From the *Division of Regional Anesthesia, Department of Anesthesia, St Paul's Hospital; and †Department of Anesthesiology, Pharmacology & Therapeutics, The University of British Columbia, Vancouver; and ‡Department of Anesthesia, Nanaimo Regional General Hospital, Nanaimo, British Columbia, Canada.
Reg Anesth Pain Med. 2015 Mar-Apr;40(2):133-8. doi: 10.1097/AAP.0000000000000215.
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.
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.
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).
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.
与当代超声引导锁骨上与锁骨下入路相比，有关膈神经麻痹的发生率比较尚未得到广泛研究。我们假设在使用标准局麻药容量和浓度时，锁骨下入路与锁骨上阻滞相比，膈神经麻痹的发生率更低。
在机构人类伦理委员会批准下，我们进行了一项随机、双盲、平行组试验，纳入 64 例接受右侧上肢手术的患者。患者被分配接受超声引导锁骨上或锁骨下入路阻滞，局麻药为 30ml0.5%罗哌卡因。主要终点是 30 分钟时完全性膈神经麻痹，定义为使用 M 模式超声测量的自主深吸气试验中膈膜活动度减少超过 75%。部分麻痹定义为减少 25%至 75%。
锁骨上组 32 例患者中有 11 例（34%）发生完全性膈神经麻痹，而锁骨下入路组 32 例患者中仅有 1 例（3%）发生（P=0.001[单侧]；相对风险，11.0[95%置信区间，1.5-80.3]）；膈神经完全或部分麻痹的发生率分别为 44%和 13%（P=0.006；相对风险，3.5[95%置信区间，1.3-9.5]）。锁骨上组 32 例患者中有 8 例（25%）报告呼吸困难，而锁骨下入路组 32 例患者中有 5 例（16%）报告呼吸困难（P=0.54）。
30ml0.5%罗哌卡因行超声引导锁骨上阻滞约有三分之一的患者出现完全性膈神经麻痹。锁骨下入路极大地降低了这种风险，但并未完全消除。这些数据可能有助于选择臂丛神经阻滞的方法，特别是在门诊患者和/或有呼吸系统合并症的患者中。
