Journal of Clinical Anesthesia (2014) 26, 407–409
Case Report
Delayed vocal fold paralysis after continuous interscalene level brachial plexus block with catheter placement: a case report☆,☆☆ Lakshman Gollapalli MD (Resident), George McKelvey PhD (Research Associate), Hong Wang MD, PhD (Anesthesiologist)⁎ Department of Anesthesiology, Wayne State University/Detroit Medical Center, Detroit, MI 48201, USA Received 18 April 2013; revised 24 February 2014; accepted 27 February 2014
Keywords: Anesthesia regional; Continuous interscalene brachial plexus block; Dysphagia; Dyspnea; Laryngeal nerve palsy; Upper extremity surgery; Vocal fold paralysis
Abstract We report an incident of delayed onset of true vocal fold paralysis with continuous interscalene brachial plexus block. A 51 year old woman underwent left shoulder manipulation and lysis of adhesions with fluoroscopy and general anesthesia. An interscalene brachial plexus block was performed and a catheter with a continuous infusion pump was placed for postoperative pain control. Following hospital discharge, approximately 8 hours after the initial catheter bolus the patient developed hoarseness, dysphagia, and dyspnea, secondary to left vocal fold palsy. The patient was admitted for observation and the catheter was discontinued with no intubation required. By the next morning, the patient’s dysphagia and dyspnea had resolved and her hoarseness improved. © 2014 Published by Elsevier Inc.
1. Introduction Brachial plexus blocks and indwelling catheters have been widely used for postoperative pain control for upper extremity surgeries [1,2]. Acute respiratory complications include ipsilateral phrenic and recurrent laryngeal nerve palsies; however, these complications are mostly selflimiting [3,4]. A case of a delayed occurrence of true vocal fold paralysis due to recurrent laryngeal nerve palsy after
☆
Supported by departmental funding only. The authors have no conflicts of interest to report. ⁎ Correspondence: Hong Wang, MD, PhD, Department of Anesthesiology, Detroit Medical Center, 3990 John R, Detroit, MI 48201, USA. Tel: + 1 313-745-7233; fax: + 1 313-993-3889. E-mail address: [email protected] (H. Wang). ☆☆
http://dx.doi.org/10.1016/j.jclinane.2014.02.004 0952-8180/© 2014 Published by Elsevier Inc.
continuous interscalene approach brachial plexus analgesia is presented.
2. Case report An obese, 51 year old woman with a past medical history of diabetes and systemic lupus erythematosus sustained a work-related left shoulder injury and developed adhesive capsulitis. For treatment, left shoulder manipulation and lysis of adhesions were performed using fluoroscopic imaging during general anesthesia. The intraoperative and Postanesthesia Care Unit (PACU) course was uneventful and the patient recovered well from the surgery. In the PACU, a left interscalene approach brachial plexus block was performed and a catheter was placed for continuous postoperative pain control. Sedation was achieved with intravenous midazolam
408 10 mg. Ultrasound was utilized to identify the anterior and middle scalene muscles. A 17-gauge Tuohy epidural needle with an internal Stimucath (Teleflex, Limerick, PA, USA) was successfully placed and advanced with direct ultrasound guidance with one attempt. Once the desired stimulation response was elicited, the catheter was advanced through the cannula and observed for continuous muscle contraction. The stimulation current was kept at 0.48 mA. The catheter was advanced approximately 5 cm. The satisfactory motor response was present and the catheter was secured with adhesive tape. Following negative aspiration, a 5 mL test dose containing 1.5% lidocaine with epinephrine 1:200,000 was administered, which tested negative. An initial bolus of 30 mL of mepivacaine 1.5% with no epinephrine was injected with intermittent aspiration. Ten minutes following the initial bolus, the patient displayed a loss of sensation to pin prick and was unable to move at the elbow and shoulder joints. The patient tolerated the procedure well, and was discharged approximately 3 hours later with an On-Q variable rate infusion pump (I-Flow, Lake Forest, CA, USA) containing 0.125% bupivacaine, administered with an infusion rate of 6 mL/hr. On hospital discharge the patient returned home. Approximately 8 hours after the initial bolus, the patient experienced hoarseness and mild dyspnea. The patient could not clear her throat and complained about “water sticking”. The patient showed no apparent odynophagia, difficulty with secretions, stridor, chest pain, or productive cough. The patient was bought back to the Emergency Department and admitted overnight for observation. Flexible fiberoptic nasopharyngoscopy was performed bedside. Both vocal folds were in the median position. The right vocal fold abducted and adducted normally during inspiration and phonation. However, the left vocal fold remained in the midline on inspiration. No obstructing lesions were observed and chest radiographs proved negative for the presence of acute infiltrates, pneumothorax, or elevation of the hemi-diaphragm. On the night of readmission, the infusion pump was discontinued and the interscalene catheter was removed. The patient was kept overnight for observation. On the following morning, the patient’s dyspnea and dysphagia resolved and her hoarseness improved. A repeat nasopharyngoscopy observed left vocal fold motion with phonation and slightly less abduction than the right fold during inspiration. The patient started clear liquids, then progressed to regular diet without complications.
L. Gollapalli et al. usage for postoperative pain by up to 50% in morphine consumption [6]. Advantages to using the continuous catheter with disposable pumps in the outpatient setting include simplicity and reliability of usage and no need for intervention by hospital staff. Phrenic nerve palsy is a well-known side effect of interscalene block and occurs in up to 100% of patient cases [4]. Recurrent laryngeal nerve (RLN) palsy is less common, occuring in 3% to 6% of interscalene blocks, normally within 30 minutes of initial bolus [7,8]. Acute unilateral palsies of these nerves may result in self-limiting symptoms such as dyspnea and hoarseness. Currently there are no published reports of delayed onset of RLN palsy. Delayed onset vocal cord paralysis following brachial plexus block, particularly in patients with preexisting risk factors such as contralateral vocal fold palsy and previous neck surgeries, may result in life-threatening respiratory obstruction [7,9]. The delayed onset of vocal fold paralysis in this case demonstrates that patients with interscalene block should not be immediately discharged and should be given a sufficient postoperative observation period. For patients with preexisting risks, hospital admission should be considered. The close proximity of neurovascular structures to the affected areas of interscalene blocks is responsible for most reported side effects and complications. The right RLN is a branch of the right side vagus nerve, which passes anterior to the subclavian artery. The RLN loops around the subclavian artery and ascends into the tracheo-esophageal groove. The left RLN branches off from the left vagus nerve in the thorax, wraps around the aorta posterior to the ligamentum arteriosum, and ascends back into the tracheo-esophageal groove. The anatomic location of the RLN and the anterior spread of the local anesthetic contribute to its susceptibility to injury from an interscalene brachial plexus block. In this case, the continuous medication from the catheter probably contributed to its prolonged palsy [10]. The delayed clinical presentation observed in our case may stem from several factors. Attenuated absorption of anesthetic and the distance between the catheter tip and the RLN may delay presentation. In addition, the large initial bolus (30 mL) plus the continuous infusion from the catheter may have resulted in a large accumulation of solution producing volumetric pressure to the RLN. Delayed Horner’s syndrome has been reported following continuous interscalene catheter block [11].
3.1. Conclusion
3. Discussion Continuous interscalene brachial plexus blocks are a reliable method of providing postoperative pain relief and they are more effective than a single-shot nerve block [5]. Using a continuous catheter, it is possible to extend the duration of the peripheral nerve block and reduce the opioid
The occurrence of ipsilateral RLN palsy following interscalene brachial plexus block is usually self-limiting. However, in patients with contralateral vocal cord palsy, previous neck surgeries, or airway disease, it may become life-threatening. A detailed preoperative evaluation and sufficient period of postoperative observation following
Vocal fold paralysis & brachial plexus block interscalene brachial plexus block is necessary to decrease the risk of any potential catastrophic occurrence.
Acknowledgment The authors would like to warmly thank Dr. Shushovan Chakrabortty, BS, MBBS, MD, for his clinical expertise, support, and encouragement.
References [1] Conroy PH, Awad IT. Ultrasound-guided blocks for shoulder surgery. Curr Opin Anaesthesiol 2011;24:638-43. [2] Brandl F, Taeger K. The combination of general anesthesia and interscalene block in shoulder surgery. Anaesthesist 1991;40:537-42. [3] Guirguis M, Karroum R, Abd-Elsayed AA, Mounir-Soliman L. Acute respiratory distress following ultrasound-guided supraclavicular block. Ochsner J 2012;12:159-62.
409 [4] Urmey WF, Talts KH, Sharrock NE. One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg 1991;72:498-503. [5] Singelyn FJ, Seguy S, Gouverneur JM. Interscalene brachial plexus analgesia after open shoulder surgery: continuous versus patientcontrolled infusion. Anesth Analg 1999;89:1216-20. [6] Klein SM, Grant SA, Greengrass RA, et al. Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump. Anesth Analg 2000;91:1473-8. [7] Solanki SL, Jain A, Makkar JK, Nikhar SA. Severe stridor and marked respiratory difficulty after right-sided supraclavicular brachial plexus block. J Anesth 2011;25:305-7. [8] Winnie AP. Plexus Anesthesia: Vol. 1: Perivascular techniques of brachial plexus block. 2nd ed. Philadelphia: W.B. Saunders; 1990. p. 236-7. [9] Plit ML, Chhajed PN, Macdonald P, Cole IE, Harrison GA. Bilateral vocal cord palsy following interscalene brachial plexus nerve block. Anaesth Intensive Care 2002;30:499-501. [10] Pere P, Pitkänen M, Rosenberg PH, et al. Effect of continuous interscalene brachial plexus block on diaphragm motion and on ventilatory function. Acta Anaesthesiol Scand 1992;36:53-7. [11] Salengros JC, Jacquot C, Hesbois A, Vandesteene A, Engelman E, Pandin P. Delayed Horner's syndrome during a continuous infraclavicular brachial plexus block. J Clin Anesth 2007;19:57-9.
Case Report
Delayed vocal fold paralysis after continuous interscalene level brachial plexus block with catheter placement: a case report☆,☆☆ Lakshman Gollapalli MD (Resident), George McKelvey PhD (Research Associate), Hong Wang MD, PhD (Anesthesiologist)⁎ Department of Anesthesiology, Wayne State University/Detroit Medical Center, Detroit, MI 48201, USA Received 18 April 2013; revised 24 February 2014; accepted 27 February 2014
Keywords: Anesthesia regional; Continuous interscalene brachial plexus block; Dysphagia; Dyspnea; Laryngeal nerve palsy; Upper extremity surgery; Vocal fold paralysis
Abstract We report an incident of delayed onset of true vocal fold paralysis with continuous interscalene brachial plexus block. A 51 year old woman underwent left shoulder manipulation and lysis of adhesions with fluoroscopy and general anesthesia. An interscalene brachial plexus block was performed and a catheter with a continuous infusion pump was placed for postoperative pain control. Following hospital discharge, approximately 8 hours after the initial catheter bolus the patient developed hoarseness, dysphagia, and dyspnea, secondary to left vocal fold palsy. The patient was admitted for observation and the catheter was discontinued with no intubation required. By the next morning, the patient’s dysphagia and dyspnea had resolved and her hoarseness improved. © 2014 Published by Elsevier Inc.
1. Introduction Brachial plexus blocks and indwelling catheters have been widely used for postoperative pain control for upper extremity surgeries [1,2]. Acute respiratory complications include ipsilateral phrenic and recurrent laryngeal nerve palsies; however, these complications are mostly selflimiting [3,4]. A case of a delayed occurrence of true vocal fold paralysis due to recurrent laryngeal nerve palsy after
☆
Supported by departmental funding only. The authors have no conflicts of interest to report. ⁎ Correspondence: Hong Wang, MD, PhD, Department of Anesthesiology, Detroit Medical Center, 3990 John R, Detroit, MI 48201, USA. Tel: + 1 313-745-7233; fax: + 1 313-993-3889. E-mail address: [email protected] (H. Wang). ☆☆
http://dx.doi.org/10.1016/j.jclinane.2014.02.004 0952-8180/© 2014 Published by Elsevier Inc.
continuous interscalene approach brachial plexus analgesia is presented.
2. Case report An obese, 51 year old woman with a past medical history of diabetes and systemic lupus erythematosus sustained a work-related left shoulder injury and developed adhesive capsulitis. For treatment, left shoulder manipulation and lysis of adhesions were performed using fluoroscopic imaging during general anesthesia. The intraoperative and Postanesthesia Care Unit (PACU) course was uneventful and the patient recovered well from the surgery. In the PACU, a left interscalene approach brachial plexus block was performed and a catheter was placed for continuous postoperative pain control. Sedation was achieved with intravenous midazolam
408 10 mg. Ultrasound was utilized to identify the anterior and middle scalene muscles. A 17-gauge Tuohy epidural needle with an internal Stimucath (Teleflex, Limerick, PA, USA) was successfully placed and advanced with direct ultrasound guidance with one attempt. Once the desired stimulation response was elicited, the catheter was advanced through the cannula and observed for continuous muscle contraction. The stimulation current was kept at 0.48 mA. The catheter was advanced approximately 5 cm. The satisfactory motor response was present and the catheter was secured with adhesive tape. Following negative aspiration, a 5 mL test dose containing 1.5% lidocaine with epinephrine 1:200,000 was administered, which tested negative. An initial bolus of 30 mL of mepivacaine 1.5% with no epinephrine was injected with intermittent aspiration. Ten minutes following the initial bolus, the patient displayed a loss of sensation to pin prick and was unable to move at the elbow and shoulder joints. The patient tolerated the procedure well, and was discharged approximately 3 hours later with an On-Q variable rate infusion pump (I-Flow, Lake Forest, CA, USA) containing 0.125% bupivacaine, administered with an infusion rate of 6 mL/hr. On hospital discharge the patient returned home. Approximately 8 hours after the initial bolus, the patient experienced hoarseness and mild dyspnea. The patient could not clear her throat and complained about “water sticking”. The patient showed no apparent odynophagia, difficulty with secretions, stridor, chest pain, or productive cough. The patient was bought back to the Emergency Department and admitted overnight for observation. Flexible fiberoptic nasopharyngoscopy was performed bedside. Both vocal folds were in the median position. The right vocal fold abducted and adducted normally during inspiration and phonation. However, the left vocal fold remained in the midline on inspiration. No obstructing lesions were observed and chest radiographs proved negative for the presence of acute infiltrates, pneumothorax, or elevation of the hemi-diaphragm. On the night of readmission, the infusion pump was discontinued and the interscalene catheter was removed. The patient was kept overnight for observation. On the following morning, the patient’s dyspnea and dysphagia resolved and her hoarseness improved. A repeat nasopharyngoscopy observed left vocal fold motion with phonation and slightly less abduction than the right fold during inspiration. The patient started clear liquids, then progressed to regular diet without complications.
L. Gollapalli et al. usage for postoperative pain by up to 50% in morphine consumption [6]. Advantages to using the continuous catheter with disposable pumps in the outpatient setting include simplicity and reliability of usage and no need for intervention by hospital staff. Phrenic nerve palsy is a well-known side effect of interscalene block and occurs in up to 100% of patient cases [4]. Recurrent laryngeal nerve (RLN) palsy is less common, occuring in 3% to 6% of interscalene blocks, normally within 30 minutes of initial bolus [7,8]. Acute unilateral palsies of these nerves may result in self-limiting symptoms such as dyspnea and hoarseness. Currently there are no published reports of delayed onset of RLN palsy. Delayed onset vocal cord paralysis following brachial plexus block, particularly in patients with preexisting risk factors such as contralateral vocal fold palsy and previous neck surgeries, may result in life-threatening respiratory obstruction [7,9]. The delayed onset of vocal fold paralysis in this case demonstrates that patients with interscalene block should not be immediately discharged and should be given a sufficient postoperative observation period. For patients with preexisting risks, hospital admission should be considered. The close proximity of neurovascular structures to the affected areas of interscalene blocks is responsible for most reported side effects and complications. The right RLN is a branch of the right side vagus nerve, which passes anterior to the subclavian artery. The RLN loops around the subclavian artery and ascends into the tracheo-esophageal groove. The left RLN branches off from the left vagus nerve in the thorax, wraps around the aorta posterior to the ligamentum arteriosum, and ascends back into the tracheo-esophageal groove. The anatomic location of the RLN and the anterior spread of the local anesthetic contribute to its susceptibility to injury from an interscalene brachial plexus block. In this case, the continuous medication from the catheter probably contributed to its prolonged palsy [10]. The delayed clinical presentation observed in our case may stem from several factors. Attenuated absorption of anesthetic and the distance between the catheter tip and the RLN may delay presentation. In addition, the large initial bolus (30 mL) plus the continuous infusion from the catheter may have resulted in a large accumulation of solution producing volumetric pressure to the RLN. Delayed Horner’s syndrome has been reported following continuous interscalene catheter block [11].
3.1. Conclusion
3. Discussion Continuous interscalene brachial plexus blocks are a reliable method of providing postoperative pain relief and they are more effective than a single-shot nerve block [5]. Using a continuous catheter, it is possible to extend the duration of the peripheral nerve block and reduce the opioid
The occurrence of ipsilateral RLN palsy following interscalene brachial plexus block is usually self-limiting. However, in patients with contralateral vocal cord palsy, previous neck surgeries, or airway disease, it may become life-threatening. A detailed preoperative evaluation and sufficient period of postoperative observation following
Vocal fold paralysis & brachial plexus block interscalene brachial plexus block is necessary to decrease the risk of any potential catastrophic occurrence.
Acknowledgment The authors would like to warmly thank Dr. Shushovan Chakrabortty, BS, MBBS, MD, for his clinical expertise, support, and encouragement.
References [1] Conroy PH, Awad IT. Ultrasound-guided blocks for shoulder surgery. Curr Opin Anaesthesiol 2011;24:638-43. [2] Brandl F, Taeger K. The combination of general anesthesia and interscalene block in shoulder surgery. Anaesthesist 1991;40:537-42. [3] Guirguis M, Karroum R, Abd-Elsayed AA, Mounir-Soliman L. Acute respiratory distress following ultrasound-guided supraclavicular block. Ochsner J 2012;12:159-62.
409 [4] Urmey WF, Talts KH, Sharrock NE. One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg 1991;72:498-503. [5] Singelyn FJ, Seguy S, Gouverneur JM. Interscalene brachial plexus analgesia after open shoulder surgery: continuous versus patientcontrolled infusion. Anesth Analg 1999;89:1216-20. [6] Klein SM, Grant SA, Greengrass RA, et al. Interscalene brachial plexus block with a continuous catheter insertion system and a disposable infusion pump. Anesth Analg 2000;91:1473-8. [7] Solanki SL, Jain A, Makkar JK, Nikhar SA. Severe stridor and marked respiratory difficulty after right-sided supraclavicular brachial plexus block. J Anesth 2011;25:305-7. [8] Winnie AP. Plexus Anesthesia: Vol. 1: Perivascular techniques of brachial plexus block. 2nd ed. Philadelphia: W.B. Saunders; 1990. p. 236-7. [9] Plit ML, Chhajed PN, Macdonald P, Cole IE, Harrison GA. Bilateral vocal cord palsy following interscalene brachial plexus nerve block. Anaesth Intensive Care 2002;30:499-501. [10] Pere P, Pitkänen M, Rosenberg PH, et al. Effect of continuous interscalene brachial plexus block on diaphragm motion and on ventilatory function. Acta Anaesthesiol Scand 1992;36:53-7. [11] Salengros JC, Jacquot C, Hesbois A, Vandesteene A, Engelman E, Pandin P. Delayed Horner's syndrome during a continuous infraclavicular brachial plexus block. J Clin Anesth 2007;19:57-9.
