title: Pneumothorax following shoulder arthroscopy under combined regional and general anaesthesia-A case report.
abstract: BACKGROUND
  Pneumothorax is a most rare intraoperative event but jeopardise safety. Risk factors for its occurrence should be acknowledged and it should be considered in cases of unexpected deterioration of oxygenation that not respond to standard management to improve oxygenation.
  
  
  METHODS
  We describe a patient with mild obesity and recent shoulder trauma scheduled for elective arthroscopy under combined interscalene block and general anaesthesia in the beach chair position. The block was performed with ultrasound guidance in accordance with the departmental routines and before the induction of general anaesthesia. The patient experienced low saturation shortly after administration of general anaesthesia. A thoracic ultrasound was performed in order to rule out pneumothorax and recruitment manoeuvres was done based on the suspicion of atelectasis. Surgery was commenced under pressure controlled ventilation and saturation was kept around 90 at FiO2 1.0 after recruitment manoeuvres. An initial postoperative lung X-ray on the operating table showed subcutaneous emphysema but no pneumothorax. A postoperative CT-thorax, patient still intubated, showed an extensive pneumothorax that was treated with pulmonary drainage. Patient had subsequently an uncomplicated postoperative course.
  
  
  CONCLUSIONS
  We can not state "whom to blame", the interscalene block, intubation and pressures assisted ventilation, recruitment manoeuvres, or surgery? In this paper we discuss possible causes that should raise the suspicion around pneumothorax in patients exhibiting unexpected low saturation perioperatively.
  
  
  CONCLUSIONS
  Compromised oxygenation during surgery that not respond to recruitment should raise suspicion about pneumothorax.
authors.affiliation: Department of Anaesthesia & Intensive Care, Institution for Clinical Science, Karolinska Institutet, Danderyds University Hospital, Stockholm, Sweden.
authors.forename: Oskar
authors.initials: O
authors.lastname: Leander-Olsson
authors.affiliation: Department of Anaesthesia & Intensive Care, Institution for Clinical Science, Karolinska Institutet, Danderyds University Hospital, Stockholm, Sweden.
authors.forename: Anna
authors.initials: A
authors.lastname: Borglund-Hemph
authors.affiliation: Department of Anaesthesia & Intensive Care, Institution for Clinical Science, Karolinska Institutet, Danderyds University Hospital, Stockholm, Sweden. Electronic address: Jan.jakobsson@ki.se.
authors.forename: Jan G
authors.initials: JG
authors.lastname: Jakobsson
keywords: Case report; General anaesthesia; Pneumothorax; Shoulder arthroscopy; Upper extremity block