Fatal Venous Air Embolism During Shoulder Arthroscopy

Abstract

Venous air embolism is a potential surgical complication when a negative pressure gradient exists between the surgical site and the right atrium of the heart. It occurs more commonly when the operative site is over the heart, the pressure of gas in the body cavity exceeds that of the venous sinusoids (15 to 30 mm Hg), air rather than carbon dioxide is injected, or the venous sinusoids of bone marrow are exposed1,2. Shoulder arthroscopy satisfies many of these criteria: the beach-chair and lateral decubitus positions place the surgical site over the right atrium, the standard settings for arthroscopic pumps are at pressures of >30 mm Hg, air bubbles are often observed entering the joint, and venous sinusoids are exposed anytime that osseous work (i.e., distal clavicular excision, acromioplasty, or fracture repair) is performed. Two case reports of fatal venous air embolism following knee arthroscopy3,4 with intentional air insufflation have appeared in the literature, but we are not aware of any reported case following liquid-only arthroscopy. We present the case of a patient undergoing revision arthroscopic rotator cuff repair and distal clavicular excision who experienced acute intraoperative cardiopulmonary collapse and was resuscitated, but died on postoperative day 14. The patient was undergoing liquid-only arthroscopy, and we postulated that air entered the joint through an unrecognized air reservoir: commercially available 3-L arthroscopic fluid bags. A forty-seven-year-old woman presented with a six-month history of severe pain in the right shoulder. The history, physical examination, and magnetic resonance imaging revealed a small, full-thickness tear of the supraspinatus tendon. After the failure of six months of conservative treatment, she elected to undergo arthroscopic supraspinatus repair and subacromial …