Dyspnea induced by hemidiaphragmatic paralysis after ultrasound-guided supraclavicular brachial plexus block in a morbidly obese patient

Abstract

Rationale: Hemidiaphragmatic paralysis (HDP) is a frequent complication of the brachial plexus block, caused by unintentional blockade of ipsilateral phrenic nerve. HDP did not rise enough alarm and attention to most anesthesiologists, because most patients with no coexisting comorbid diseases are asymptomatic and able to tolerate it. However, it may cause severe respiratory complication for patients with preexisting compromised cardiorespiratory function. Patient concerns: A 67-year-old woman with morbidly obesity was planned to receive opening reduction and internal fixation of right humeral shaft fracture under regional anesthesia considering less respiratory and cardiovascular system interference compared with general anesthesia. Diagnoses: After ultrasound guided supraclavicular brachial plexus block, the patient developed severe hypoxia and hypercapnia.Unintentional block of phrenic nerve and diaphragm paralysis was diagnosed by diaphragm ultrasound, which was considered as the main reason of severe hypoxia. Interventions: It led to a conversion from regional anesthesia to general anesthesia with endotracheal intubation for patient's safety and smooth operation. Outcomes: The unintentional phrenic nerve block leads to a prolonged ventilation time, length of stay in intensive care unit and length of stay in hospital. Lessons: This case report highlights the risk of diaphragm paralysis in morbidly obese patients. Though new diaphragm sparing brachial plexus block (BPB) methods were developed intended to reduce the risk of HDP, no approaches could absolutely spare phrenic nerve involvement. Therefore, clinicians should always consider the risk of HDP associated with BPBs. For each individual, a detailed preoperative evaluation and sufficient preparation are paramount to avoid serious complications.

Erector Spinae Plane Block as the Phrenic Nerve Sparing Anaesthetic Technique for Shoulder Arthroplasty

“…The most notable yet accepted complication of BPB in this context is hemi-diaphragmatic paralysis resulting from local anesthetic going over the phrenic nerve [ 5 , 8 ], the incidence of which approaches 100% [ 9 ]. Phrenic nerve palsy, in turn, may lead to dyspnea and hypoxic episodes in high-risk patients such as the obese (BMI >30) [ 6 , 7 ] and those with pre-existing respiratory disease [ 8 ].…”

“…In the context of shoulder surgery, the most common regional techniques of branchial plexus block (BPB) are supraclavicular and interscalene approaches, both of which pose a significant risk of phrenic nerve palsy, semi-diaphragmatic paralysis, and subsequent respiratory failure [5]. This is especially true in patients with a high risk of respiratory complications, such as those with chronic respiratory compromise, and in the obese [6][7][8]. ESPB subverts this risk while also providing good analgesia at multiple dermatome levels [1].…”

Diagnosis of hemidiaphragm paralysis: refine ultrasound criteria

“…Hemidiaphragm paralysis is most frequently well tolerated in previously healthy subjects. In contrast, tolerance is bad in patients with comorbidities such as obesity, and cardiac or respiratory disorders ( 15 , 16 ). In these patients and in case of bilateral diaphragm dysfunction, ventilatory mechanical support may be necessary ( 17–19 ).…”