Severe stridor and marked respiratory difficulty after right-sided supraclavicular brachial plexus block

Abstract

Brachial plexus block is commonly used for upper limb surgery. Although the procedure is safe, it may be associated with some life-threatening complications. We performed right-sided supraclavicular brachial plexus block for below-elbow amputation in a 45-year-old female. At completion of the block the patient developed marked respiratory difficulty with audible inspiratory stridor. Although SpO(2) decreased to 82% initially, it was increased to 100% by continuous positive airway pressure with a face mask. On conventional direct laryngoscopy, the left vocal cord was found to be in the midline position and the right vocal cord was in the paramedian position. The trachea was intubated and surgery proceeded without any other complication. Postoperative indirect laryngoscopy revealed that the left vocal cord was fixed, whereas the right vocal cord was mobile, and diagnosis of pre-existing incomplete left vocal cord paralysis was made. This clinical report is to emphasize the importance of thorough pre-operative evaluation of the vocal cord in patients who have undergone any surgical procedure or radiation treatment of the neck before planning for brachial plexus block. If such an evaluation cannot be obtained, an alternative technique, for example axillary approach, should be preferred.

Delayed bilateral vocal cord paresis after a continuous interscalene brachial plexus block and endotracheal intubation

“…When the recurrent laryngeal nerve is blocked following ISB, it is known to normally present symptoms within 30 minutes of the initial bolus. [6] Complications of an ipsilateral recurrent laryngeal nerve block usually have less clinical implications, such as mild hoarseness. However, there are reported cases which presented with acute respiratory failure owing to bilateral vocal cord paresis after ISB.…”

“…However, there are reported cases which presented with acute respiratory failure owing to bilateral vocal cord paresis after ISB. [5,6,13] Plit et al [5] described a case of bilateral vocal cord paresis following ISB in a patient who had previously undergone a total thyroidectomy and had symptoms of persistent mild hoarseness. Solanski et al [6] also reported a case of acute respiratory difficulty after a right-side supraclavicular brachial plexus block in a patient with an unrecognized preexisting left side vocal cord palsy.…”

“…[5,6,13] Plit et al [5] described a case of bilateral vocal cord paresis following ISB in a patient who had previously undergone a total thyroidectomy and had symptoms of persistent mild hoarseness. Solanski et al [6] also reported a case of acute respiratory difficulty after a right-side supraclavicular brachial plexus block in a patient with an unrecognized preexisting left side vocal cord palsy. To our knowledge, however, no previous report has documented bilateral vocal cord paresis resulting from ISB and endotracheal intubation in a patient with no preexisting vocal cord palsy or previous neck-associated surgical history, which we report in our current case.…”

“…[2–4] Severe life-threatening complications are also possible, however, and care must be taken to prevent such adverse events. [5,6] Recurrent laryngeal nerve block is an uncommon complication that can occur after ISB, which may lead to vocal cord palsy or paresis. The majority of cases are known to be unilateral and arise on the ipsilateral side of the procedure.…”