Case from today

[aphistis]

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Our block team had a situation come up this afternoon. It's still developing, so I don't know all the details at this point, but I thought I'd throw it out to discuss over the weekend until I get the whole story.

60 year old white female presenting for scheduled ortho case. She broke her left radius last summer, has been ex-fixed since then(?!), and is now infected with frank purulent drainage from the area.

She's a morbidly obese (~5'2"/120kg) smoker w/COPD, afib, type 2 diabetic, cardiac status definitely poor but details unknown to me right now. Plan is for ortho debridement/washout under regional+MAC. Preop vitals HR 90, BP 142/90, SaO2 92% on room air.

Block team decides against sedation and performs left ultrasound-guided single-shot supraclavicular with 30cc 0.5% ropiv. The procedure is observed by staff throughout, and completed successfully without difficulty or evidence of complication.

Over the next ten minutes, the patient becomes diaphoretic and complains of shortness of breath. Vitals now HR 60, BP 164/116, SaO2 78-82% on 15L non-rebreather, patient A&O. FYI, the block team holding area is a corded-off section of our outpatient PACU. Your attending left after the block, so it's just you and a pretty good PACU RN who spends a lot of time helping the block team.

What's going on, and what do you do next?

 

[G0S2]

is she completely supine?

 

[aredoubleyou]

could be phrenic nerve. Intubate, CXR, r/o pneumo

 

[dfk]

first thought is a pneumo. wouldn't a 14g angiocath to 2nd ICS MCL help buy some time here?

 

[thegasman]

Block team decides against sedation and performs left ultrasound-guided single-shot suprascapular with 30cc 0.5% ropiv. The procedure is observed by staff throughout, and completed successfully without difficulty or evidence of complication.

What's going on, and what do you do next?

Don't you mean supraclavicular? And if so I would be concerned about ptx, although with us-guidance you would hope to avoid this.

 

[OB1🤙]

Sounds to me like the phrenic got bagged in a pt without good reserve (and I think that a supraclavicular maybe should have been avoided in this pt for this reason). Less likely PTX given U/S guidance, but possible. Can you tell us more about how the block went- was everything absolutely silky smooth and needle visualized throughout or was there ambiguity in landmarks?

Can you give us exam info? Breath sounds, chest rise, etc? RR?

And why the hell is the HR 60 in an agitated decompensating pt?

Anyway, intubation gear to bedside stat and call for help. Slap on the EKG leads. Call for a CXR too, but it'll probably be a while before it's shot let alone available to view and it sounds like you'll have to start acting now-ish. While that's going on, locate your nearest ambu-bag and have it ready.

 

[aredoubleyou]

first thought is a pneumo. wouldn't a 14g angiocath to 2nd ICS MCL help buy some time here?

maybe if he was hypotensive and desating but this doesnt sound like an emergent tension- intubate 100% fio2, get a cxr and then chest tube in a controlled fashion if pneumo present. Id stay away from stabbing the chest at this point

 

[aredoubleyou]

And why the hell is the HR 60 in an agitated decompensating pt?

.

Toprol or maybe atenolol. That stuff is the water now

 

[aphistis]

Don't you mean supraclavicular? And if so I would be concerned about ptx, although with us-guidance you would hope to avoid this.

Yeah, that's what I meant. My bad. Fixed it. I'll put the next part up in a few hours.

 

[OB1🤙]

Toprol or maybe atenolol. That stuff is the water now

Well, he said pre-procedure it was 90.

 

[huktonfonix]

rule out MI as well

 

[Jeff05]

in her case anything that blocks the phrenic is contraindicated. she clearly has borderline pulmonary function. absolutely no reserve. this is not an MI, or a PTX, i mean you're obviously gonna rule her out for medico-legal. common things are common and knocking out a hemiD in a patient like this very classically and predictably cause this sort of deterioration.

you tube her. if she's with it and you have a bipap immediately avail, you can try non-invasive ventilation.

 

[huktonfonix]

in her case anything that blocks the phrenic is contraindicated. she clearly has borderline pulmonary function. absolutely no reserve. this is not an MI, or a PTX, i mean you're obviously gonna rule her out for medico-legal. common things are common and knocking out a hemiD in a patient like this very classically and predictably cause this sort of deterioration.

you tube her. if she's with it and you have a bipap immediately avail, you can try non-invasive ventilation.

Yes, common things are common and this is LIKELY phrenic nerve involvement given the volume of local used. Typically, I dont use more than 20 ml if that for a good supraclavicular block. However, in this case an ax block or individual blockade of the nerves in the arm would be a better choice given her likely comorbidities. However, taking a narrow view of it and saying it ABSOLUTELY is not another condition is short sighted and could get you into trouble later on. Its important to be able to identify the most likely cause and treat quickly, but tunnel vision could prevent you from identifying a potential problem in other cases. It could very well be a smaller PTX that is not hemodynamically compromising, but enough to tip over someone with poor pulmonary reserve or MI. Its not as likely as phrenic block, but possible.

Local anesthetic toxicity is also possible although not very likely

 

[urge]

The simplest answer would be my starting point. "Bagged the phrenic"- get an x ray on deep inspiration. Should show up there. Pneumo is also a possibility... Aspiration?..

Assuming x ray was negatine, then i would get an abg-check co2, ph, good for A-a gradient calculation,glucose for diabetus/dka,... Some cardiac labs just in case + ekg.

I would start worrying about a PE and or early sepsis.

She meets criteria for intubation. Might want to do that sooner than later.

 

[Bertelman]

And why the hell is the HR 60 in an agitated decompensating pt?

Doubtful they had her hooked up to ECG. Last year I found the floor vitals (from BP cuff/pulse ox roll-around) woefully insufficient for measuring HR in AFib. I'd see a HR of 60 recorded, then Tele would show 90+ irregular. I don't trust a HR for AFib unless I see the QRS.

Just a thought.

 

[SleepIsGood]

likely phrenic nerve is blocked.

sit the patient up. Ask her to breath deeply. Check vitals,etc. If still unacceptable...intubate.

 

[BLADEMDA]

You guys are all over this case. I have seen this at least a dozen times in my career. If you want to do an interscalene or supraclavicular block in a patient with bad lungs (severe COPD) then be prepared to intubate the patient. The tricky part is that many of these shoulders/elbows are supposed to go home. Instead, if you do the block they me be intubated over-night.

Thus, you must discuss this known complication with the patient and the surgeon. Usually, even severe COPD patients tolerate the block with just O2 supplementation. However, even the most experienced Regional expert can go from being the hero (pain free patients) to a ZERO (outpatient admitted on a vent for over-night stay) in a small subset of patients.

In this case an Infraclavicular block or Axillary block was a better choice.


Supraclavicular Nerve Block: Ultrasound-Guided Technique ...
Treatment may require hospitalization and placement of a chest tube. Paralysis of the phrenic nerve. Occurs in 40% to 60% of supraclavicular blocks, ...
www.proceduresconsult.com/medical.../supraclavicular-nerve-block-ultrasound-guided-technique-AN-procedure.aspx - 108k - Cached - Similar pages

 

[dfk]

alright, so i've been educated that if one is to give such a block, one has to be prepared to deal with phrenic nerve block and ready for the worst. i was guided into having an epi drip at the ready. most especially for an interscalene, but not with standing the other locale blocks. do any of you guys prepare an epi bag for the ready with such blocks?

 

[maceo]

alright, so i've been educated that if one is to give such a block, one has to be prepared to deal with phrenic nerve block and ready for the worst. i was guided into having an epi drip at the ready. most especially for an interscalene, but not with standing the other locale blocks. do any of you guys prepare an epi bag for the ready with such blocks?

if you like your career and you hate lawyers.. Stay the F>>> away from blocks in that territory. The pain associated with these are far reaching. and im not talking about the patients pain. I agree sedation is not the best move for this patient (for the block or case) . neither is a block. In this patient > Do an iv induction (possible rapid sequence) and put a cuffed et tube in. Have a nice day! control post op pain with mild-moderate PO opiates. Youll have a good nights rest. Trust me.

 

[OB1🤙]

I disagree maceo- I think a block is a great idea for this case, just not a supraclavicular.

 

[aphistis]

is she completely supine?

She started out that way. Sitting her up 60 degrees didn't seem to affect anything.

Sounds to me like the phrenic got bagged in a pt without good reserve (and I think that a supraclavicular maybe should have been avoided in this pt for this reason). Less likely PTX given U/S guidance, but possible. Can you tell us more about how the block went- was everything absolutely silky smooth and needle visualized throughout or was there ambiguity in landmarks?

Can you give us exam info? Breath sounds, chest rise, etc? RR?

And why the hell is the HR 60 in an agitated decompensating pt?

Anyway, intubation gear to bedside stat and call for help. Slap on the EKG leads. Call for a CXR too, but it'll probably be a while before it's shot let alone available to view and it sounds like you'll have to start acting now-ish. While that's going on, locate your nearest ambu-bag and have it ready.

1) Absolutely silky smooth, yes. Landmarks identified with u/s ahead of time, needle in plane throughout, local went where it was expected to, no sign of trouble anywhere.

2) Breath sounds equal throughout but unimpressive, not much air moving. Chest rise w/some abdominal rocking on each inspiration. RR 25-30.

3) Good question.

Doubtful they had her hooked up to ECG. Last year I found the floor vitals (from BP cuff/pulse ox roll-around) woefully insufficient for measuring HR in AFib. I'd see a HR of 60 recorded, then Tele would show 90+ irregular. I don't trust a HR for AFib unless I see the QRS.

Just a thought.

They had a 3-lead on her.

So they also went with respiratory distress secondary to phrenic nerve block as a working diagnosis. Called for help, intubating equipment to bedside, called for the stat CXR. Albuterol nebulizer while waiting improved her lung sounds and raised her sats to about 88% for a few minutes before they started drifting back down.

I left while the CXR was processing due to room crowding, with her sats stabilized around 82% on the neb, and other vitals unchanged. Neither PE nor MI came up in the discussion while I was there. Our block team had always preferred infraclavicular blocks for these distal arm cases, but recently they've been doing a lot of these u/s supraclavicular blocks. I expect, at least on patients like this lady, we'll go back to the infraclaviculars to avoid any repeat performances like today. I'll come back with the official epilogue Monday.

 

[maceo]

I disagree maceo- I think a block is a great idea for this case, just not a supraclavicular.

yeah morbidly obese diabetic who smokes like a chimney.. perfect case for a block..


secure the airway and move on..

 

[jwk]

yeah morbidly obese diabetic who smokes like a chimney.. perfect case for a block..


secure the airway and move on..

Can't say I disagree with you much on this one.

 

[turnupthevapor]

infraclav probably always spare phrenic issues

 

[jetproppilot]

Can't say I disagree with you much on this one.

Someone teetering on the fence of pulmonary failure just walking up to the Burger King window at the local mall is someone I'd avoid a procedure in with a high incidence of phrenic nerve involvement.

I'm a big regional advocate as all of you know.

And there is no right answer here....had nothing deleterious happened you guys wouldda been the heroes.

I've found myself being more selective, though, with regional intervention.

Had I felt moved to go regional on this case I'd do an axillary block.....with .5% bupivicaine... no chance of adversely affecting her breathing....yeah, its analgesic penetrance at the elbow is sketchy but I'd say more than 50% of the ones I've done have had results at that level acceptable enough to get thru an upper-forearm case along with sedation. I'd go into the procedure knowing I may have to put her to sleep anyway.

More than likely though I wouldda just put her to sleep especially if the fracture was more proximal than distal.

Interesting case and thanks for sharing.

 

[BLADEMDA]

1: Anesth Analg. 1996 Oct;83(4):747-51. Links

The efficacy of axillary block for surgical procedures about the elbow.

Schroeder LE, Horlocker TT, Schroeder DR.
Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota 55905, USA.
Surgical procedures to the distal humerus, elbow, and proximal ulna and radius are ideally suited to regional techniques. However, axillary block is usually not recommended for surgery about the elbow because blockade at this level may result in inadequate block of the terminal nerves that arise from the medial, posterior, and lateral cords, and provide sensory innervation to the upper arm. This study reports the success rates for interscalene, supraclavicular, and axillary blocks for surgery about the elbow. Three hundred thirty surgical procedures in 260 patients were reviewed retrospectively. Approach to the brachial plexus (interscalene, supraclavicular, axillary), anesthetic technique (paresthesia, nerve stimulator, transarterial), and local anesthetic solution were recorded. Success rate, defined as the percent of cases in which the block provided adequate surgical anesthesia, and the frequency of perioperative respiratory compromise were also determined. In 156 cases, the surgical procedure involved a bony structure. The surgery involved only soft tissue in the remaining 174 cases. Adequate surgical anesthesia was present in 283 cases, for an overall success rate of 86%. Adequate surgical anesthesia was present in 219 of 247 axillary (89%), 46 of 59 supraclavicular (78%), and 18 of 24 interscalene (75%) blocks (P < 0.025). Successful axillary block was achieved in 95% of blocks using paresthesia technique, 88% of blocks using a nerve stimulator/motor response, 94% of combination blocks (paresthesia or nerve stimulator combined with transarterial injection), and 81% of blocks performed exclusively with transarterial injection (P < 0.05). In addition, axillary blocks performed with mepivacaine had a higher success rate (93%) than those performed with bupivacaine (81%) (P < 0.01). There were no patients with perioperative respiratory compromise. These results demonstrate that the axillary approach to the brachial plexus may be successfully used for surgical procedures about the elbow

 

[aphistis]

The simplest answer would be my starting point. "Bagged the phrenic"- get an x ray on deep inspiration. Should show up there. Pneumo is also a possibility... Aspiration?..

Assuming x ray was negatine, then i would get an abg-check co2, ph, good for A-a gradient calculation,glucose for diabetus/dka,... Some cardiac labs just in case + ekg.

I would start worrying about a PE and or early sepsis.

She meets criteria for intubation. Might want to do that sooner than later.

Question to urge and the other guys with more experience than me: Is this a lot of overkill initially? I agree with everyone else that said it seems like a pretty classic presentation of phrenic block in patient with marginal respiratory function, but I'm interested to hear whether anyone else would also order these extra tests and why. My own thoughts:

1) CXR on deep inspiration: The lady can't generate a deep inspiration anymore; if she could still take deep breaths, presumably we wouldn't have a problem at all. Still need to order the CXR to rule out PTX, I just wouldn't expect it to be very helpful diagnosing the phrenic block.

2) ABG/BG: In terms of the immediate problem, it seems the only clinically useful info an ABG would provide is that she's not ventilating very effectively, which we already knew. Pre-op BG from a couple hours prior is OK.

3) Pt had no complaints of chest pain, only the trouble catching her breath. If a 12-lead showed no signs of MI (though with all the rocking and heaving she's doing it might be hard to say for certain), would you still send markers?

Again, not wanting to be argumentative, just interested in hearing more about the thought processes.

 

[BLADEMDA]

Received: 6 June 1990 Accepted: 21 June 1990
Summary One of the complications of neck dissection to control regional metastatic disease in cancer of the head and neck is phrenic nerve paralysis. The resulting elevation of the ipsilateral diaphragm can be diagnosed on a postoperative chest X-ray and confirmed by fluoroscopy. Symptoms can be respiratory, cardiac or gastrointestinal. In a retrospective study, unilateral phrenic nerve paralysis was observed in 14 (8%) of 176 consecutive neck dissections. None of the patients with postoperative phrenic nerve paralysis displayed severe symptoms, although a significantly higher number sustained atelectasis with or without pulmonary infiltrates to complicate the postoperative course.
Key words Phrenic nerve paralysi

 

[aredoubleyou]

Question to urge and the other guys with more experience than me: Is this a lot of overkill initially? I agree with everyone else that said it seems like a pretty classic presentation of phrenic block in patient with marginal respiratory function, but I'm interested to hear whether anyone else would also order these extra tests and why. My own thoughts:

1) CXR on deep inspiration: The lady can't generate a deep inspiration anymore; if she could still take deep breaths, presumably we wouldn't have a problem at all. Still need to order the CXR to rule out PTX, I just don't know how helpful it would be in diagnosing the phrenic block.

2) ABG/BG: In terms of the immediate problem, it seems like the only clinically useful info an ABG would provide is that she's not ventilating very effectively, which we already knew. Pre-op BG from a couple hours prior is OK.

3) Pt had no complaints of chest pain, only the trouble catching her breath. If a 12-lead showed no signs of MI, would you still send markers?

Again, not wanting to be argumentative, just interest in hearing more about the thought processes.

1) besides ruling out pneumo, you can rule in a phrenic n block in this setting with an elevated hemidiaphagm

2) Shes rapidly desating and dyspnic, dont f..k around with ABG's, put an ETT in, then get an abg if you want

3) If it doesnt seem consistent with phrenic n or pneumo, then look for other causes like ecg, enzymes, etc - otherwise a waste of time. And yes, if you thought that she could be having an MI, send troponins now and 6 hrs later - DOE is a classic non-classic MI presentation 🙂

 

[BLADEMDA]

Asymptomatic profound oxyhemoglobin desaturation following interscalene block in a geriatric patient. - Smith MP - Reg Anesth Pain Med - 01-MAR-1998; 23(2): 210-3 (MEDLINE is the source for the citation and abstract of this record )

Abstract:

BACKGROUND AND OBJECTIVES: Interscalene block can be chosen for complete anesthesia for shoulder surgery. Phrenic nerve block occurs with almost all interscalene blocks, but is well tolerated in most patients. This may not be the case in selected geriatric patients. METHODS: The patient is a 90-year-old female with osteoarthritis of the left shoulder scheduled for total shoulder anthroplasty. Past medical history revealed hypertension, mild mitral valve insufficiency, and a remote episode of congestive heart failure. She underwent interscalene block with 40 mL of 1.4% mepivacaine, 1:200,000 epinephrine freshly added, alkalinized with sodium bicarbonate. RESULTS: The onset of the block was rapid and complete. The patient had minimal intravenous sedation (0.5 mg midazolam) and was resting comfortably with a respiratory rate of 12-14 breaths/min. Approximately 5 minutes after the injection of local anesthetic, the patient was noted to be alert, cyanotic, denying dyspnea, with an oxygen saturation of 75-85%. A chest radiograph revealed elevation of the ipsilateral hemidiaphragm and no pneumothorax or other pathology. Despite supplemental oxygen by face mask, desaturation persisted and general anesthesia was induced. On emergence from anesthesia, the patient had a complete interscalene block. Repeat chest radiograph after resolution of the block revealed return of hemidiaphragm position and no other pathology. The patient was extubated in the recovery room without difficulty. Following extubation the patient demonstrated stable respirations and normal oxyhemoglobin saturation. CONCLUSIONS: Ipsilateral phrenic nerve paralysis caused significant respiratory compromise in an elderly patient without known significant pulmonary disease.

 

[pjl]

Someone mentioned a pneumothorax. You guys seem to have figured out pretty quickly that it wasn't a pneumo, but in a different case a real fast first test after you just did an ultrasound guided block is to put the probe on the chest and look.

Also, with an ultrasound guided I have heard you can aim off to the side a bit and use 1/2 of the volume and try to avoid the phrenic that way. Not sure that would be worth doing over just doing a different block or skipping the block altogether.

 

[jetproppilot]

1) besides ruling out pneumo, you can rule in a phrenic n block in this setting with an elevated hemidiaphagm

AWESOME!!

actually, uhhh, not too awesome.

I'm not luvvin the vibe here about ruling s hit in, ruling s hit out.

This is not the internal medicine forums, ladies and gentlemen.

We can all "rule in, rule out."

Actually my mom, a cafeteria worker, pretty smart gal, could do the RULE IN RULE OUT s hit with some tutoring.

With all due respect, to me, thats CROSSWORD PUZZLE mentality.

Its pretty obvious to me, my mom, all my colleagues out there, and the 7-11 manager across the street that the two most likely diagnoses are 1)phrenic nerve involvement and ....uhhhh..... 2) PNEUMO.

The differential FALLS OFF from there.

I'd rather speak minimally about what the cause was, and speak maximally about what the SOLUTION is...i.e. what couldve been a better initial clinical decision.....for future cases.

Thats what separates us from the RULING OUT specialties...

The ability to identify an issue quickly and move on with a better solution, rather than spending the next three days writing notes, ordering tests, and ruling out zebras.

Whats happened has happened. And yeah, lets hear what happened.

But lets spend more time figuring out a better SOLUTION instead of mentally masturbating on the cause.

 

[maceo]

I disagree maceo- I think a block is a great idea for this case, just not a supraclavicular.

a block may be great for this case but not for this patient. MOst of the time you will have to give sedation? you say a little. I say ok fine. You give a little sedation to this patient and see what happens during the case. . you are opening up a can of worms you dont wanna be involved with.actually this is a great oral board scenario. They wanna see how well you can stay out of trouble. great exercise

 

[Lonestar]

I dunno whats going on. b/c not enough info is given. Its most likely blockade of phrenic nerve. Have the nurse get an ambu bag and mask and mask ventilate if you have to. Get the sats up and then worry about getting cxr/labs.

At our place, for a radius fracture we do lots of axillary blocks. I was trained with infraclavicular blocks (i feel more comfortable with these). Infact for wrist surgeries, i will do a combination of axillary and infraclavicular if i don't get more than 1 nerve in the axilla. Works like a charm everytime and doesn't take up much time. Haven't had any that i had to convert to general. (wrist arthroscopies, ORIF radius fx, ORIF ulnar fx, carpal tunnels, etc). For elbow/upper arm surgeries, i will frequently do a combination of infraclavicular/interscalene blocks.

BUT there is no way i am doing a supraclavicular for wirst/forearm surgery. Thats asking for trouble.

 

[aredoubleyou]

AWESOME!!

actually, uhhh, not too awesome.

I'm not luvvin the vibe here about ruling s hit in, ruling s hit out.

This is not the internal medicine forums, ladies and gentlemen.

We can all "rule in, rule out."

Actually my mom, a cafeteria worker, pretty smart gal, could do the RULE IN RULE OUT s hit with some tutoring.

With all due respect, to me, thats CROSSWORD PUZZLE mentality.

Its pretty obvious to me, my mom, all my colleagues out there, and the 7-11 manager across the street that the two most likely diagnoses are 1)phrenic nerve involvement and ....uhhhh..... 2) PNEUMO.

The differential FALLS OFF from there.

I'd rather speak minimally about what the cause was, and speak maximally about what the SOLUTION is...i.e. what couldve been a better initial clinical decision.....for future cases.

Thats what separates us from the RULING OUT specialties...

The ability to identify an issue quickly and move on with a better solution, rather than spending the next three days writing notes, ordering tests, and ruling out zebras.

Whats happened has happened. And yeah, lets hear what happened.

But lets spend more time figuring out a better SOLUTION instead of mentally masturbating on the cause.

As a card carrying member of the Association of Physicinas for Crossword Puzzle Mentality, I get your point, but partly disagree.

This case is a pretty bad example of why you would want to approach a situation like a crossword puzzle, since there are really only two items on the differential, excluding the 0.001% chance its a coincidental MI, or whatever else one can imagine.

But in medicine we deal with probabilities and rarely absolutes, in diagnosis, treatment, and outcome. There are various ways to deal with probabilities, one of which is to willy nilly fly by your seat pants and experience - and treat the first thing that pops in to your head. I prefer the crossword approach of developing a quick differential and trying to distinguish between them with some form of test...AS TIME ALLOWS. The first problem is that in our specialty there is often very little time between presentation and outcome, so you gotta do something fast. But at the same time, I think, we as a specialty are at times over-reacting to situations by treating three things as once - solving one problem and creating two new ones....when in fact, there was sufficient time to solve the crossword puzzle. And by test, I do not mean to say it has to be something you send to the lab or fill out an order form for - it can be a fluid bolus, a change in ventilatory settings, etc where you are effectively diagnosing and hopefully treating at the same time. But mindlessly pushing phenylephrine thru a case for low BPs and ignoring the multiple possible causes of hypotension other than you have your vaporizer on, never trying to figure out if there is another underlying cause because the number on your screen looks good as long as you keep pushing the syringe, is what separates the physician from the technician.

In this case, which admittedly is a poor example of the benefits of constructing and testing a differential, it is still important to diagnose if this was phrenic n or pneumo. Besides the overall treatment being slightly different (basically +/- chest tube), if you want to find a better solution to the problem, you need to know what the problem was. Since ax block is not a perfect solution, nor is general anesth, IF this was phrenic n involvement with a picture perfect u/s guided block it would be reasonable to conclude that this is evidence that even with u/s there is a certain probability of phrenic nerve involvement and I am not going to select this block for COPD pts in the future. IF, however, this was a pneumo, one might conclude that it was a technical error that unfortunately just occurred on a patient who had no pulmonary reserve and one may conclude that with more practice/ experience/ vigilance/ jedi powers/ whatever, that you would continue to perform this block on COPD'rs.

Just a thought