenzielle negative Auswirkungen dieser Operationen auf die Atmung, besonders bei Patienten mit einer vorbestehenden kardiopulmonalen Erkrankung. Die in der vorliegenden Studie vorgestellten Maßnahmen könnten beim Monitoring des atemwegsbezogenen Risikos für diese Patienten hilfreich sein.

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The corresponding author states that there are no conflicts of interest.

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Authors and Affiliations

  1. Department of Anesthesiolgy and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-Dong, 135-710, Seoul, Republic of Korea

    M.S. Gwak, W.H. Kim MD, S.J. Choi, J.J. Lee, J.S. Ko, G.S. Kim, Y.I. Kim & M.H. Kim

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  1. M.S. Gwak
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  2. W.H. Kim MD
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  4. J.J. Lee
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Correspondence to W.H. Kim MD.

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Gwak, M., Kim, W., Choi, S. et al. Arthroscopic shoulder surgery under general anesthesia with brachial plexus block. Anaesthesist 62, 113–120 (2013). https://doi.org/10.1007/s00101-012-2125-y

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  • DOI: https://doi.org/10.1007/s00101-012-2125-y

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