Incidence of Hemidiaphragmatic Paralysis After Ultrasound Guided Low Dose Interscalene Brachial Plexus Block

June 10, 2024/1,011 Comments/in Volume 5; Issue 1: January-June 2024/by Ijraijraadmin

Vol 5 | Issue 1 | January-June 2024 | Page 18-23| Tanvir Samra, Pankaj Kushal, Vikas Saini, Sameer Sethi, Rahul Kathuria, Anjuman Chander

DOI: https://doi.org/10.13107/ijra.2024.v05.i01.086

Authors: Tanvir Samra [1], Pankaj Kushal [1], Vikas Saini [1], Sameer Sethi [1], Rahul Kathuria [2], Anjuman Chander [1]

[1] Department of Anaesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
[2] Department of Anaesthesia, Park Hospital, Ambala, Haryana, India.

Address of Correspondence

Dr. Anjuman Chander,
Department of Anaesthesia, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
E-mail: Achander08@gmail.com

Abstract

Background and Aims: Hemidiaphragmatic paralysis is a complication of single shot and continuous interscalene brachial plexus block that can be minimised by ultrasound guided extra fascial catheter placements and by limiting the amount of local anaesthetic administered. In this study, we report incidence of hemidiaphragmatic paralysis with patient-controlled infusion of low volume of ropivacaine after ultrasound guided low dose interscalene brachial plexus block (LD-ISB).
Methods: Patients aged 18-65 years undergoing surgery for shoulder dislocation or proximal humerus fracture were recruited and administered general anaesthesia. Before extubation ultrasound guided LD-ISB (10 ml of 0.5% ropivacaine) was administered and a catheter tunneled so that patient controlled interscalene analgesia (PCIA) could be given with low volume ropivacaine. PCIA was initiated after four hours in the post operative recovery to deliver background infusion of 2 ml/h, bolus of 5ml (0.2% of ropivacaine) with lockout interval of 30 minutes for a total duration of 24 hours. Incidence of hemidiaphragmatic paralysis was recorded at extubation using M-mode ultrasonography. Before start of PCIA i.e. at 4 hours and after start of PCIA i.e. 6,12 and 24 h after extubation.
Results: PCIA after LD-ISB was administered to 29 patients. Subsequently, two patients were excluded due to catheter dislodgement. The incidence of complete and partial paresis of diaphragm after extubation was 85% and 3.7% with LD-ISB respectively but was resolved before start of PCIA i.e., at 4 hours. Thus, at time of commencement of PCIA all patients had normal diaphragmatic excursions and subsequently at 6,12 and 24 h no paresis/paralysis was reported in patients administered only the background infusion or an additional single bolus dose of ropivacaine with the background infusion. Partial paresis was noted in all patients in which two bolus doses/h were administered. All patients with paresis had diaphragmatic excursion normalised in the next recording made at 4 hours and no complication was reported in any patient. VAS (Visual Analog Scale) was below 3 at all time points.
Conclusion: Partial/complete paresis after a single shot injection of 10 ml of 0.5% ropivacaine resolves in 4 hours. PCIA initiated after it for subsequent 20 hours with a single bolus dose of 5ml of 0.2% ropivacaine and background infusion at 2 ml/h does not cause phrenic paresis. Partial paresis is reported with two bolus doses/h, but it is clinically asymptomatic. Thus, the above dose regimes are safe and effective in managing post-operative pain.
Keywords: Interscalene block, Diaphragmatic paresis, Ropivacaine, continuous infusion, Analgesic efficacy

References

1. Cugnin N, Le Gaillard B, Souza Neto EP. Permanent hemidiaphragmatic paresis after interscalene brachial plexus block: a case report. Braz J Anesthesiol. 2021 Mar-Apr;71:175-177.
2. Oliver-Fornies P, Ortega Lahuerta JP, Gomez Gomez R, Gonzalo Pellicer I, Oliden Gutierrez L, Viñuales Cabeza J,et al. Diaphragmatic paralysis, respiratory function, and postoperative pain after interscalene brachial plexus block with a reduced dose of 10 ml levobupivacaine 0.25% versus a 20 ml dose in patients undergoing arthroscopic shoulder surgery: study protocol for the randomized controlled double-blind REDOLEV study. Trials. 2021;22:287.
3. Meng Y, Wang S, Zhang W, Xie C, Chai X, Shu S,et al. Effects of Different 0.2% Ropivacaine Infusion Regimens for Continuous Interscalene Brachial Plexus Block on Postoperative Analgesia and Respiratory Function After Shoulder Arthroscopic Surgery: A Randomized Clinical Trial. J Pain Res. 2022;15:1389-1399
4. Kim KS, Ahn JH, Yoon JH, Ji HT, Kim IS. Hemidiaphragmatic Paresis Following Interscalene Brachial Plexus Block With 2-Point Injection Technique. Pain Physician. 2021 ;24:507-515.
5. Vorobeichik L, Brull R, Bowry R, Laffey J, Abdallah F. Should continuous rather than single-injection interscalene block be routinely offered for major shoulder surgery? A meta-analysis of the analgesic and side-effects profiles. Br J Anaesth. 2018;120:679-692.
6. Albrecht E, Bathory I, Fournier N, Jacot-Guillarmod A, Farron A, Brull R. Reduced hemidiaphragmatic paresis with extrafascial compared with conventional intrafascial tip placement for continuous interscalene brachial plexus block: a randomized, controlled, double-blind trial. Br J Anaesth. 2017;118:586-592.
7. Ayyanagouda B, Hosalli V, Kaur P, Ambi U, Hulkund SY. Hemi-diaphragmatic paresis following extrafascial versus conventional intrafascial approach for interscalene brachial plexus block: A double-blind randomised, controlled trial. Indian J Anaesth. 2019;63:375-381
8. Sun LY, Basireddy S, Gerber LN, Lamano J, Costouros J, Cheung E,et al. Continuous interscalene versus phrenic nerve-sparing high-thoracic erector spinae plane block for total shoulder arthroplasty: a randomized controlled trial. Can J Anaesth. 2022;69:614-623.
9. Vandepitte C, Gautier P, Xu D, Salviz EA, Hadzic A. Effective volume of ropivacaine 0.75% through a catheter required for interscalene brachial plexus blockade. Anesthesiology. 2013 ;118:863-7.
10. Diwan S, Nair A, Adhye B, Sancheti P. Continuous incremental interscalene block for proximal humerus in patients with severe pulmonary injury. Indian J Anaesth. 2022 ;66:460-463.
11. Lang J, Cui X, Zhang J, Huang Y. Dyspnea induced by hemidiaphragmatic paralysis after ultrasound-guided supraclavicular brachial plexus block in a morbidly obese patient. Medicine (Baltimore). 2022;101:28525.
12. Liu Y, Xu C, Wang C, Gu F, Chen R, Lu J. Median Effective Analgesic Concentration of Ropivacaine in Ultrasound-Guided Interscalene Brachial Plexus Block as a Postoperative Analgesia for Proximal Humerus Fracture: A Prospective Double-Blind Up-Down Concentration-Finding Study. Front Med (Lausanne). 2022;9:857427.
13. Khurana J, Gartner SC, Naik L, Tsui BCH. Ultrasound Identification of Diaphragm by Novices Using ABCDE Technique. Reg Anesth Pain Med. 2018;43:161-165.
14. Sripriya R, Manisha Gupta J, Arthi PR, Parthasarathy S. Ultrasound measurement of the distance of the phrenic nerve from the brachial plexus at the classic interscalene point and upper trunk: A volunteer-based observational study. Indian J Anaesth. 2023 ;67:457-462.
15. Robles C, Berardone N, Orebaugh S. Effect of superior trunk block on diaphragm function and respiratory parameters after shoulder surgery. Reg Anesth Pain Med. 2022 ;47:167-170.
16. Srinivasan KK, Ryan J, Snyman L, O’Brien C, Shortt C. Can saline injection protect phrenic nerve? – A randomised controlled study. Indian J Anaesth. 2021;65:445-450.
17. Ngai LK, Ma W, Costouros JG, Cheung EV, Horn JL, Tsui BCH. Successful reversal of phrenic nerve blockade following washout of interscalene nerve block as demonstrated by ultrasonographic diaphragmatic excursion. J Clin Anesth. 2020 ;59:46-48.
18. Smith LM, Barrington MJ. A novel approach to reversal of respiratory distress following insertion of an interscalene nerve catheter. J Clin Anesth. 2018;47:43-44.

How to Cite this Article: Samra T, Kushal P, Saini V, Sethi S, Kathuria R, Chander A | Incidence of Hemidiaphragmatic Paralysis After Ultrasound Guided Low Dose Interscalene Brachial Plexus Block | International Journal of Regional Anaesthesia | Januar y-June 2024; 5(1): 18-23 | DOI: https://doi.org/10.13107/ijra.2024.v05.i01.86