DIAPHRAGMATIC HEMIPARALYSIS AS A RARE CONSEQUENCE OF HIGH THORACIC EPIDURAL ANESTHESIA IN LUNG TRANSPLANTATION: A CASE REPORT

Abstract

SESSION TITLE: Fellows Transplantation Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Thoracic epidural anesthesia is routinely placed intraoperatively for postoperative pain management in lung transplant recipients [1]. Herein, we sought to detail a rare consequence of thoracic epidural anesthesia if placed too high. CASE PRESENTATION: A 56-year-old male underwent bilateral lung transplant in April 2020 for treatment of end-stage idiopathic pulmonary fibrosis. There were no major intraoperative complications, and no phrenic nerve injury noted. Thoracic epidural anesthesia was placed in the operating room for routine postoperative pain management. The immediate postoperative period was uncomplicated, as the patient had no primary graft dysfunction at time 0 or 24 hours after transplant. The allograft was functioning well with minimal secretions and no positive cultures detected. After rapid ventilator weaning, the patient was extubated on post-transplant day one. However, the patient required two unsuspected re-intubations, and the right hemidiaphragm was found notably elevated on chest radiograph. The epidural block was weaned within six hours, and the patient was successfully extubated, without need for further re-intubation. The initial and follow-up chest radiographs after recovery are depicted in Figure 1. DISCUSSION: Upon review, it was noted that the epidural catheter was inserted high at the T2-3 intervertebral space. Although thoracic epidural block extending up to the T2 level does not normally alter ventilation significantly in healthy persons, our patient recovering from lung transplant was dyspneic and had difficulty generating adequate tidal volume, necessitating re-intubation. Importantly, large volumes of anesthetics may be necessary after a highly invasive thoracic surgery such as lung transplant. A high thoracic epidural block with significant anesthetic volume may affect the roots of the brachial plexus, some of which are responsible for the phrenic nerve and diaphragmatic contraction. CONCLUSIONS: Anesthesiologists and transplant clinicians should be aware that intraoperative high thoracic epidural anesthesia in a lung transplant recipient may have post-transplant motor repercussions of diaphragmatic hemiparalysis, resulting in changes to respiratory dynamics and pulmonary symptoms. Reference #1: Von Dossow V, Welte M, Zaune U, et al. Thoracic epidural anesthesia combined with general anesthesia: the preferred anesthetic technique for thoracic surgery. Anesth Analg. 2001;92(4):848-854. doi:10.1097/00000539-200104000-00010 DISCLOSURES: No relevant relationships by Hesham Abdelrazek, source=Web Response No relevant relationships by ASHWINI ARJUNA, source=Web Response No relevant relationships by Hesham Mohamed, source=Web Response No relevant relationships by Michael Olson, source=Web Response No relevant relationships by Josna Padiyar, source=Web Response Speaker/Speaker's Bureau relationship with Genentech Please note: $5001 - $20000 by Rajat Walia, source=Admin input, value=Honoraria Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Please note: $5001 - $20000 by Rajat Walia, source=Admin input, value=Honoraria Speaker/Speaker's Bureau relationship with Grifols Please note: $5001 - $20000 by Rajat Walia, source=Admin input, value=Honoraria Speaker/Speaker's Bureau relationship with Shire Please note: $1001 - $5000 by Rajat Walia, source=Admin input, value=Honoraria Speaker/Speaker's Bureau relationship with Astellas Please note: $5001 - $20000 by Rajat Walia, source=Admin input, value=Honoraria