Fukuoka Ryosuke, Mayahara Taku, Katayama Tomohiro, Uchihashi Masao, Hirai Yuya
Department of Anesthesiology, Kobe Ekisaikai Hospital, Kobe, JPN.
Department of Emergency and General Medicine, Kobe Ekisaikai Hospital, Kobe, JPN.
Cureus. 2025 Jul 20;17(7):e88387. doi: 10.7759/cureus.88387. eCollection 2025 Jul.
Interscalene brachial plexus block (ISB) is frequently employed for analgesia in clavicle surgery but can cause ipsilateral diaphragmatic paresis, potentially leading to respiratory compromise in patients with limited pulmonary reserve. Trauma patients with pneumothorax may undergo regional anesthesia with spontaneous ventilation to avoid positive pressure ventilation (PPV), but this approach carries significant risk if respiratory function is already compromised. A woman in her 60s with multiple rib fractures, a small pneumothorax, and persistent hypoxemia underwent ISB for clavicle surgery. To avoid PPV, general anesthesia with spontaneous ventilation was performed using a laryngeal mask airway. Soon after induction, oxygenation worsened, and postoperative chest imaging revealed right diaphragmatic elevation consistent with phrenic nerve involvement. Emergent intubation and PPV were required. Further investigation identified a previously undiagnosed pulmonary embolism as a contributing factor to persistent hypoxemia. This case highlights the need for careful preoperative evaluation of respiratory reserve and thromboembolic risk when considering ISB in hypoxemic trauma patients. Strategies aimed at avoiding PPV may inadvertently increase the risk of respiratory decompensation in patients with limited respiratory capacity.
肌间沟臂丛神经阻滞（ISB）常用于锁骨手术的镇痛，但可导致同侧膈肌麻痹，可能致使肺储备有限的患者出现呼吸功能不全。气胸创伤患者可在自主通气状态下接受区域麻醉以避免正压通气（PPV），但如果呼吸功能已经受损，这种方法会带来重大风险。一名60多岁的女性，有多根肋骨骨折、少量气胸和持续性低氧血症，因锁骨手术接受了ISB。为避免PPV，使用喉罩气道在自主通气状态下实施全身麻醉。诱导后不久，氧合情况恶化，术后胸部影像学检查显示右膈肌抬高，符合膈神经受累表现。需要紧急插管和PPV。进一步检查发现了一个先前未诊断出的肺栓塞，这是导致持续性低氧血症的一个因素。该病例凸显了在低氧血症创伤患者中考虑ISB时，术前仔细评估呼吸储备和血栓栓塞风险的必要性。旨在避免PPV的策略可能会在呼吸能力有限的患者中无意中增加呼吸失代偿的风险。
