Friday, June 29, 2018

Interscalene brachial plexus block and respiratory compromise

These authors present an interesting case of persistent diaphragmatic paralysis associated with an intescalene brachial plexus block (ISB).

While interscalene nerve blocks have are often used for shoulder surgery, they are not without risk and carry an overall complication rate between 2% and 4%.

Transient ipsilateral hemidiaphragmatic paralysis can be observed in association with ISB, and may transiently occur in up to 100% of patients because the phrenic nerve is close to the target brachial plexus nerve roots.

They point out that interscalene block (ISB) can result in a 20% to 25% decrease in forced vital capacity attributable to ipsilateral diaphragm paralysis associated with phrenic nerve involvement during an ISB. Healthy patients are able to compensate for this decrease in forced vital capacity by increasing their respiratory rate and using accessory respiratory muscles until the block wears off, which typically occurs within 3 to 5 hours. They advise that caution should be taken in patients with preexisting respiratory conditions because an ISB may predispose these patients to potential respiratory complications. Although rare, the occurrence of chronic respiratory symptoms is a possible severe complication that has been associated with the use of ISB. They suggest that supportive measures, including supplemental oxygen, airway access, and postoperative surveillance, are key in preventing respiratory complications associated with ISB.

Comment: We do not use interscalene blocks in our practice for multiple reasons (cost, time, complications, pain rebound) as expressed here.

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