Respiratory arrest in patients undergoing arteriovenous graft placement with supraclavicular brachial plexus block: a case series

doi:10.1016/j.jclinane.2012.11.009

Journal of Clinical Anesthesia

Volume 25, Issue 4, June 2013, Pages 321-323

https://doi.org/10.1016/j.jclinane.2012.11.009 Get rights and content

Abstract

Supraclavicular brachial plexus block is commonly used for upper extremity surgery. Respiratory arrest in three patients with end-stage renal disease after ultrasound-guided supraclavicular brachial plexus block for creation of an arteriovenous graft over a 6-month period is presented. Patients with renal failure may represent a group at particular risk for respiratory failure following supraclavicular brachial plexus block.

Introduction

Regional anesthesia for upper extremity surgery, including creation of arteriovenous (AV) grafts and fistulas, is increasingly more common. Decreased hospital length of stay, increased patient satisfaction, effective postoperative analgesia, reduced opioid requirements, and avoidance of airway instrumentation are just some of the reasons that regional anesthesia has gained popularity [1], [2], [3]. Regional anesthesia for AV graft formation has the additional benefit of improved graft patency [4].

Known complications of brachial plexus blocks include inadvertent subarachnoid or epidural injection, vertebral artery injection, recurrent laryngeal, cervical sympathetic, and vagus nerve blockade, pneumothorax, and phrenic nerve blockade manifesting as ipsilateral hemidiaphragmatic paresis [5], [6]. Hemidiaphragmatic paresis is a common complication of brachial plexus blocks, occurring 67% [7] of the time following a supraclavicular brachial plexus block, and up to 100% of the time following interscalene block [8]. Three cases of respiratory failure after supraclavicular brachial plexus block for AV graft placement at a single institution, over a 6-month period, are presented.

Section snippets

Case 1

A 48 year old man presented for right arm AV graft insertion for dialysis for end-stage renal disease (ESRD). His past medical history was significant for hypertension, congestive heart failure requiring an implantable cardioverter defibrillator, and morbid obesity, with a body mass index (BMI) of 40.3 kg/m² and baseline shortness of breath. The patient received midazolam 1 mg for premedication and oxygen via nasal cannula. Initial oxygen saturation (SpO₂) was 98%. Shortly following

Discussion

Three cases of respiratory distress following supraclavicular brachial plexus block in patients with ESRD undergoing AV graft formation are presented. These cases occurred over the course of 6 months, during which time we performed 67 brachial plexus blocks for AV graft formation, giving an incidence of 4.5%. During the same 6-month period, 421 supraclavicular brachial plexus blocks were placed for other procedures in patients without renal failure, primarily orthopedic, without respiratory

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Cited by (3)

Supraclavicular and paravertebral blocks: Are we underutilizing these regional techniques in perioperative analgesia?
2014, Best Practice and Research: Clinical Anaesthesiology
Citation Excerpt :
However, in these studies [16,28] a much higher volume of local anesthetic was injected (30–50 ml and 33 ± 8 ml, respectively). A recent case series describes three patients who developed respiratory insufficiency requiring endotracheal intubation following an ultrasound-guided SCB for arterio-venous fistula surgery [39]. Chest X-ray showed no evidence of a pneumothorax.
There has been a renewed interest in supraclavicular and paravertebral blocks for regional anesthesia. Studies have shown a high block success rate with the supraclavicular approach to the brachial plexus. Despite the use of ultrasound, pleural puncture and pneumothorax may still occur. The supraclavicular block is associated with a higher incidence of phrenic nerve paralysis and caution should be exercised in patients with respiratory difficulties. Paravertebral blocks have been used successfully to provide analgesia and anesthesia for a variety of surgical procedures. When compared to thoracic epidural blockade for thoracic surgery, paravertebral blockade provides comparable analgesia with a better preservation of pulmonary function and a lower incidence of hypotension. This brings forth the question as to whether paravertebral blocks have replaced epidural blockade as the gold standard in perioperative pain management for thoracoabdominal procedures.
Local anesthetics
2014, Side Effects of Drugs Annual
Citation Excerpt :
Inflammation including adhesions, fascial thickening, vascular changes, myotoxicity and the predisposing anatomy of the phrenic nerve may all play a role. Respiratory: In a single-centre institutional case series over a 6-month period a total of 67 supraclavicular blocks in patients with renal failure for arteriovenous graft formation were performed, and 3 cases of respiratory arrest occurred (4.5% incidence) [6C]. The authors conclude that ipsidiaphragmatic paresis, a known complication of supraclavicular block and its associated drop in forced vital capacity is poorly tolerated by some chronic renal failure patients and contributed to the respiratory arrests.
The Side Effects of Drugs Annuals form a series of volumes in which the adverse effects of drugs and adverse reactions to them are surveyed. The series supplements the contents of Meyler's Side Effects of Drugs: the International Encyclopedia of Adverse Drug Reactions and Interactions. This review of relevant publications from January 2012 to June 2013 covers adverse reactions to local anesthetics after brachial plexus anesthesia, combined spinal and epidural anesthesia, epidural anesthesia, dental anesthesia, femoral nerve anesthesia, infiltration anesthesia, intra-articular anesthesia, lumbar sympathetic nerve block, ocular anesthesia and tumescent anesthesia; individual compounds that are included are articaine, benzocaine, bupivacaine and levobupivacaine, lidocaine, mepivacaine, prilocaine and EMLA (prilocaine + lidocaine) as well as ropivacaine and tetracaine. Typical adverse reactions related to the route of administration include unintentional spread of the local anesthetic into the intrathecal space, uptake into the systemic circulation or chondrolysis after intra-articular infusion. Typical adverse reactions related to certain individual compounds are methaemoglobinaemia after the use of benzocaine and prilocaine and cardiotoxicity with bupivacaine.
Hemidiaphragmatic paralysis after costoclavicular approach versus other brachial plexus blocks in upper limb surgery: a meta-analysis
2023, Korean Journal of Anesthesiology

^☆: Supported by the Department of Anesthesiology, Mount Sinai School of Medicine, New York, NY 10029, USA.

^☆☆: Presented in part at the 37th Annual Regional Anesthesia and Pain Meeting and Workshops, San Diego, CA, March 16, 2012.

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Journal of Clinical Anesthesia

Case ReportRespiratory arrest in patients undergoing arteriovenous graft placement with supraclavicular brachial plexus block: a case series☆,☆☆

Abstract

Introduction

Section snippets

Case 1

Discussion

Interscalene block for shoulder arthroscopy: comparison with general anesthesia

Arthroscopy

A retrospective comparison of interscalene block and general anesthesia for ambulatory surgery shoulder arthroscopy

Reg Anesth

Hemodialysis vascular access morbidity

J Am Soc Nephrol

Regional anesthesia: preferred technique for venodilatation in the creation of upper extremity arteriovenous fistulae

Vascular

Upper extremity regional anesthesia: essentials of our current understanding, 2008

Reg Anesth Pain Med

Case Report: pneumothorax as a complication of the ultrasound-guided supraclavicular approach for brachial plexus block

Anesth Analg

The incidence and aetiology of phrenic nerve blockade associated with supraclavicular brachial plexus block

Anaesth Intensive Care

One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography

Anesth Analg

Hemidiaphragmatic paresis during interscalene brachial plexus block: effects on pulmonary function and chest wall mechanics

Anesth Analg

Supraclavicular and paravertebral blocks: Are we underutilizing these regional techniques in perioperative analgesia?

Local anesthetics

Hemidiaphragmatic paralysis after costoclavicular approach versus other brachial plexus blocks in upper limb surgery: a meta-analysis

Case Report
Respiratory arrest in patients undergoing arteriovenous graft placement with supraclavicular brachial plexus block: a case series☆,☆☆