Hypercapnic respiratory distress and loss of consciousness: a complication of supraclavicular brachial plexus block

Yuka Sakuta,Masatsugu Tsuge,Naoko Kuroda,Yoshihisa Fujita

doi:10.1186/s40981-015-0014-5

Abstract

Supraclavicular brachial plexus block is a common anesthetic technique performed for surgery of the upper extremities. We experienced a case of acute hypercapnic respiratory distress with loss of consciousness during creation of an arteriovenous fistula under ultrasound-guided supraclavicular brachial plexus block using 30 mL of 0.75 % ropivacaine. We detected ipsilateral hemidiaphragmatic paralysis by means of M-mode ultrasonography of the block. We thus speculate that phrenic nerve palsy caused by supraclavicular brachial plexus block was the underlying mechanism of the event. Bedside ultrasonography played a pivotal role in making a differential diagnosis and in managing this patient.

Highlights

Phrenic nerve paralysis is known to anesthesiologists as a common complication associated with interscalene brachial plexus block [1], while it is often ignored after supraclavicular brachial plexus block [2]
We present the case of a patient with ipsilateral hemidiaphragmatic paralysis after supraclavicular brachial plexus block, which manifested as loss of consciousness and hypercapnic respiratory distress
We found that there was no movement of the right diaphragm during the respiratory cycle, while normal respiratory movement of the left diaphragm was visualized by M-mode ultrasound imaging (Fig. 2)

Summary

Background

Phrenic nerve paralysis is known to anesthesiologists as a common complication associated with interscalene brachial plexus block [1], while it is often ignored after supraclavicular brachial plexus block [2]. While no sedatives were administered during surgery, the patient was given supplementary oxygen at 3 l per minute via a face mask during the surgery because he reported some difficulty breathing 20 min after injection of the local anesthetic. A portable supine chest radiograph was not remarkable as compared with the preoperative one, showing hilar haziness of the lung field, no signs for pneumothorax, and a slight elevation of the right hemidiaphragm, with increased density at both lung bases These findings were compatible with pulmonary congestion (Fig. 1). A new arteriovenous fistula was uneventfully created under supraclavicular brachial plexus block with 20 mL of 0.75 % ropivacaine 1 week later

Discussion

Conclusions