P063: MANAGEMENT OF ACUTE RESPIRATORY FAILURE FOLLOWING ULTRASOUND GUIDED SUPRACLAVICULAR NERVE BLOCK
Dwayne C Young, MD; Jackson Memorial Hospital/University of Miami
Background: In recent times, Supraclavicular brachial plexus nerve block for upper extremity surgeries has become very popular. The block occurs at the distal truck-proximal division level of brachial plexus and so covers C5-T1 nerve roots.
In this case report, I present management of a patient who suffered acute respiratory failure following a right supraclavicular brachial plexus block.
Case Description: This is a 51 year old male patient, 102.5 kg with BMI 33.5 kg/m2, who presented for Excision of Olecranon Bursa and bone spur from right elbow.
His past medical history is significant for Hypertension, OSA, hypothyroidism and type2 DM.
He has no cardiopulmonary complaints and metabolic equivalent is greater than 4.
In his past anesthetic history, he has a history of difficult intubation in last two surgeries including need for a tracheotomy during anesthesia for thyroid surgery.
In his subsequent surgery he was noted again to have difficulty with intubation which took several attempts. With his history of difficult intubation and OSA, decision was made to perform an ultrasound guided Supraclavicular Brachial plexus block for surgical anesthesia using 30 cc of 0.5% Ropivacaine and use minimal sedation.
Supraclavicular nerve block was performed in preoperative area after standard ASA monitors were applied. Vital signs were stable and SPO2 was 98% on room air. 2mg midazolam was administered and block was uneventful.
15 minutes after block was done, patient started becoming very anxious and complained of difficulty breathing. SPO2 on room air fell to 92% and improved to 95-96% with 5L oxygen via face mask and deep breathing. Patient was reassured as the possibility of a phrenic nerve block was discussed preprocedure. A stat erect CXR was done in preoperative area and was negative for a pneumothorax but right hemidiaphragm was significantly elevated and signs of bilateral atelectasis was noted.
Patient was taken to OR for surgery. On arrival to operating room the patient became hypoxic with SPO2 84% requiring assisted ventilation with face mask and 100% oxygen. Set up for difficult intubation was at bedside.
He was then transitioned to CPAP and oxygenation improved to 94%.
Surgery was canceled and he was transferred to recovery area and after four hours in recovery room he was weaned from CPAP and transitioned to room air before being discharged home.
Discussion: Supraclavicular brachial plexus block is a common regional technique for forearm and hand procedures. With use of ultrasound and experience with the block the incidence of major complications such as pneumothorax is very rare.
However, 40-60% of patients will have an ipsilateral phrenic nerve blockade and in the presence of baseline respiratory compromise might experience significant respiratory insult requiring respiratory support.
However not all will require intubation and some patients might benefit from non-invasive respiratory support like CPAP. Key to management of these patients is to rule out a pneumothorax and early supportive care to maintain oxygenation above 92%.