Ipsilateral hemidiaphragmatic paresis after a supraclavicular and costoclavicular brachial plexus block: A randomised observer blinded study.

BACKGROUND

The costoclavicular brachial plexus block (BPB) produces faster onset of sensory motor blockade than the lateral sagittal approach. However, the incidence of phrenic nerve palsy (PNP) after a costoclavicular BPB is not known.

OBJECTIVES

The current study compared the incidence of ipsilateral hemidiaphragmatic paresis, and thus PNP, between a supraclavicular and costoclavicular BPB.

DESIGN

Randomised observer blinded study.

SETTING

Operating room.

PATIENTS

Forty patients undergoing right-sided upper extremity surgery.

INTERVENTION

All patients received either a supraclavicular group or costoclavicular group BPB using 20 ml of an equal mixture of 0.5% bupivacaine and 2% lidocaine with 1 : 200 000 epinephrine.

MAIN OUTCOME MEASURES

Measurements included ipsilateral hemidiaphragmatic excursion and peak expiratory flow rate (PEFR) taken before and at 30 min after the BPB. Diaphragmatic excursion was measured using M-mode ultrasound during normal breathing, deep breathing and with the sniff manoeuvre. Ipsilateral PNP was defined as a reduction in hemidiaphragmatic excursion by at least 50% during deep breathing at 30 min after the BPB.

RESULTS

The incidence of ipsilateral PNP was lower (P = 0.008) in the costoclavicular group (5%) than in the supraclavicular group (45%). Fewer (P = 0.04) patients in the costoclavicular group [1(5%)] exhibited a positive sniff test, with paradoxical movement of the diaphragm, than in the supraclavicular group [7(35%)]. PEFRs were similar (P = 0.09) between the groups. When ipsilateral hemidiaphragmatic paresis was present, the median reduction in PEFR was 32% (interquartile range 23.6 to 45.5%).

CONCLUSION

Costoclavicular BPB produces a lower incidence of ipsilateral PNP than a supraclavicular BPB.

NAME OF REGISTRY

Clinical Trial Registry of India.

IDENTIFIER

CTRI/2017/09/009763.