Effect of superior trunk block on diaphragm function and respiratory parameters after shoulder surgery.

BACKGROUND: The interscalene brachial plexus block has been used effectively for intraoperative and postoperative analgesia in patients undergoing shoulder surgery, but it is associated with high rates of diaphragmatic dysfunction. Performing the block more distally, at the level of the superior trunk, may reduce the incidence of phrenic nerve palsy. We hypothesized that superior trunk block would result in diaphragmatic paralysis rate of less than 20%. METHODS: 30 patients undergoing arthroscopic shoulder surgery received superior trunk block under ultrasound guidance. Measurements of diaphragm excursion were determined with ultrasound prior to the block, 15 min after the block, and postoperatively in phase II of postanesthesia care unit, in conjunction with clinical parameters of respiratory function. RESULTS: 10 patients (33.3%, 95% CI 17.3% to 52.8%) developed complete hemidiaphragmatic paralysis at the postoperative assessment. An additional eight patients (26.7%) developed paresis without paralysis. Of the 18 patients with diaphragm effects, seven (38.9%) reported dyspnea. 83.3% of patients with abnormal diaphragm motion (56.7% of the total sample) had audibly reduced breath sounds on auscultation. Oxygen saturation measurements did not correlate with diaphragm effect and were not significantly reduced by the postoperative assessment. CONCLUSION: Although injection of local anesthetic at the superior trunk level is associated with less diaphragmatic paralysis compared with traditional interscalene block, a significant portion of patients will continue to have ultrasonographic and clinical evidence of diaphragmatic weakness or paralysis.

Effects of Local Anesthetic Volume (Standard Versus Low) on Incidence of Hemidiaphragmatic Paralysis and Analgesic Quality for Ultrasound-Guided Superior Trunk Block After Arthroscopic Shoulder Surgery.

BACKGROUND: Relative to interscalene block, superior trunk block (STB) provides comparable analgesia and a reduced risk of hemidiaphragmatic paralysis. However, the incidence of hemidiaphragmatic paralysis remains high when a standard volume (15 mL) of local anesthetic is used. This study aimed to evaluate the effects of local anesthetic volume of STB on the incidence of phrenic nerve palsy, as well as its analgesic efficacy following arthroscopic shoulder surgery. METHODS: Patients scheduled for elective arthroscopic shoulder surgery were randomized to receive ultrasound-guided STB using either 5- or 15-mL 0.5% ropivacaine before general anesthesia. The primary outcome was the incidence of hemidiaphragmatic paralysis at 30 minutes after block. The secondary outcomes were pulmonary function, grade of sensory and motor blockade, pain score, opioid consumption, adverse effects, and satisfaction. RESULTS: Relative to standard-volume STB, low-volume STB was associated with a lower incidence of hemidiaphragmatic paralysis after block (14.3 [4.8%-30.3%] vs 65.7 [46.8%-80.9%]; difference 51.4% [95% confidence intervals {CIs}, 29.0%-67.1%]; P < .0001) and at the postanesthesia care unit (9.4% vs 50.0%; difference 40.6 [95% CI, 18.9%-57.7%]; P = .0004). Pulmonary function was also better preserved in the low-volume group than in the standard-volume group. The extent of the sensory and motor blocks was significantly different between the groups. Pain-related outcomes, satisfaction, and any adverse events were not significantly different between the groups. CONCLUSIONS: Low-volume STB provided a lower incidence of hemidiaphragmatic paralysis with no significant difference in analgesic efficacy relative to standard-volume STB for arthroscopic shoulder surgery.

Awareness With Paralysis in Mechanically Ventilated Patients in the Emergency Department and ICU: A Systematic Review and Meta-Analysis.

OBJECTIVE: Awareness with paralysis is a devastating complication for mechanically ventilated patients and can carry long-term psychologic sequelae. Hundreds of thousands of patients require mechanical ventilation in the emergency department and ICU annually, yet awareness has only been rigorously examined in the operating room (incidence ~0.1%). This report collates the global literature regarding the incidence of awareness with paralysis outside of the operating room. DATA SOURCES: We searched OvidMedline, Embase, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, conference proceedings, and reference lists. STUDY SELECTION: Randomized or nonrandomized studies (except single case studies) reporting on awareness with paralysis in the emergency department or ICU were eligible. DATA EXTRACTION: Two independent reviewers screened abstracts for eligibility. DATA SYNTHESIS: The search identified 4,454 potentially eligible studies. Seven studies (n = 941 patients) were included for analysis. A random effects meta-analysis of proportions along with multiple subgroup analyses was performed. Significant between-study heterogeneity in reporting of awareness with paralysis was noted, and the quality of the evidence was low. Analyses stratified by: 1) good-quality studies and 2) use of the modified Brice questionnaire to detect awareness revealed estimates of 3.4% (95% CI, 0-10.2%) and 1.9% (95% CI, 1.0-3.0%), respectively. CONCLUSIONS: The incidence of awareness with paralysis in mechanically ventilated patients in the emergency department and ICU, as evaluated in a small number of qualifying studies from this comprehensive systematic review, appears much higher than that reported from the operating room. Given the clinical and statistical heterogeneity, caution is warranted in the interpretation of these findings. Further high-quality studies are needed to both define the true incidence and to target the prevention of awareness with paralysis in this vulnerable patient cohort.

Diaphragm Paralysis After Pediatric Cardiac Surgery: An STS Congenital Heart Surgery Database Study.

BACKGROUND: Previous single-center studies of diaphragm paralysis (DP) after pediatric cardiac surgery report incidence of 0.3% to 12.8% and associate DP with respiratory complications, prolonged ventilation and length of stay, and mortality. To better define incidence and associations between DP and various procedures and outcomes, we performed a multicenter study. METHODS: The Society of Thoracic Surgeons Congenital Heart Surgery Database was queried to identify children who experienced DP after cardiac surgery (2010-2018; 126 centers). Baseline characteristics and postoperative outcomes were compared between patients with and without DP as well as between patients who underwent plication and those who did not. Associations between center volume and center rates of DP and use of plication were also explored. RESULTS: A total of 2214 of 191,463 (1.2%) patients experienced DP. Postoperative DP portended worse outcomes, including mortality (5.6% vs 3.5%; P < .001), major morbidity (37.2% vs 10.7%; P < .001), tracheostomy (7.1% vs 0.9%; P < .001), prolonged mechanical ventilation (38.0% vs 7.8%; P < .001), and 30-day readmission (22.0% vs 10.6%; P < .001). A total of 1105 of 2214 (49.9%) patients with DP underwent plication. Patients who underwent plication were younger, were smaller, had more risk factors, and underwent more complex surgeries. Plication rates varied widely across centers. There was no correlation between center volume and center risk-adjusted rates of DP (r = .05, P = .5), nor frequency of plication (r = .08, P = .4). CONCLUSIONS: DP complicating pediatric heart surgery is rare but portends significantly worse outcomes. One-half of patients underwent plication. Center-level risk-adjusted rates of DP and plication are not associated with case volume. Significant variability in plication practices suggests a target for quality improvement.

Unilateral diaphragmatic paralysis associated with surgical mitral valve repair in dogs.

OBJECTIVES: Unilateral diaphragmatic paralysis (UDP) due to phrenic nerve injury is a potential complication of thoracic surgery. This study evaluated the prevalence of UDP associated with surgical mitral valve repair (MVR) and its effect on surgical outcomes in dogs. ANIMALS, MATERIALS AND METHODS: Two hundred ninety-four dogs that underwent MVR were included in the study. A retrospective review of medical records was performed for dogs surviving surgery. Diagnosis of UDP was based on preoperative and postoperative thoracic dorsoventral radiographs. RESULTS: A total of 284 dogs survived until the day after surgery. The prevalence of UDP on the day after surgery, on the day of discharge, and after the first postoperative month was 30%, 24%, and 9%, respectively. One case of UDP was observed at 3 months after surgery. Unilateral diaphragmatic paralysis was exhibited by nine of the 21 patients that died in the hospital. The proportion of patients with UDP was higher in dogs that died of respiratory failure than in dogs that died of other causes (p = 0.002). Most dogs whose deaths were suspected to have been related to respiratory failure also had pre-existing respiratory diseases. The occurrence of UDP did not relate to the lengths of stay in the intensive care unit or the hospital. CONCLUSIONS: Our findings suggest that UDP is a common complication in dogs after MVR and that the prevalence of UDP decreases with time after surgery. Unilateral diaphragmatic paralysis is a risk factor for postoperative death, especially in patients with pre-existing respiratory disease.

Incidence of hemi-diaphragmatic paresis after ultrasound-guided intermediate cervical plexus block: a prospective observational study.

PURPOSE: An intermediate cervical plexus block (CPB) targets the posterior cervical space between the sternocleidomastoid muscle and the prevertebral fascia. The phrenic nerve descends obliquely on the surface of the anterior scalene muscle beneath the prevertebral fascia after originating from the C3-C5 ventral rami. Therefore, the phrenic nerve can be affected by a local anesthetic during an intermediate CPB, depending on the permeability characteristics of the prevertebral fascia. This study investigated whether an intermediate CPB affects the phrenic nerve, inducing hemidiaphragmatic paresis. METHODS: In this prospective observational study, 20 patients undergoing single-incision transaxillary robot-assisted right thyroidectomy were enrolled. The intermediate CPB (0.25% ropivacaine 0.2 ml/kg) was performed at the C4-5 intervertebral level carefully, without penetrating the prevertebral fascia, before the patient emerged from general anesthesia. Diaphragmatic motions of the block side were measured by M-mode ultrasonography at three time points: before anesthesia (baseline) and at 30 and 60 min after the intermediate CPB. Hemidiaphragmatic paresis was divided into three grades, depending on the percentage of diaphragm movement compared to the baseline: none (> 75%), partial paresis (25-75%), and complete paresis (< 25%). RESULTS: No patient showed any partial or complete ipsilateral hemidiaphragmatic paresis within 60 min after the intermediate CPB. CONCLUSION: Intermediate CPB using 0.2 ml/kg of 0.25% ropivacaine at the C4-5 intervertebral level did not cause ipsilateral hemidiaphragmatic paresis. This may imply that the effect of the intermediate CPB on the phrenic nerve is not significant.

Characteristics and outcomes of children with congenital heart disease needing diaphragm plication.

BACKGROUND: Diaphragm dysfunction following surgery for congenital heart disease is a known complication leading to delays in recovery and increased post-operative morbidity and mortality. We aimed to determine the incidence of and risk factors associated with diaphragm plication in children undergoing cardiac surgery and evaluate timing to repair and effects on hospital cost and length of stay. METHODS: We conducted a multi-institutional retrospective observational cohort study. Forty-three hospitals from the Pediatric Health Information System database were included, and a total of 112,110 patients admitted between January 2004 and December 2014 were analysed. RESULTS: Patients less than 18 years of age who underwent cardiac surgery were included. Risk Adjustment for Congenital Heart Surgery was utilized to determine procedure complexity. The overall incidence of diaphragm dysfunction was 2.2% (n = 2513 out of 112,110). Of these, 24.0% (603 patients) underwent diaphragm plication. Higher complexity cardiac surgery (Risk Adjustment for Congenital Heart Surgery 5-6) and age less than 4 weeks were associated with a higher likelihood of diaphragm plication (p-value < 0.01). Diaphragmatic plication was associated with increased hospital length of stay (p-value < 0.01) and increased medical cost. CONCLUSIONS: Diaphragm plication after surgery for congenital heart disease is associated with longer hospital length of stay and increased cost. There is a strong correlation of prolonged time to plication with increased length of stay and medical cost. The likelihood of plication increases with younger age and higher procedure complexity. Methods to improve early recognition and treatment of diaphragm dysfunction should be developed.

Hemidiaphragmatic paralysis with continuous interscalene block and diluted solutions of levobupivacaine / Bloqueo interescalénico y parálisis diafragmática con dosis diluidas de levobupivacaína

The continuous interscalene block represents the analgesic standard for shoulder surgery. However, the incidence of hemidiaphragmatic paralysis can reach up to 100% of cases. We hypothesized that more dilute local anesthetics would decrease the phrenic palsy at 24 hours. METHODS: Prospective series of patients undergoing arthroscopic shoulder surgery with continuous interscalene block. A 15-ml bolus of lidocaine 1%-levobupivacaine 0.25% plus an infusion of levobupivacaine 0.04% at an 8 mL/h rate plus 5 mL boluses on-demand with a 20-minutes lockout was used until discharge. Hemidiaphragmatic excursion was evaluated with M-mode ultrasound in the subcostal region before blocks, in the post-anesthetic unit, and at 24 h. The primary outcome was the presence of hemidiaphragmatic paralysis at 24 hours. Secondary outcomes included postoperative pain, amount of rescue boluses, postoperative opioids consumption, and side effects. RESULTS: Thirty patients were recruited and analyzed. The incidence of diaphragm paralysis at 24 h was 96.7%. The median [IQR] of pain at rest (patients with shoulder immobilizer) in a NRS from 0 to 10 at 0.5; 1; 3; 6; 12; 24; 48; 72 hours were 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-2]; 0 [0-2.5]; 0 [0-2], respectively. The median [IQR] consumption of LA boluses was 1.5 [0-7]. There were no postoperative morphine requirements. The most frequent side effect was Horner´s syndrome. CONCLUSIONS: Continuous interscalene block with 0.04% levobupivacaine provides adequate analgesia for arthroscopic shoulder surgery but does not prevent hemidiaphragmatic paralysis at 24 hours under the conditions of this study.

El bloqueo interescalénico representa el estándar analgésico para cirugía de hombro. No obstante, la incidencia de parálisis hemidiafragmática puede alcanzar 100% de los casos. Nuestra hipótesis es que infusiones con anestésicos locales más diluidos disminuirían la PHD 24 horas postbloqueo. MÉTODOS: Serie prospectiva de pacientes sometidos a cirugía artroscópica electiva de hombro con bloqueo interescalénico continuo. Un bolo de 15 mL de lidocaína 1%-levobupivacaína 0,5% más infusión postoperatoria de levobupivacaína al 0,04% a 8 ml/h más bolos a demanda de 5 mL con intervalo de 20 minutos hasta el alta. La excursión hemidiafragmática se evaluó con ultrasonido con transductor curvo 2-5 MHz en modo M en la región infracostal antes del bloqueo, en la unidad postanestésica y a las 24 h, antes del alta. El outcome primario fue la presencia de parálisis hemidiafragmática 24 horas postbloqueo. Los resultados secundarios incluyeron dolor postoperatorio, total de bolos de rescate, requerimiento de opioides postoperatorios y efectos secundarios. RESULTADOS: Treinta pacientes fueron reclutados y analizados. La incidencia de PHD a las 24 h fue 96,7%. La mediana [RIC] de dolor en reposo (pacientes con inmovilizador de hombro) medido en escala numérica de 0 a 10, a las 0,5; 1; 3; 6; 12; 24; 48; 72 horas fueron 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-0]; 0 [0-2]; 0 [0-2.5]; 0 [0-2] respectivamente. La mediana [RIC] de consumo de bolos de rescate fue 1,5 [0-7]. No hubo pacientes con requerimientos de morfina postoperatoria. El efecto colateral más frecuente fue el síndrome de Horner. CONCLUSIONES: El bloqueo interescalénico continuo con levobupivacaína 0,04% proporciona analgesia postoperatoria adecuada, pero no evita la PHD a las 24 h en las condiciones de esta serie.

[Hemidiaphragmatic paralysis after ultrasound-guided supraclavicular block: a prospective cohort study]. / Paralisia hemidiafragmática após bloqueio supraclavicular guiado por ultrassom: um estudo coorte prospectivo.

BACKGROUND AND OBJECTIVES: The frequent onset of hemidiaphragmatic paralysis during interscalene block restricts its use in patients with respiratory insufficiency. Supraclavicular block could be a safe and effective alternative. Our primary objective was to assess the incidence of hemidiaphragmatic paralysis following ultrasound-guided supraclavicular block and compare it to that of interscalene block. METHODS: Adults warranting elective shoulder surgery under regional anesthesia (Toulouse University Hospital) were prospectively enrolled from May 2016 to May 2017 in this observational study. Twenty millilitres of 0.375% Ropivacaine were injected preferentially targeted to the "corner pocket". Diaphragmatic excursion was measured by ultrasonography before and 30 minutes after regional anesthesia. A reduction ≥ 25% in diaphragmatic excursion during a sniff test defined the hemidiaphragmatic paralysis. Dyspnoea and hypoxaemia were recorded in the recovery room. Predictive factors of hemidiaphragmatic paralysis (gender, age, weight, smoking, functional capacity) were explored. Postoperative pain was also analysed. RESULTS: Forty-two and 43 patients from respectively the supraclavicular block and interscalene block groups were analysed. The incidence of hemidiaphragmatic paralysis was 59.5% in the supraclavicular block group compared to 95.3% in the interscalene block group (p < 0.0001). Paradoxical movement of the diaphragm was more common in the interscalene block group (RR = 2, 95% CI 1.4-3; p = 0.0001). A similar variation in oxygen saturation was recorded between patients with and without hemidiaphragmatic paralysis (p = 0.08). No predictive factor of hemidiaphragmatic paralysis could be identified. Morphine consumption and the highest numerical rating scale (NRS) at 24 hours did not differ between groups. CONCLUSIONS: Given the frequent incidence of hemidiaphragmatic paralysis following supraclavicular block, this technique cannot be recommended for patients with an altered respiratory function.

Hemidiaphragmatic paralysis after ultrasound-guided supraclavicular block: a prospective cohort study / Paralisia hemidiafragmática após bloqueio supraclavicular guiado por ultrassom: um estudo coorte prospectivo

Abstract Background and objectives: The frequent onset of hemidiaphragmatic paralysis during interscalene block restricts its use in patients with respiratory insufficiency. Supraclavicular block could be a safe and effective alternative. Our primary objective was to assess the incidence of hemidiaphragmatic paralysis following ultrasound-guided supraclavicular block and compare it to that of interscalene block. Methods: Adults warranting elective shoulder surgery under regional anesthesia (Toulouse University Hospital) were prospectively enrolled from May 2016 to May 2017 in this observational study. Twenty millilitres of 0.375% Ropivacaine were injected preferentially targeted to the "corner pocket". Diaphragmatic excursion was measured by ultrasonography before and 30 minutes after regional anesthesia. A reduction ≥25% in diaphragmatic excursion during a sniff test defined the hemidiaphragmatic paralysis. Dyspnoea and hypoxaemia were recorded in the recovery room. Predictive factors of hemidiaphragmatic paralysis (gender, age, weight, smoking, functional capacity) were explored. Postoperative pain was also analysed. Results: Forty-two and 43 patients from respectively the supraclavicular block and interscalene block groups were analysed. The incidence of hemidiaphragmatic paralysis was 59.5% in the supraclavicular block group compared to 95.3% in the interscalene block group (p < 0.0001). Paradoxical movement of the diaphragm was more common in the interscalene block group (RR = 2, 95% CI 1.4-3; p = 0.0001). A similar variation in oxygen saturation was recorded between patients with and without hemidiaphragmatic paralysis (p = 0.08). No predictive factor of hemidiaphragmatic paralysis could be identified. Morphine consumption and the highest numerical rating scale numerical rating scale (NRS) at 24 hours did not differ between groups. Conclusions: Given the frequent incidence of hemidiaphragmatic paralysis following supraclavicular block, this technique cannot be recommended for patients with an altered respiratory function.

Resumo Justificativa e objetivos: O aparecimento frequente de paralisia hemidiafragmática durante o bloqueio interescalênico restringe seu uso em pacientes com insuficiência respiratória. O bloqueio supraclavicular pode ser uma opção segura e eficaz. Nosso objetivo primário foi avaliar a incidência de paralisia hemidiafragmática após bloqueio supraclavicular guiado por ultrassom e compará-lo com o bloqueio interescalênico. Métodos: Os adultos agendados para cirurgia eletiva do ombro sob anestesia regional (Hospital Universitário de Toulouse) foram prospectivamente incluídos neste estudo observacional, de maio de 2016 a maio de 2017. Vinte mililitros de ropivacaína a 0,375% foram injetados, preferencialmente objetivando a interseção da primeira costela e da artéria subclávia. A excursão diafragmática foi medida por ultrassonografia antes e 30 minutos após a anestesia regional. Uma redução ≥ 25% na excursão diafragmática durante um sniff test definiu a paralisia hemidiafragmática. Dispneia e hipoxemia foram registradas na sala de recuperação. Fatores preditivos de paralisia hemidiafragmática (sexo, idade, peso, tabagismo, capacidade funcional) foram explorados. A dor pós-operatória também foi avaliada. Resultados: Quarenta e dois e 43 pacientes dos grupos bloqueio supraclavicular e bloqueio interescalênico, respectivamente, foram avaliados. A incidência de paralisia hemidiafragmática foi de 59,5% no grupo bloqueio supraclavicular em comparação com 95,3% no grupo bloqueio interescalênico (p < 0,0001). O movimento paradoxal do diafragma foi mais comum no grupo bloqueio interescalênico (RR = 2, 95% IC 1,4-3; p = 0,0001). Uma variação semelhante na saturação de oxigênio foi registrada entre os pacientes com e sem paralisia hemidiafragmática (p = 0,08). Nenhum fator preditivo de paralisia hemidiafragmática pôde ser identificado. O consumo de morfina e o maior escore na escala numérica (NRS) em 24 horas não diferiram entre os grupos. Conclusão: Devido à frequente incidência de paralisia hemidiafragmática após bloqueio supraclavicular, essa técnica não pode ser recomendada para pacientes com função respiratória alterada.

Association Between Diaphragmatic Paralysis and Ipsilateral Cervical Spondylosis on MRI.

PURPOSE: Diaphragmatic paralysis (DP) is an important cause of dyspnea with many underlying etiologies; however, frequently no cause is identified despite extensive investigation. We hypothesized that cervical spondylosis (CS), as manifest by cervical neuroforaminal stenosis on magnetic resonance imaging (MRI), is an underrecognized cause of unilateral DP. METHODS: A retrospective study was performed assessing cervical spine imaging utilization in the investigation of unilateral DP, and the contribution of CS to its pathogenesis. To assess the relationship between CS and DP, comparison was made between severity of ipsilateral and contralateral foraminal stenosis on cervical spine MRI in individuals with idiopathic DP, and to controls with DP of known etiology. RESULTS: Record searches identified 334 individuals with DP who were classified as idiopathic (n = 101) or DP of known etiology (n = 233). Of those with idiopathic DP, only 37% had undergone cervical spine imaging. Cervical spine MRIs, available for 32 individuals from the total cohort identified (n = 15 idiopathic DP, n = 17 DP of known etiology), were reviewed and severity of CS graded (0-2). In idiopathic DP, CS was significantly more severe (grade 2 stenosis) on the side of DP at C3-C4 (73% affected vs 13% unaffected side; p = 0.031) and C4-C5 (60% affected vs 20% unaffected side; p = 0.0039), while no difference was observed in DP of known etiology. Overall severity of CS across all cervical spine levels was significantly worse in idiopathic DP versus those with DP of known etiology. CONCLUSIONS: In unilateral idiopathic DP, severity of CS is associated with DP laterality and is an underrecognized cause of diaphragmatic dysfunction. We propose that evaluation of 'idiopathic' DP should routinely include cervical spine imaging, preferably by MRI.

Interscalene versus supraclavicular plexus block for the prevention of postoperative pain after shoulder surgery: A systematic review and meta-analysis.

BACKGROUND: Interscalene brachial plexus blockade is the most common regional anaesthesia technique for alleviating pain after shoulder surgery, but complications occur, including ipsilateral hemidiaphragmatic paresis, Horner's syndrome and hoarseness. The supraclavicular approach might be an effective alternative with fewer adverse effects. OBJECTIVES: The aim of this study was to determine whether there is a difference in postoperative pain scores and morphine equivalents between interscalene and supraclavicular brachial plexus blocks. Secondary endpoints were serious adverse events. DESIGN: A systematic review and meta-analysis of randomised controlled trials. DATA SOURCES: A comprehensive literature search of Embase, CENTRAL, MEDLINE and Web of Science was performed from the earliest record to December 2018. ELIGIBILITY CRITERIA: Prospective randomised controlled trials that compare interscalene and supraclavicular brachial plexus blocks in patients undergoing shoulder surgery were eligible for inclusion. Only studies that reported their methods transparently and comprehensibly were included. Conference abstracts or meeting abstracts were not excluded a priori. Risk of bias was assessed using Cochrane methodology. RESULTS: Twelve studies were eligible for meta-analysis. The supraclavicular approach showed overall comparable 24-h pain scores (mean difference -0.34; 95% CI -0.75 to 0.07, P = 0.11) and comparable morphine equivalent consumption (mean difference 1.84 mg per 24 h; 95% CI -0.00 to 3.69, P = 0.05). Secondary endpoint analysis revealed a significantly lower rate of hemidiaphragmatic paresis (risk ratio 0.56; 95% CI 0.39 to 0.82, P = 0.003) and Horner's syndrome (risk ratio 0.29; 95% CI 0.19 to 0.44, P < 0.00001) for the supraclavicular approach. There was no significant difference in hoarseness (risk ratio 0.73; 95% CI 0.48 to 1.13, P = 0.16). CONCLUSION: After 24 postoperative hours, pain scores and consumption of morphine equivalents were comparable. Adverse effects were less common with the supraclavicular approach. The supraclavicular approach might be an efficient alternative to the interscalene approach for shoulder surgery. However, the available evidence is inadequate and prevents a firm conclusion.

Hemidiaphragmatic paralysis: A case report.

Hemidiaphragmatic paralysis is initially recognised as postoperative respiratory distress. The subsequent sequential management of the patient following arthroscopic shoulder surgery under interscalene block is described. Ultrasound-guided technique is considered to be the safest for interscalene block. Reducing the volume of anaesthetic used reduces its spread to the phrenic nerve and thus reduces the incidence of hemidiaphragmatic paralysis. Furthermore, a reduction in anaesthetic volume has equivalent analgesic efficacy.

Diaphragmatic paralysis in obese patients in arthroscopic shoulder surgery: consequences and causes.

PURPOSE: Ambulatory process in arthroscopic shoulder surgery has boomed over past decades. Some anesthetic techniques such as interscalene block (ISB) and its surrogates are associated with diaphragmatic paralysis and might compromise outpatient procedure. HYPOTHESIS: This study aims to assess consequences of diaphragmatic paralysis in obese patients. METHODS: This prospective observational study screened patients with body mass index (BMI) ≥ 30 kg/m2 undergoing acromioplasty or supraspinatus tendon repair. Surgery was performed using brachial plexus block, and the method of brachial plexus block was left at the discretion of attending anesthesiologists. Post-operative hemidiaphragmatic paralysis was evaluated using M-mode ultrasonography and its consequences on patient ventilation were assessed: occurrence of hypoxic episode defined as oxygen saturation less than 90% (by pulse oximeter) in room air, dyspnea and failure of ambulatory procedure. Causes of diaphragmatic paralysis were also analyzed. RESULTS: Ninety-one patients were screened, 82 patients were included in this study and 37 patients (45%) presented diaphragmatic paralysis. Compared to patients without diaphragmatic paralysis, diaphragmatic paralysis was associated with dyspnea [10 (27%) versus 1 (2%); p = 0.0019], occurrence of patients presenting at least one hypoxic episode [6 (16%) versus 1 (2%); p = 0.02] and failure of ambulatory process [10 (27%) versus 1 (2%); p = 0.009]. The combination of axillary and suprascapular nerve blocks, but also low volume ISB, was found to be protective against diaphragmatic paralysis when compared to high volume ISB [Odds ratios 0.0019 (0.001-0.026) and 0.0482 (0.008-0.27), respectively; p < 0.001]. CONCLUSION: In patients with BMI ≥ 30 kg/m2 undergoing arthroscopic shoulder surgery, diaphragmatic paralysis is associated with dyspnea, occurrence of hypoxic episodes and failure of ambulatory procedure. High volume ISB and also, to a lesser extent, low volume ISB were found to be responsible for diaphragmatic paralysis. TRIAL REGISTRY NUMBER: Registration n° 2014-202.

In-situ left-sided bilateral internal thoracic artery: elevated hemidiaphragm.

Background Procurement of the internal thoracic artery risks ipsilateral phrenic nerve injury and elevated hemidiaphragm. Anatomical variations increase the risk on the right side. Patients receiving left-sided in-situ right internal thoracic artery configurations appear to be at greatest risk. Methods From 2014 to 2016, 432 patients undergoing left-sided in-situ bilateral internal thoracic artery grafting were grouped according to right internal thoracic artery configuration: retroaortic via transverse sinus (77%) or ante-aortic (23%); targets were the circumflex and left anterior descending artery territories, respectively. Elevated hemidiaphragm was assessed by serial chest radiographs and categorized by side, complete (≥2 intercostal spaces) versus partial, and permanent versus transient. Results Right elevated hemidiaphragm occurred in 4.2% of patients. The incidence of radiological complete right elevated hemidiaphragm was 2.8% (12/432); 8 cases were transient with recovery in 3.5 ± 0.3 weeks. Permanent right elevated hemidiaphragm occurred in 0.9% (retroaortic group only). Permanent left elevated hemidiaphragm occurred in 0.9% and was significantly higher in the ante-aortic group (3/99 vs. 1/333, p = 0.039). No bilateral hemidiaphragm elevation was documented. Partial right elevated hemidiaphragm occurred in 1.4% and was not associated with adverse early or late respiratory outcomes. Conclusions Despite susceptible right phrenic nerve-internal thoracic artery anatomy, the incidence of permanent right elevated hemidiaphragm is low and no higher than left-sided in prone bilateral internal thoracic artery subsets. This reflects skeletonized internal thoracic artery procurement. Although statistical significance was not achieved, a retroaortic right internal thoracic artery configuration may constitute a higher risk of right phrenic nerve injury.

Reduced hemidiaphragmatic paresis with extrafascial compared with conventional intrafascial tip placement for continuous interscalene brachial plexus block: a randomized, controlled, double-blind trial.

BACKGROUND.: The incidence of hemidiaphragmatic paresis with continuous interscalene brachial plexus block (CISB) can approach 100%. We tested the hypothesis that extrafascial placement of the catheter tip reduces the rate of hemidiaphragmatic paresis compared with intrafascial tip placement for CISB while providing effective analgesia. METHODS.: Seventy patients undergoing elective major shoulder surgery under general anaesthesia were randomized to receive an ultrasound-guided CISB plexus block for analgesia with the catheter tip placed either within (intrafascial group) or immediately outside (extrafascial group) the brachial plexus sheath midway between the levels of C5 and C6. Catheters were bolus dosed with ropivacaine 0.5% 20 ml before surgery, followed by an infusion of ropivacaine 0.2% at 4 ml h -1 for the first 2 days after surgery. The primary outcome was hemidiaphragmatic paresis measured by M-mode ultrasonography on postoperative day (POD) 1. Secondary outcomes included forced vital capacity, forced expiratory volume in 1 s, and rest pain scores. RESULTS.: The incidence of hemidiaphragmatic paresis on POD 1 was significantly reduced in the extrafascial group {intrafascial, 41% [95% confidence interval (CI) 25-59%]; extrafascial, 15% (95% CI 5-32%); P =0.01}. We were unable to detect a difference between groups in any of the functional respiratory outcomes or in rest pain scores [numerical rating scale (1-10): intrafascial, 3 (95% CI 2-3); extrafascial, 3 (95% CI: 2-4); P =0.93] on POD 1. CONCLUSIONS.: Placement of the catheter tip immediately outside of the brachial plexus sheath reduced the incidence of hemidiaphragmatic paresis on POD 1 associated with ultrasound-guided CISB while providing effective analgesia after major shoulder surgery. Our results do not support the routine placement of the catheter tip within the brachial plexus sheath for CISB. CLINICAL TRIAL REGISTRATION.: NCT02433561.

Lessons Learned at the Epicenter of Brazil's Congenital Zika Epidemic: Evidence From 87 Confirmed Cases.

Congenital Zika virus infection has stimulated great international concern. A prospective case series of 87 infants with laboratory-confirmed congenital Zika syndrome (CZS) at the epicenter of the Brazilian Zika epidemic in Pernambuco state is presented. Mothers were interviewed for symptoms of possible Zika virus (ZIKV) infection during pregnancy, and fetal ultrasounds were obtained. Infant cerebrospinal fluid (CSF) samples were tested for ZIKV-specific antibodies, and sera were screened for other congenital infections. Neuroimaging and ophthalmologic evaluations were also performed. Sixty-six mothers (76%) reported symptoms of ZIKV infection during gestation. Fetal ultrasounds were available from 90% of the mothers, and all demonstrated brain structural abnormalities. All of the CSF samples tested positive for ZIKV immunoglobulin M. The majority of infants (89%) were term; the mean birth weight was 2577 ± 260 g, and the mean head circumference was 28.1 ± 1.8 cm. Severe microcephaly, defined as head circumference 3 SD below the mean for sex and gestational age, was found in 72 (82%) infants. All infants had an abnormal neurological exam, and 18 (20.7%) had arthrogryposis. The main abnormalities detected in computed tomography scans were calcifications (99%), followed by ventricular enlargement (94%), cortical hypogyration (81%), and less commonly, cerebellar hypoplasia (52%). Unilateral diaphragm paralysis was identified in 3 infants. Maternal young age, term infant, small for gestational age, and the presence of ophthalmologic abnormalities were significantly associated with a smaller head circumference Z score. Our findings, based on laboratory-confirmed ZIKV infection, add valuable evidence for the understanding of CZS.