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  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References

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  Table of Contents 
CASE REPORT
Year : 2017  |  Volume : 18  |  Issue : 2  |  Page : 86-88
 

Hoarseness of voice after supraclavicular ultrasound-guided subclavian perivascular brachial plexus block


Department of Anesthesiology and Critical Care, Jaipur Golden Hospital, New Delhi, India

Date of Submission07-Jul-2017
Date of Acceptance28-Aug-2017
Date of Web Publication12-Dec-2017

Correspondence Address:
Dr. Monika Gupta
Department of Anesthesiology and Critical Care, Jaipur Golden Hospital, New Delhi - 110 085
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_16_17

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  Abstract 

Supraclavicular brachial plexus nerve block is ideal for surgical procedures at or distal to the elbow. Ultrasound (USG) continues to grow in popularity as a method of nerve localization, and for the supraclavicular block, it has the advantage of allowing real-time visualization of the plexus, pleura, and vessels along with the needle and local anesthetic spread, but it may conversely create a false sense of security. The incidence of the recurrent laryngeal nerve (RLN) block occurring with supraclavicular approach is 1.3% of patients.[10] Incidence of RLN block with USG-guided supraclavicular block is not known. In this case report, we discuss a rare complication of RLN block which occurred while performing a supraclavicular perivascular block performed under USG guidance.


Keywords: Brachial plexus, digital pressure, hoarseness of voice, recurrent laryngeal nerve, supraclavicular block, ultrasonography


How to cite this article:
Gupta M, Jain P, Bhalla S, Upadhyay N. Hoarseness of voice after supraclavicular ultrasound-guided subclavian perivascular brachial plexus block. Indian Anaesth Forum 2017;18:86-8

How to cite this URL:
Gupta M, Jain P, Bhalla S, Upadhyay N. Hoarseness of voice after supraclavicular ultrasound-guided subclavian perivascular brachial plexus block. Indian Anaesth Forum [serial online] 2017 [cited 2019 Oct 22];18:86-8. Available from: http://www.theiaforum.org/text.asp?2017/18/2/86/220550



  Introduction Top


Once described as the “spinal of the arm,” a supraclavicular brachial plexus nerve block is ideal for surgical procedures at or distal to the elbow. Block is performed at the level of the brachial plexus trunks formed by the C5-T1 nerve roots, where almost the entire sensory, motor, and sympathetic innervations of the upper extremity are carried in just three nerve structures confined to a very small surface area. Ultrasound (USG)-guided blocks were first described for the supraclavicular region.[1] Principal complications of the procedure are the risks of vascular puncture in an area that is difficult to compress and the risk of pneumothorax. In this case report, we discuss a rare complication of supraclavicular perivascular block performed under USG guidance.


  Case Report Top


A 28-year-old female patient, weighing 64 kg, American Society of Anesthesiologists Physical Status I, 160 cm, presented with fracture of distal end of the right radius and ulna for open reduction and internal fixation with plating. There was nothing abnormal found on physical and systemic examination of the patient. Preoperative laboratory investigations were unremarkable. USG-guided right supraclavicular block was planned for her.

On arrival in the operation theater, after establishing the monitors, baseline parameters were noted. Pulse rate was 90/min, which was regular and good volume. Her blood pressure measured 130/80 mmHg and oxygen saturation was 97% on room air. Oxygen administration with face mask at 4 L/min was started. An 18-gauge peripheral intravenous (iv) cannula was inserted.

The patient was positioned for blockade with her head rotated to the left side and right arm close to her body. Under all aseptic precautions, high-frequency linear transducer of SonoSite MicroMaxx USG machine was positioned in the transverse plane immediately superior to the clavicle at approximately its midpoint. The transducer was tilted caudally to obtain a cross-sectional view of the subclavian artery as a pulsating circular structure (transverse view). Brachial plexus was seen as a collection of hypoechoic oval structures lateral and superficial to the artery. A 27-gauge needle was used to inject 1–2 mL of local anesthetic into the skin 1 cm lateral to the transducer to decrease the discomfort during needle insertion. Color Doppler was used to identify and avoid arterial puncture. A 5-cm, 22-gauge, short-bevel insulated stimulating Stimuplex needle was then inserted in-plane toward the brachial plexus, in a lateral-to-medial direction. After being convinced with the location of needle, 15 cc of 0.5% bupivacaine with 20 cc of 2% lignocaine diluted up to 35 cc with normal saline (0.9%) was injected after repeated negative aspiration. Digital compression massage was given in the area. After 2–3 min, the patient developed progressive weakness of voice. She became increasingly anxious without any respiratory distress. Chest expansion was good, and on auscultation, breath sounds were equal on both sides. Oxygen saturation was well maintained. Effect of both motor and sensory blocks were inadequate, and propofol supplementation (loading dose 1 mg/kg followed by infusion at the rate of 100 μg/kg/min) was given. Oxygen supplementation was continued. Surgery was started. The symptoms did not worsen, and vitals remained stable. Vigilant monitoring was continued. Propofol infusion was continued with oxygen supplementation. Analgesia was achieved with injection paracetamol 1 g iv infusion and injection diclofenac sodium 75 mg iv. Surgery lasted for 1 h and was uneventful. Propofol infusion was stopped before the completion of the procedure. After the surgery, the patient was assessed and definitive finding of hoarseness of voice was confirmed with no difficulty in breathing.

The patient was shifted to postanesthesia care unit for observation. Oxygen supplementation was continued. Her voice recovered completely after approximately 3 h. The patient was observed for next 1 h before shifting to the ward.


  Discussion Top


USG continues to grow in popularity as a method of nerve localization, and for the supraclavicular block, it has the advantage of allowing real-time visualization of the plexus, pleura, and vessels along with the needle and local anesthetic spread.[2] Several authors have described an USG-guided supraclavicular approach to the brachial plexus, beginning with la Grange et al., who in 1978 utilized Doppler USG to indirectly facilitate needle positioning.[1] Technology subsequently improved, and in 1994, Kapral et al. were the first to report direct needle, plexus, and local anesthetic visualization A retrospective review of over 1000 USG-guided supraclavicular blocks at Toronto Western Hospital revealed a success rate of 94.7% (no need for further supplementation or general anesthesia) and importantly no pneumothoraces (Dr. Anahi Perlas, personal communication, article in press). While there is no definitive evidence as yet that USG is superior to other methods of nerve localization for the supraclavicular block, there are now case reports appearing where USG scanning has detected abnormal anatomy that would otherwise not have been evident using “blind” approaches.[3],[4] By alerting the anesthesiologist to either choose another approach or simply avoid regional anesthesia altogether USG may in this manner improve the safety of supraclavicular brachial plexus blockade. Despite these benefits, USG may conversely create a false sense of security and care must be taken, particularly when learning. If the needle tip is not adequately visualized, errors can still occur during USG-guided nerve blocks.[5],[6],[7] USG-guided supraclavicular block is the mainstay of our regional anesthesia practice for upper limb surgical procedures at or below the elbow.

Although a supraclavicular block has many advantages, it can have important or fatal complications, which include dyspnea and pneumothorax.[8],[9] Dyspnea occurs from diaphragmatic paralysis or pneumothorax. Unlike conventional techniques, USG can show the size, depth, and precise location of the brachial plexus and its adjacent structures including the first rib, pleura, and movement of the needle. Therefore, real-time USG imaging can help avoid complications such as pneumothorax, inadvertent intravascular injection, or nerve injury.

The complications associated with USG-guided supraclavicular block are dependent on the level of block. However, the complications are few and infrequent in experienced hands, making it a popular procedure. The incidence of the recurrent laryngeal nerve (RLN) block occurring with supraclavicular approach using landmark technique is 1.3% of patients.[10] Incidence of RLN block with USG-guided supraclavicular block is not known.

This complication is attributed to an excessive spread of local anesthetic. The fascial sheath surrounding the brachial plexus is a determinant of the spread of the local anesthetic. The sheath is a derivative of deep cervical fascia and terminates by merging with the medial intermuscular septum of the arm. The local anesthetic injected spreads up and down the nerves in a longitudinal manner and circumferential spread is limited by the fascial sheath.[11]

Several clinical maneuvers have been proposed or utilized in attempt to influence the distribution, or to limit the spread, of local anesthetic injected into the brachial plexus. These include use of a tourniquet,[12] position of the arm,[13] use of massage,[14] multiple injection techniques,[15],[16] and digital pressure.[13] Based on the radiological evidence, digital pressure has been touted as an effective method to halt progression of local anesthetic into areas of the brachial or cervical plexus during brachial plexus block.[17]

In our patient, digital pressure was not applied after supraclavicular block as we were using USG-guided technique. We would like to propose a hypothesis that digital pressure would have prevented the excessive spread proximally which would have prevented the involvement of recurrent laryngeal nerve; even if the visual confirmation of the local anesthetic drug instillation is achieved with the help of USG. The volume of the drug used might have been an additional contributing factor for the excessive spread. This erroneous distribution might be the reason for the inadequate block effect. As USG does not show the spread of the distribution, a visually confirmed supraclavicular brachial plexus block under USG guidance might not assure the adequacy of the block and prevention of complications, and we would like to suggest application of digital pressure after USG-guided supraclavicular block, as in the conventional landmark technique, to prevent the cephalad spread of local anaesthetic agent and use of lower volume.


  Conclusion Top


Further studies are required to determine the incidence of the discomforting complication of hoarseness of voice after USG-guided supraclavicular block and effectiveness of applying digital pressure and other maneuvers as a routine practice after USG-guided supraclavicular block to prevent the cephalad spread of local anesthetics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
la Grange P, Foster PA, Pretorius LK. Application of the Doppler ultrasound bloodflow detector in supraclavicular brachial plexus block. Br J Anaesth 1978;50:965-7.  Back to cited text no. 1
[PUBMED]    
2.
Sites BD, Brull R. Ultrasound guidance in peripheral regional anesthesia: Philosophy, evidence-based medicine, and techniques. Curr Opin Anaesthesiol 2006;19:630-9.  Back to cited text no. 2
    
3.
Chin KJ, Niazi A, Chan V. Anomalous brachial plexus anatomy in the supraclavicular region detected by ultrasound. Anesth Analg 2008;107:729-31.  Back to cited text no. 3
    
4.
Macfarlane AJ, Perlas A, Chan V, Brull R. Eight ball, corner pocket ultrasound-guided supraclavicular block: Avoiding a scratch. Reg Anesth Pain Med 2008;33:502-3.  Back to cited text no. 4
    
5.
VadeBoncouer TR, Weinberg GL, Oswald S, Angelov F. Early detection of intravascular injection during ultrasound-guided supraclavicular brachial plexus block. Reg Anesth Pain Med 2008;33:278-9.  Back to cited text no. 5
    
6.
Loubert C, Williams SR, Hélie F, Arcand G. Complication during ultrasound-guided regional block: Accidental intravascular injection of local anesthetic. Anesthesiology 2008;108:759-60.  Back to cited text no. 6
    
7.
Schafhalter-Zoppoth I, Zeitz ID, Gray AT. Inadvertent femoral nerve impalement and intraneural injection visualized by ultrasound. Anesth Analg 2004;99:627-8.  Back to cited text no. 7
    
8.
Fleisher LA, Johns RA, Savarese JJ, Wiener-Kronish JP, Young WL. Miller's Anesthesia. 6th ed. Philadelphia: Churchill-Livingstone; 2005. P 1690.  Back to cited text no. 8
    
9.
Morgan GE, Mikhail MS, Murray MJ. Clinical Anesthesiology. 4th ed. New York: Lange Medical Books/McGraw-Hill Medical Publishing Division; 2006. p. 332-3.  Back to cited text no. 9
    
10.
Neal JM, Gerancher JC, Hebl JR, Ilfeld BM, McCartney CJ, Franco CD, et al. Upper extremity regional anesthesia: Essentials of our current understanding, 2008. Reg Anesth Pain Med 2009;34:134-70. Review. Erratum in: Reg Anesth Pain Med 2010;35:407.  Back to cited text no. 10
    
11.
Thompson GE, Rorie DK. Functional anatomy of the brachial plexus sheaths. Anesthesiology 1983;59:117-22.  Back to cited text no. 11
    
12.
Eriksson E, Skarby H. A simplified method of axillary block. Nord Med 1962;68:1325.  Back to cited text no. 12
    
13.
Winnie AP, Radonjic R, Akkineni SR, Durrani Z. Factors influencing distribution of local anesthetic injected into the brachial plexus sheath. Anesth Analg 1979;58:225-34.  Back to cited text no. 13
    
14.
Hirschel G. Anesthesia of the brachial plexus for operations on the upper extremity. Munch Med Wochenschr 1911;58:1555-6.  Back to cited text no. 14
    
15.
Burnham PJ. Simple regional nerve block for surgery of the hand and forearm. J Am Med Assoc 1959;169:941-3.  Back to cited text no. 15
    
16.
Urmey WF. Combined axillary-interscalene (axis) brachial plexus block for elbow surgery. Reg Anesth 1993;18:88.  Back to cited text no. 16
    
17.
Urmey WF, Grossi P, Sharrock NE, Stanton J, Gloeggler PJ. Digital pressure during interscalene block is clinically ineffective in preventing anesthetic spread to the cervical plexus. Anesth Analg 1996;83:366-70.  Back to cited text no. 17
    




 

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