Phrenic Nerve Paralysis after Infraclavicular block

[BLADEMDA]

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Reg Anesth Pain Med 2015 March/April;40(2):133-138.
Hemidiaphragmatic Paralysis Following Ultrasound-Guided Supraclavicular Versus Infraclavicular Brachial Plexus Blockade: A Randomized Clinical Trial.
Petrar SD1, Seltenrich ME, Head SJ, Schwarz SK.
Author information

Abstract
BACKGROUND AND OBJECTIVES:
The comparative incidences of hemidiaphragmatic paralysis associated with contemporary ultrasound-guided supraclavicular versus infraclavicular blockade have not received extensive study. We tested the hypothesis that the infraclavicular approach results in a lower incidence of hemidiaphragmatic paralysis compared with supraclavicular blockade when a standard local anesthetic volume and concentration are used.

METHODS:
With institutional human ethics board approval, we enrolled 64 patients undergoing right-sided upper extremity surgery in a randomized, blinded, parallel-group trial. Patients were assigned to ultrasound-guided supraclavicular or infraclavicular blockade with 30 mL of 0.5% ropivacaine. The primary end point was complete hemidiaphragmatic paralysis at 30 minutes, defined as a greater than 75% reduction in diaphragmatic excursion measured with the voluntary sniff test using M-mode ultrasonography. Partial paralysis was defined as a 25% to 75% reduction.

RESULTS:
Eleven (34%) of 32 patients in the supraclavicular group versus 1 (3%) of 32 in the infraclavicular group had complete hemidiaphragmatic paralysis (P = 0.001 [1-tailed]; relative risk, 11.0 [95% confidence interval, 1.5-80.3]); 44% versus 13% had any (complete or partial) paralysis (P = 0.006; relative risk, 3.5 [95% confidence interval, 1.3-9.5]). Eight (25%) of 32 patients in the supraclavicular group versus 5 (16%) of 32 in the infraclavicular group reported dyspnea (P = 0.54).

CONCLUSIONS:
Ultrasound-guided supraclavicular blockade with 30 mL of 0.5% ropivacaine produced complete hemidiaphragmatic paralysis in approximately one-third of patients. The infraclavicular approach greatly reduced this risk but did not eliminate it. These data may aid in the selection of the approach to brachial plexus blockade, particularly in ambulatory patients and/or those with respiratory comorbidities.

 

[BLADEMDA]

The study found the following for ICBs:

1. The incidence of Complete Phrenic Nerve Block was 3%
2. The incidence of partial Phrenic Nerve Block was 13%
3. The volume utilized was 30 mls

I use 20 mls and my incidence of Dyspnea/SOB has been zero after about 250 ICBs many of which were performed on high risk patients (COPD, One Lung, O2 dependent, etc). The study is useful in reminding me that while ICB is a safe block there is a small risk of Phrenic nerve Paralysis with higher volumes (anything over 20 mls).

This same study also quoted that a volume 0f 30 mls is needed to perform a succesful SCB; in my practice we utilize 20 mls and our success rate is over 98%.
My personal success rate with 20 mls of local is 99% for SCB and 100% for ICB. 30 mls isn't needed if the Anesthesiologist uses a multi-quadrant block where the local is placed in the proper locations.

 

[Noyac]

This study doesn't make sense. It is a poor study.