Interscalene block and bronchospasm

[Planktonmd]

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Here is what happened:
I did an interscalene block post op on a patient who had an ORIF of a fracture of the upper humerus under GA.
The patient had a history of mild asthma.
A few minutes after the block he developed severe wheezing and bilateral miosis.
I tried very hard to break the bronchospasm:
Albuterol nebs X 3 + Ipratropium Neb X1 + Dexamethasone IV + Magnesium IV + Terbutaline IM.
I did not think of giving an anticholinergic but maybe I should have.
Still he got worse and I had to intubate him.
12 hours later he was extubated without problems.
This was a very easy block using a nerve stimulator but no ultrasound.
I have never seen that before but it is reported in the literature.
Have you seen this??

 

[urge]

Interesting. We did a bunch in my residency and this never happened as far as I know. I assume if you cut all the sympathetics to the lung there might be some unopposed bronchoconstriction.

How much volume did you give?

 

[Noyac]

Never seen it.

 

[jetproppilot]

WOW.

Thats impressive.

Never seen it either.

 

[seinfeld]

Thanks for the interesting case, curious as to whether you used an amide or ester for the block and also how long it took for the asthma to start in relation to the start of the block taking effect

 

[Planktonmd]

Thanks for the interesting case, curious as to whether you used an amide or ester for the block and also how long it took for the asthma to start in relation to the start of the block taking effect

I used 30 cc Bupivacaine 0.25% with epi.
The wheezing started 10 minutes after finishing the injection.
Patient had excellent block otherwise.

 

[Planktonmd]

How much volume did you give?

Patient had 2500cc LR over 3 hours.
This was a late case and patient was NPO all day.
They lost 300cc of blood.
CXR did not show pulmonary edema but I still gave Furosemide empirically.

 

[ncdoc1974]

Here is what happened:
I did an interscalene block post op on a patient who had an ORIF of a fracture of the upper humerus under GA.
The patient had a history of mild asthma.
A few minutes after the block he developed severe wheezing and bilateral miosis.
I tried very hard to break the bronchospasm:
Albuterol nebs X 3 + Ipratropium Neb X1 + Dexamethasone IV + Magnesium IV + Terbutaline IM.
I did not think of giving an anticholinergic but maybe I should have.
Still he got worse and I had to intubate him.
12 hours later he was extubated without problems.
This was a very easy block using a nerve stimulator but no ultrasound.
I have never seen that before but it is reported in the literature.
Have you seen this??

I have NEVER seen this before, I am aware it has been reported in the literature...a few thoughts for what it's worth:
1. There is obviously nothing wrong with doing an interscalene block in this patient, and this is a pretty obscure complication...just for discussion, another potential option for this case (upper humerus fx) minimizing the risk of respiratory complications would have been an infraclavicular block combined with a suprascapular block...I personally would have proceeded with the interscalene block...and I probably would have used 40cc 0.5% Bupiv with epi...
2. The BILATERAL miosis confuses me....
3. An anticholinergic may have helped...also, did you think about a little or a lot of ketamine?
4. Maybe something other than the block triggered the bronchospasm? Any other drugs/abx around that time?

 

[Arch Guillotti]

CXR did not show pulmonary edema but I still gave Furosemide empirically.

Can you elaborate on your thought process behind this please? Thanks.

 

[indo]

Was the diaphragm affected at all?

 

[DrDre']

I assume hemodynamics werent a prob or you would have mentioned them? Cardiac asthma is a long shot although not as rare as some of the others on the DDx list. Could be anaphylaxis or toid to amide (rarer than schnot and some believe impossible...)

Here is what happened:
I did an interscalene block post op on a patient who had an ORIF of a fracture of the upper humerus under GA.
The patient had a history of mild asthma.
A few minutes after the block he developed severe wheezing and bilateral miosis.
I tried very hard to break the bronchospasm:
Albuterol nebs X 3 + Ipratropium Neb X1 + Dexamethasone IV + Magnesium IV + Terbutaline IM.
I did not think of giving an anticholinergic but maybe I should have.
Still he got worse and I had to intubate him.
12 hours later he was extubated without problems.
This was a very easy block using a nerve stimulator but no ultrasound.
I have never seen that before but it is reported in the literature.
Have you seen this??

 

[Fastrach]

Surprised people are mentioning such large volumes for their injections... at our institution, we're routinely using about 10cc 0.5% Bupiv + Epi for interscalenes these days... new study out showing as good results as with larger volumes when done under ultrasound guidance, which we do. Not saying a larger volume necessarily contributed to this case, but who knows, this one was a pretty big curveball...

 

[Monty Python]

Thanks for the interesting case, curious as to whether you used an amide or ester for the block and also how long it took for the asthma to start in relation to the start of the block taking effect

For the students who haven't heard this before: a quick way to differentiate an amide local anesthetic from an ester local anesthetic (other than to memorize the lists) is to count the number of "i's" in the generic name (not proprietary name).

Esters have one i: tetracaine, cocaine, etc.

Amides have two i's: lidocaine, bupivacaine (sometimes spelled bupivicaine), etc.

 

[Duane E]

Here is what happened:
I did not think of giving an anticholinergic but maybe I should have.

Doesn't Ipratropium fall in this category? 😕

BTW, it does sound like a sympathetic block: miosis, bronchoconstriction...

 

[jetproppilot]

Doesn't Ipratropium fall in this category? 😕

Yes, but I'm pretty sure Plank was referencing giving a systemic anticholinergic, not one confined to the bronchopulmonary tree.

 

[ncdoc1974]

Surprised people are mentioning such large volumes for their injections... at our institution, we're routinely using about 10cc 0.5% Bupiv + Epi for interscalenes these days... new study out showing as good results as with larger volumes when done under ultrasound guidance, which we do. Not saying a larger volume necessarily contributed to this case, but who knows, this one was a pretty big curveball...

What good studies are out there? The only one I've seen is one from Mexico using 3-5cc of local, but it was a pretty bad study...the reason I am using 40cc of 0.5% with epi (fresh) is to try to get 24-36 hours out of the block...are you able to get that duration consistently with 10cc? just curious...any direction would be appreciated

 

[Duane E]

Ah, thanks Jet. 👍

 

[Planktonmd]

I have NEVER seen this before, I am aware it has been reported in the literature...a few thoughts for what it's worth:
1. There is obviously nothing wrong with doing an interscalene block in this patient, and this is a pretty obscure complication...just for discussion, another potential option for this case (upper humerus fx) minimizing the risk of respiratory complications would have been an infraclavicular block combined with a suprascapular block...I personally would have proceeded with the interscalene block...and I probably would have used 40cc 0.5% Bupiv with epi...
2. The BILATERAL miosis confuses me....
3. An anticholinergic may have helped...also, did you think about a little or a lot of ketamine?
4. Maybe something other than the block triggered the bronchospasm? Any other drugs/abx around that time?

1- Infraclavicular + Supraclavicular block is too much work.
2- The bilateral miosis confuses me too, there was no narcotic overdose and the patient was actually tachypneic. there was no other symptoms of Horner's syndrome.
It might be unrelated.
3- I did not give Ketamine but I gave Terbutaline IM which I think is a better beta agonist than Ketamine.
4-Sure it could be anything else but the bronchospasm appeared after the block.
By the way on the CXR the diaphragm did not look elevated on the ipsilateral side.

 

[Planktonmd]

Yes, but I'm pretty sure Plank was referencing giving a systemic anticholinergic, not one confined to the bronchopulmonary tree.

Yes.

 

[Planktonmd]

Can you elaborate on your thought process behind this please? Thanks.

In the very early stages of pulmonary edema the CXR might still look OK.
And when nothing else is working you just try to cover all possibilities.

 

[Fastrach]

What good studies are out there? The only one I've seen is one from Mexico using 3-5cc of local, but it was a pretty bad study...the reason I am using 40cc of 0.5% with epi (fresh) is to try to get 24-36 hours out of the block...are you able to get that duration consistently with 10cc? just curious...any direction would be appreciated

Wow, 24-36 hrs??? We usually are aiming to get about 12-18 hrs max out of the blocks, hence our results with lesser volumes (10ml 0.5% Bupiv + Epi) are yielding fairly similar results as the study I mentioned before, which is here:

1: Br J Anaesth. 2008 Oct;101(4):549-56. Epub 2008 Aug 4. Links

Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block.

Riazi S, Carmichael N, Awad I, Holtby RM, McCartney CJ.
Department of Anesthesia, Sunnybrook Health Sciences Center, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, Canada M4N 3M5.
BACKGROUND: Interscalene brachial plexus block (ISBPB) is an effective nerve block for shoulder surgery. However, a 100% incidence of phrenic nerve palsy limits the application of ISBPB for patients with limited pulmonary reserve. We examined the incidence of phrenic nerve palsy with a low-volume ISBPB compared with a standard-volume technique both guided by ultrasound. METHODS: Forty patients undergoing shoulder surgery were randomized to receive an ultrasound-guided ISBPB of either 5 or 20 ml ropivacaine 0.5%. General anaesthesia was standardized. Both groups were assessed for respiratory function by sonographic diaphragmatic assessment and spirometry before and after receiving ISBPB, and after surgery. Motor and sensory block, pain, sleep quality, and analgesic consumption were additional outcomes. Statistical comparison of continuous variables was analysed using one-way analysis of variance and Student's t-test. Non-continuous variables were analysed using chi(2) tests. Statistical significance was assumed at P<0.05. RESULTS: The incidence of diaphragmatic paralysis was significantly lower in the low-volume group compared with the standard-volume group (45% vs 100%). Reduction in forced expiratory volume in 1 s, forced vital capacity, and peak expiratory flow at 30 min after the block was also significantly less in the low-volume group. In addition, there was a significantly greater decrease in postoperative oxygen saturation in the standard-volume group (-5.85 vs -1.50, P=0.004) after surgery. There were no significant differences in pain scores, sleep quality, and total morphine consumption up to 24 h after surgery. CONCLUSIONS: The use of low-volume ultrasound-guided ISBPB is associated with fewer respiratory and other complications with no change in postoperative analgesia compared with the standard-volume technique.

 

[urge]

we're routinely using about 10cc 0.5% Bupiv + Epi for interscalenes these days...

I must be getting old. We used 60ml(ropi 0.5) when I was in residency.

😱

 

[Gern Blansten]

I must be getting old. We used 60ml(ropi 0.5) when I was in residency.

😱

If you used ropivacaine during your residency, you are, by definition, not old. Unless of course, you were already old when you started residency.🙂

 

[Jeff05]

we do most ISB with u/s.

use either bupiv 0.5% with epi - 40ml or
bupi 0.5% 20ml and mepiv 1.5% 20ml.

the study quoted used GA for the case. all we do is give a prop infusion. patients go to phase 2 pacu from the room. i do agree 40ml is probably overkill.

bilateral miosis suggests an epidural/spinal injection of a portion of the local. this could potentially knockout both recurrent laryngeal nerves (not completely otherwise total airway obstruction) and cause respiratory distress. these upper airway sounds could be transmitted to the lungs and sound like wheezing.

second option is amide allergy.

after nebs failed, pt would have received 5-10mcg epi IV.

 

[Gern Blansten]

Here is what happened:
I did an interscalene block post op on a patient who had an ORIF of a fracture of the upper humerus under GA.
The patient had a history of mild asthma.
A few minutes after the block he developed severe wheezing and bilateral miosis.
I tried very hard to break the bronchospasm:
Albuterol nebs X 3 + Ipratropium Neb X1 + Dexamethasone IV + Magnesium IV + Terbutaline IM.
I did not think of giving an anticholinergic but maybe I should have.
Still he got worse and I had to intubate him.
12 hours later he was extubated without problems.
This was a very easy block using a nerve stimulator but no ultrasound.
I have never seen that before but it is reported in the literature.
Have you seen this??

I think an inadvertent injection into a dural sleeve is probably the culprit.

Darn it. Jeff beat me to it by 3 minutes.

 

[Planktonmd]

we do most ISB with u/s.

use either bupiv 0.5% with epi - 40ml or
bupi 0.5% 20ml and mepiv 1.5% 20ml.

the study quoted used GA for the case. all we do is give a prop infusion. patients go to phase 2 pacu from the room. i do agree 40ml is probably overkill.

bilateral miosis suggests an epidural/spinal injection of a portion of the local. this could potentially knockout both recurrent laryngeal nerves (not completely otherwise total airway obstruction) and cause respiratory distress. these upper airway sounds could be transmitted to the lungs and sound like wheezing.

second option is amide allergy.

after nebs failed, pt would have received 5-10mcg epi IV.

The patient had a perfect Unilateral sensory block.
And this was wheezing not stridor that I misinterpreted for wheezing, the patient had a very distinct prolongation of the expiratory phase.

 

[Planktonmd]

after nebs failed, pt would have received 5-10mcg epi IV.

No hypotension.
Is 5-10 mcg of Epi IV better than 0.5 mg Terbutaline IM??

 

[Planktonmd]

I think an inadvertent injection into a dural sleeve is probably the culprit.

Darn it. Jeff beat me to it by 3 minutes.

Maybe, but I would have expected a bilateral sensory block.
I feel that somehow I had a bilateral sympathetic block although not complete, because you would expect fully blown horner's syndrome on both sides and that did not happen.
Bronchospasm after interscalene block is mentioned in the literature and some people attribute it to a unilateral sympathetic block in a susceptible patient.

 

[Jeff05]

Terb SC takes 20-30 min to kick in.
Epi IV works within 30seconds.

No hypotension.
Is 5-10 mcg of Epi IV better than 0.5 mg Terbutaline IM??

 

[Planktonmd]

Terb SC takes 20-30 min to kick in.
Epi IV works within 30seconds.

Right, but I said IM not SC.
This patient was not in anaphylactic shock so I had a few minutes to spare.

 

[urge]

Terb SC takes 20-30 min to kick in.

Not in my experience. I have had 2 severe allergic reactions within the last 6 weeks. One got SC terb for a recurring bronchospasm. The other SC epi for hypotension resistant to neo. Terb (1mg- I was getting upset already) worked within seconds. Epi took like a minute (I only gave .25mg) to work. No recrudescence.

 

[Jeff05]

why would you give SC meds when you have IV access?

Not in my experience. I have had 2 severe allergic reactions within the last 6 weeks. One got SC terb for a recurring bronchospasm. The other SC epi for hypotension resistant to neo. Terb (1mg- I was getting upset already) worked within seconds. Epi took like a minute (I only gave .25mg) to work. No recrudescence.

 

[Arch Guillotti]

why would you give SC meds when you have IV access?

I had the same question.

 

[Planktonmd]

why would you give SC meds when you have IV access?

Because you want the effect of a short acting medication to last more than 2 minutes without starting a drip?
Or because the medication in question causes severe tachycardia when given IV?

 

[periopdoc]

Wow, 24-36 hrs??? We usually are aiming to get about 12-18 hrs max out of the blocks, hence our results with lesser volumes (10ml 0.5% Bupiv + Epi) are yielding fairly similar results as the study I mentioned before, which is here:

1: Br J Anaesth. 2008 Oct;101(4):549-56. Epub 2008 Aug 4. Links

Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block.

That study was powered to show the efficacy of 5 ml vs 20 ml injections in reducing phrenic nerve block. It successfully demonstrated this.

It was not powered to study the equivalence of 5 vs 20 mL injections for postoperative pain control. While there was a "non-significant" trend towards higher opiate utilization in the 5 mL group, no conclusions can be drawn about this as the study was not powered to detect a difference.

- pod

 

[Arch Guillotti]

Because you want the effect of a short acting medication to last more than 2 minutes without starting a drip?
Or because the medication in question causes severe tachycardia when given IV?

That all is reasonable however unforunately I didn't get much experience (any) giving anything other than IV/PO during anesthesia residency that I can recall. In an extreme situation I am gonna go with what I am familiar with. Obviously epi causes tachycardia but I think that in small incremented doses you can avoid anything too extreme.

 

[Arch Guillotti]

Not in my experience. I have had 2 severe allergic reactions within the last 6 weeks. One got SC terb for a recurring bronchospasm. The other SC epi for hypotension resistant to neo.

Why were you giving neo for an allergic reaction (other than for low bp🙄)? I would think that epi would be your first drug to go to.

 

[urge]

Why were you giving neo for an allergic reaction (other than for low bp🙄)? I would think that epi would be your first drug to go to.

Her reaction was hypotension and a rash. No bronchospasm. We always have a drip neo ready. My crna started the drip without realizing it was an allergic reaction. Half an hour later( yes, half an hour later) I get called because the neo "ain't cutting it". I looked at the pt under the bair hugger:flushed with hives. Gave some epi sc, cut down the neo. Can I blame the crna for not being a good clinician? They are not clinicians? hmm? I don't know what the right answer is.

 

[Arch Guillotti]

Her reaction was hypotension and a rash. No bronchospasm. We always have a drip neo ready. My crna started the drip without realizing it was an allergic reaction. Half an hour later( yes, half an hour later) I get called because the neo "ain't cutting it". I looked at the pt under the bair hugger:flushed with hives. Gave some epi sc, cut down the neo. Can I blame the crna for not being a good clinician? They are not clinicians? hmm? I don't know what the right answer is.

👍

yes as I am sure you can tell from my spate of recent posts I feel your pain.

 

[Arch Guillotti]

Her reaction was hypotension and a rash. No bronchospasm. We always have a drip neo ready. My crna started the drip without realizing it was an allergic reaction. Half an hour later( yes, half an hour later) I get called because the neo "ain't cutting it". I looked at the pt under the bair hugger:flushed with hives. Gave some epi sc, cut down the neo. Can I blame the crna for not being a good clinician? They are not clinicians? hmm? I don't know what the right answer is.

AKA "sabotage"