ipsilateral vagus nerve block with interscalene block?

[zippy2u]

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Was wondering what signs and symptoms you'd see in a pt. if this occurred. Nearly 3200 pages of Miller's text, and I don't have an answer. Any ideas gurus? Regards----- Zippy

 

[DuckhuntingDoc]

Well what does it intervate? he said in a raspy voice gasping for breath...😉

 

[Noyac]

The patient complains of hoarse voice, difficulty in swallowing and choking when drinking fluid. There is also loss of gag reflex. Uvula deviates away from the side of lesion and there is failure of palate elevation.

Very little chance of cardiac effects.

 

[zippy2u]

What about hemodynamics like pulse and bp and any known arrhythmias? Remember, just a one-sided block. Will there be a difference with a right-sided block as opposed to a left-sided block? Regards, ----Zip

 

[Noyac]

What about hemodynamics like pulse and bp and any known arrhythmias? Remember, just a one-sided block. Will there be a difference with a right-sided block as opposed to a left-sided block? Regards, ----Zip

The right vagus innervates the sinoatrial node. Parasympathetic hyperstimulation predisposes those affected to bradyarrhythmias. The left vagus when hyperstimulated predisposes the heart to atrioventricular blocks.

Therefore, blocking the right side could lead to tachyarrhythmias but very unlikely IMO. The left should really not cause any dysrrhythmias.

 

[zippy2u]

Why do you say it's unlikely Noyac, to get elevated HR with the right-sided block? ---Zip

 

[Noyac]

Why do you say it's unlikely Noyac, to get elevated HR with the right-sided block? ---Zip

Mostly because there are 2 vagus nerves. Yo may get some tachycardia but not to the extent of arrhythmias. Think of the heart transplant pt, they don't have tachyarrhythmias. I have done probably b/t 1000 to 2000 interscalene blocks. I have never seen an arrhythmia. Thats why I say unlikely. Not impossible but unlikely.

So tell us, what happened?

 

[zippy2u]

A buddy of mine about a week ago had a 50s lady with resting HR in 90s with IDDM. obese did an interscalene(great block) with GETA for shoulder surgery, beach chair, and towards end of case he said HR gradually went to 130s with slight hypotension. BP would go up with neo but HR would stay same. In PACU, she had no pain,BP normalized but HR still in 130s. O2 sats were 98-100. Fluid bolus of 500mls didn't change it. Labetalol 10mgs brought it down to 110s with decent BP so he left it at that. Asked me what I thought and I said maybe she had a component of diabetic autonomic dysfunction. He blamed it on the block and vagus nerve blockade. Regards, ---Zip

 

[Noyac]

A buddy of mine about a week ago had a 50s lady with resting HR in 90s with IDDM. obese did an interscalene(great block) with GETA for shoulder surgery, beach chair, and towards end of case he said HR gradually went to 130s with slight hypotension. BP would go up with neo but HR would stay same. In PACU, she had no pain,BP normalized but HR still in 130s. O2 sats were 98-100. Fluid bolus of 500mls didn't change it. Labetalol 10mgs brought it down to 110s with decent BP so he left it at that. Asked me what I thought and I said maybe she had a component of diabetic autonomic dysfunction. He blamed it on the block and vagus nerve blockade. Regards, ---Zip

I'll be the first to tell you that I don't know what the cause was but if he spilled his block over to the vagus which may be likely she still had the contralateral side working although it innervates the heart at a slightly different area (SA vs AV nodes). Did she experience the hoarseness, difficulty swallowing, etc?

 

[zippy2u]

Yeah, she had hoarseness which can be from the recurrent laryngeal nerve.

 

[VentdependenT]

Yeah, she had hoarseness which can be from the recurrent laryngeal nerve.

SOunds like that what happened. Supposedly higher incidence on the right because the nerve hooks under the subclavian rather than the aortic (on the left) which is anatomically higher up.