Reporte de Caso

Antonio José Bonilla Ramírez*, Reinaldo Grueso Angulo**, Edwin Enrique Peñate Suárez***

* Profesor Asistente Facultad de Medicina Pontificia Universidad Javeriana, Anestesiólogo, Coordinador de la clínica de dolor agudo postoperatorio y crónico benigno. Departamento de Anestesiología, Hospital Universitario San Ignacio Bogotá DC, Colombia. Correspondencia: Calle 138 No. 58 D - 01 Apto 501 Torre 11 Bogotá, Colombia, Correo electrónico: antoniojbonilla@hotmail.com

** Director Departamento Anestesia, Profesor Asistente Facultad de Medicina Pontificia Universidad Javeriana, Anestesiólogo, Departamento de Anestesiología Hospital Universitario San Ignacio, Bogotá DC, Colombia.

*** Residente de Anestesiología de Tercer Año, Facultad de Medicina, Pontificia Universidad Javeriana. Departamento de Anestesiología Hospital Universitario San Ignacio Bogotá DC, Colombia. Correo electrónico: epenate@javeriana.edu.co

Recibido: agosto 10 de 2011. Enviado para modificaciones: agosto 15 de 2010. Aceptado: agosto 20 de 2011.

Introduction. Regional anesthesia techniques have grown exponentially in the last decades, and there is a growing number of patients who can benefit from anesthetic or analgesic peripheral nerve blocks. The use of Regional Anesthesia has shown to be a helpful tool for postoperative analgesic management. The infraclavicular approach to the brachial plexus block is widely used in upper extremity surgery.

This article reports a case of diaphragmatic paresis (1,2), secondary to an infraclavicular brachial plexus block, an unusual complication when compared with the 100 % incidence in patients with interscalene brachial plexus block ( 3,4), and with the 50 %-67 % incidence found with the supraclavicular approach, resulting from the ipsilateral phrenic nerve block (5).

Case presentation

Fifty-two year-old female patient, 82 kg in weight, 1.57 m tall, BMI = 33, with a diagnosis of extra-articular distal metaphiseal fracture of the radius, with dorsal angulation. The patient has a history of bilateral ovarian cyst removal, two C-sections, myomectomy, release of pelvic adhesions, inguinal hernia repair, and erratic use of tramadol. The patient is mentally competent and shows adequate interaction with the environment in a functional class I/IV, and denies having a history of cardiopulmonary, medical, toxic or allergic disorders. Laboratory tests are within normal limits at the time (complete blood count, blood chemistry and chest X-rays).

The patient was scheduled for open reduction and internal fixation with plates. She is taken to the operating room with stable vital signs, and EKG, pulse oxymetry and indirect blood pressure monitoring is initiated. Oxygen supplementation is provided through a nasal cannula at 2 L/m, and conscious sedation is given with Midazolam 1.5 mg and Fentanyl 75 mcg. An infraclavicular brachial plexus block is performed through the coracoid approach under monitoring with a Stimuplex® nerve stimulator (HNS12 BRAUN®) fitted with a 50 mm, 24 G Stimuplex® needle (A BRAUN® 24G); maximum and minimum voltages were 1.5 mAmp and 0.4 mAmp, respectively; stimulation time was 0.1 msec at a frequency of 1Hz. The multiple injection technique is used in order to provide 2 % lidocaine with epinephrine 1:200.000 (20 ml), plus 0.5 % bupivacaine without epinephrine (20 ml), for a total volume of 40 ml. There is no paresthesia or blood aspiration, and low infiltration pressures are maintained, with a 15 minute onset latency.

The surgical procedure lasts 60 minutes and there no complications or a need for additional local anesthetic or sedation. During surgery, the patient complains of non-specific chest discomfort; saturations are over 92 %, never reaching more than 95 %.

The patient is transferred later to the recovery room without oxygen supplementation. Upon arrival, continuous blood pressure and oxygen saturation monitoring reveal persistent desaturation down to 81 %, with no signs of respiratory distress, and normal cardiopulmonary findings on auscultation. A 50 % inspired fraction is delivered, evoking a good response, with saturations above 92 %. A chest X-ray is performed and shows no evidence of consolidation or pneumothorax, although there is evidence of left diaphragmatic paralysis. (Figure 1.)

The patient continues under observation in the post-anesthetic care unit for five hours. The patient tolerates oxygen weaning, does not require supplementation during the last hour and shows stable vital signs and no respiratory distress.

She is discharged and continues under outpatient management.

A case of diaphragmatic paresis following an infraclavicular brachial plexus block through the coracoid approach is presented.

Diaphragmatic paresis is a frequent complication in cases where the brachial plexus block is done through the interscalene or the supraclavicular approaches, with an incidence of 100 % and 67 %, respectively. However, there are only two cases reported in the literature of ipsilateral hemidiaphragmatic paralysis following and infraclavicular block: the first is an 85 year-old female patient taken to carpal tunnel surgery in whom a mix of 1 % ropivacaine (20 ml) and 1 % prilocaine al (20 ml) was used with a total volume of 40 ml (6); the second case is a 75 year-old male patient with Dupuytren’s disease and a history of Chronic Obstructive Pulmonary Disease, in whom 40 ml of 0.75 % ropivacaine was used (7). Rettig et al. showed that diaphragmatic function is affected in 26 % of cases following infraclavicular brachial plexus block (8).

The mechanism whereby hemidiaphragmatic paralysis occurs in brachial plexus blockade is the concomitant blockade of the phrenic nerve in its course along the anterior aspect of the anterior scalene muscle, posterior to its origin in C3 - C5, because of the distribution of the local anesthetic along the perineuromuscular fascias. This phenomenon occurs more frequently in supraclavicular approaches to the brachial plexus block.

It is believed that the infraclavicular approach to the brachial plexus block, since it is anatomically distal to the phrenic nerve, does not produce the proximal distribution of the local anesthetic that is actually responsible for nerve compromise and ipsilateral hemidiaphragmatic paralysis (9). However, recent reports in the literature mention a percentage greater than ever described before of certain clinical manifestations consistent with the blockade of the cervical sympathetic chain (Horner’s syndrome) in patients taken to infraclavicular brachial plexus block through the coracoid approach (10,11,12). This theory is in contrast with the literature and with the studies mentioned above, according to which local anesthetic distribution in the infraclavicular approach was limited to the infraclavicular fossa, with no impact on diaphragmatic function (13,14).

In this case, apparently the third to be published in the literature, there is phrenic nerve block and ipsilateral diaphragmatic paresis following the infraclavicular approach, with its consequent clinical repercussions, leading to a delayed discharge of a patient coming for ambulatory upper limb surgery.

In the past, the infraclavicular block was identified as an upper axillary block and it was con sidered that the local anesthetic would distribute distally, but apparently this is not always true.

The literature is not clear on whether the incidence of the reported event is sufficiently high or not, as to take precautions in populations prone to hemidiaphragmatic dysfunction. On the other hand, although the incidence of this problem with the interscalene approach is 100 %, it does not always have clinical repercussions.

Considering these aspects, the question arises of who may and may not be offered a block that entails the risk of diaphragmatic paresis.

Certain potential factors that might contribute to diaphragmatic paresis following infraclavicular brachial block may be considered. Age could be a factor, considering that two out of two cases described in the literature occurred in patients over 75; the volume of 40 ml of anesthetic solution may be another factor; patient body build, the distance between the infraclavicular fossa and the phrenic nerve; the interfascial infiltration distribution outside the perineural aponeurosis; and, of course, the individual anatomical variations. Lack of knowledge about these factors is a motivation for undertaking studies designed to evaluate the potential variables involved.

The availability of ultrasound guidance for the performance of brachial plexus blocks has shown to reduce the volumes of local anesthetic infiltrations, as well as blockade latencies, without affecting the effectiveness of the block. Consequently, ultrasound might be useful in guiding the infiltration, reducing infiltration volumes and minimizing the potential for extraperineurovascular interfascial infiltration with its resulting proximal distribution. As such, ultrasound might contribute to a reduced incidence of this undesired effect. (15,16).

In conclusion, although a phrenic nerve block may occur when an infraclavicular brachial plexus block is performed through the coracoid approach, it appears to be an infrequent complication, or at least an infrequent clinical complication. Studies designed to assess diaphragm mobility following these types of blocks are warranted, as well as studies to identify risk factors of diaphragmatic paralysis.

Although this approach is safe in older patients with comorbid conditions associated mainly with a history of lung disease, the possibility of this complication occurring also in other ambulatory patients must not be overlooked.

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2. Vincent M, Fourcade O, Idabouk L, Claassen J, Chassery C, Nguyen L, et al. Infraclavicular brachial plexus block versus humeral block in trauma patients: a comparison of patient comfort. Anesthesia and Analgesia 2006;102:912-6.

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4. Urmey WF, Talts KH, Sharrock NE. One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesthesia and analgesia 1991;72:498-503.

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6. Stadlmeyer W, Neubauer J, Finkl RO, Groh J. Unilateral phrenic nerve paralysis after vertical infraclavicular plexus block. Anaesthesist 2000;49:1030-3.

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13. Rodríguez J, Bárcena M, Alvarez J. Restricted infraclavicular distribution of the local anesthetic solution after infraclavicular brachial plexus block. Regional Anesthesia and Pain Medicine 2003;28(1):33-6.

14. Dullenkopf A, Blumenthal S, Theodorou P, Roos J, Perschak H, Borgeat A. Diaphragmatic excursion and respiratory function after the modified Raj technique of the infraclavicular plexus block. Regional Anesthesia and Pain Medicine. 2004;29(2):110-4.

15. Renes SH, Rettig HC, Gielen MJ, Wilder-Smith OH, Van Geffen GJ. Ultrasound-guided low-dose interscalene brachial plexus block reduces the incidence of hemidiaphragmatic paresis. Regional Anesthesia and Pain Medicine 2009;34(5):498-502.

16. Renes SH, Spoormans HH, Gielen MJ, Rettig HC, Van Geffen GJ. Hemidiaphragmatic paresis can be avoided in ultrasound-guided supraclavicular brachial plexus block. Regional Anesthesia and Pain Medicine 2009;34(6):595-9.