Hypoxic respiratory failure due to phrenic nerve palsy from an interscalene brachial plexus block and previously asympto
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CASE REPORT
Hypoxic respiratory failure due to phrenic nerve palsy from an interscalene brachial plexus block and previously asymptomatic pulmonary embolism Danielle M. Minett • Jason E. Nace Jason T. Nomura
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Received: 23 May 2011 / Accepted: 6 June 2011 / Published online: 21 June 2011 Ó Springer-Verlag 2011
Abstract Interscalene brachial plexus block is a common regional anesthesia method for upper extremity surgery. A rare complication of this procedure is dyspnea secondary to phrenic nerve palsy and hemidiaphragm paralysis. In our case, this rare complication diagnosed using ultrasound led to the diagnosis of a previously asymptomatic pulmonary embolism. The use of ultrasonography was key in the diagnosis of the iatrogenic nerve palsy and was part of a multiple-modality diagnostic workup for her hypoxemia. Keywords Ultrasonography Phrenic Palsy Hypoxia Diaphragm
Introduction The use of brachial plexus blocks has been widely accepted as a safe and reliable method of anesthesia for upper extremity surgical procedures. Despite its relative safety, known complications can include seizure, pneumothorax, high cervical blocks, peripheral neuropathies, and cardiovascular collapse [1]. Transient phrenic nerve palsy resulting in hemidiaphragm paralysis is a common side effect of the procedure that rarely produces symptoms [2]. There have only been a small number of case reports on symptomatic dyspnea related to hemidiaphragm paralysis during interscalene blocks. While all these cases involved patients with symptomatic respiratory distress, clinical hypoxemia was reported only once [3]. The acute hypoxemic respiratory failure observed in this case led to the D. M. Minett J. E. Nace J. T. Nomura (&) Department of Emergency Medicine, Christiana Care Health System, 4755 Ogletown Stanton Road, Newark, DE 19720, USA e-mail: [email protected]
further evaluation and diagnosis of an underlying, sub-acute pulmonary embolism.
Case A 63-year-old female with past medical history of hypertension, obesity, and obstructive sleep apnea, was transferred from an outpatient surgery center in acute respiratory distress after the placement of an interscalene brachial plexus block prior to right shoulder surgery. A previous traumatic injury had left her with chronic shoulder pain and paresthesias. These symptoms had led to a decrease in her normal level of activity in the time leading up to her surgery. Preoperatively an interscalene brachial plexus block had been placed with the position confirmed by nerve stimulation testing. Adequate regional anesthesia was accomplished and no apparent complications were initially observed. When the patient was moved to the operating room, she experienced acute dyspnea and her oxygen saturation (SpO2) fell to 85% on room air. This improved with supplemental oxygen, but her dyspnea continued and breath sounds were noted as absent on the right side. Due to the concern for iatrogenic pneumothorax, the patient was urgently transferred to the emergency department (ED) for further evaluation.
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