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

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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

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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.
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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

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Landmark Guided Lower Interscalene Block as a Rescue Approach in a Case of Elusive Supraclavicular Block for Elbow Surgery

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Vol 3 | Issue 2 | July-December 2022 | Page 105-106 | Pratibha Jain, A. Sashank, Divyanand Mishra

DOI: 10.13107/ijra.2022.v03i02.064

Authors: Pratibha Jain [1], A. Sashank [1], Divyanand Mishra [1]

[1] Department of Anaesthesia and Pain Management, Pandit Jawaharlal Nehru Memorial Medical College, Raipur, Chhattisgarh, India.

Address of Correspondence
Dr. Divyanand Mishra,
Department of Anaesthesia and Pain Management, Pandit Jawaharlal Nehru Memorial Medical College, Raipur, Chhattisgarh, India.
E-mail: itsdnmishra09@gmail.com

Letter to Editor

Dear Editor,
Our case was an 18 yrs/m, weighing 54 kg without co morbidities presented with pain in right elbow and was posted for screw fixation of fracture capitulum. His routine blood work and airway examination were normal to undergo the surgery under supraclavicular block (SCB). On arrival, patient’s PR was 84/min, BP- 118/72 mm Hg, SpO2- 98% on room air.
For right sided SCB, patient was placed supine, head turned to left side with shoulder depressed and needle was inserted lateral to subclavian artery pulsation just above the clavicle, posterolaterally. There was inadvertent puncture of subclavian artery each time, despite using standard techniques. Hence we decided to abandon standard SCB and proceed with lower interscalene block (LISB).Using modified Winnie’s approach interscalene groove was palpated and needle was inserted 2-3 cm below the classical interscalene block (ISB) site. Paresthesia was attained over whole upper limb and then Inj. Lignocaine + Adrenaline (2%) 10 ml along with inj. Bupivacaine 0.5% 10 ml was injected after repeated negative aspirations. A satisfactory sensory and motor blockade was obtained after 15 minutes of injection. Throughout the procedure, patient was continuously monitored and surgery was completed within 1.5h without any adverse event. The patient was shifted to ward. The block weaned off in 6 hrs and his vitals were stable throughout his course of stay in the hospital.
Traditionally, the subclavian artery is an important relation of the brachial plexus for landmark guided SCB. However, anatomical variation may be present in as much as 50% of the population. [1] T1 nerve root supplies skin both above and below the elbow. Some authors have suggested a combined ISB + axillary block to get profound anaesthesia for elbow surgery. [2,3] Axillary nerve block was not contemplated in our case as optimal arm positioning was precluded due to severe pain at elbow. The advantages of LISB over SCB and ISB or ISB + axillary block are that it significantly reduces the risk of pneumothorax , inadvertent arterial puncture, ulnar sparing (as lower trunks of brachial plexus are more superficial in LISB) and avoids multiple injections. LISB also provides adequate anaesthesia and analgesia to whole upper limb which could be due to the relative proximity of the inferior trunks to the other components of brachial plexus as they become tightly bundled between the clavicle and first rib at this level.[2] Performing an LISB is easier due to its accessibility and shallow location of the brachial plexus, which may be favourable to those who disfavour or may not be comfortable with the supraclavicular approach. [4]
Our case exemplifies that in those centres where ultrasound machine is unavailable and access to the brachial plexus for SCB by landmark technique remains elusive despite troubleshooting, lower interscalene block can be safely used to provide similar quality and extent of surgical anaesthesia.

References

1. Uysal I, Sekar M, Karabulut AK, Buyukmumcu M, Ziylan T. Brachial plexus variations in human foetuses. Neurosurgery 2003;53(3):676-684.
2. Gadsden JC, Tsai T, Iwata T, Somsundarum L, Robards C, Hadzic A. Low interscalene block provides reliable anesthesia for surgery at or about the elbow. Journal of Clinical Anesth 2009;21:98-102.
3. Faryniarz D, Morelli C, Coleman S, et al. Interscalene block anesthesia at an ambulatory surgery center performing predominantly regional anesthesia: a prospective study of one hundred thirty-three patients undergoing shoulder surgery. J Shoulder Elbow Surg 2006;15:686-90.
4. Brown AR, Parker GC. The use of a reverse axis (axillary interscalene) block in a patient presenting with fractures of the left shoulder and elbow. Anesth Analg 2001;93:1618-20.

How to Cite this Article: Jain P, Sashank A, Mishra D | Landmark Guided Lower Interscalene Block as a Rescue Approach in a Case of Elusive Supraclavicular Block for Elbow Surgery | International Journal of Regional Anaesthesia | July-December 2022; 3(2): 105-106.

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