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Hemidiaphragmatic paralysis following ultrasound-guided supraclavicular versus infraclavicular brachial plexus blockade: a randomized clinical trial.
Reg Anesth Pain Med. 2015 Mar-Apr; 40(2):133-8.RA

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.

Authors+Show Affiliations

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.No affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Comparative Study
Journal Article
Randomized Controlled Trial
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

25650633

Citation

Petrar, Steven D., et al. "Hemidiaphragmatic Paralysis Following Ultrasound-guided Supraclavicular Versus Infraclavicular Brachial Plexus Blockade: a Randomized Clinical Trial." Regional Anesthesia and Pain Medicine, vol. 40, no. 2, 2015, pp. 133-8.
Petrar SD, Seltenrich ME, Head SJ, et al. Hemidiaphragmatic paralysis following ultrasound-guided supraclavicular versus infraclavicular brachial plexus blockade: a randomized clinical trial. Reg Anesth Pain Med. 2015;40(2):133-8.
Petrar, S. D., Seltenrich, M. E., Head, S. J., & Schwarz, S. K. (2015). Hemidiaphragmatic paralysis following ultrasound-guided supraclavicular versus infraclavicular brachial plexus blockade: a randomized clinical trial. Regional Anesthesia and Pain Medicine, 40(2), 133-8. https://doi.org/10.1097/AAP.0000000000000215
Petrar SD, et al. Hemidiaphragmatic Paralysis Following Ultrasound-guided Supraclavicular Versus Infraclavicular Brachial Plexus Blockade: a Randomized Clinical Trial. Reg Anesth Pain Med. 2015 Mar-Apr;40(2):133-8. PubMed PMID: 25650633.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Hemidiaphragmatic paralysis following ultrasound-guided supraclavicular versus infraclavicular brachial plexus blockade: a randomized clinical trial. AU - Petrar,Steven D, AU - Seltenrich,Michael E, AU - Head,Stephen J, AU - Schwarz,Stephan K W, PY - 2015/2/5/entrez PY - 2015/2/5/pubmed PY - 2015/11/13/medline SP - 133 EP - 8 JF - Regional anesthesia and pain medicine JO - Reg Anesth Pain Med VL - 40 IS - 2 N2 - 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. SN - 1532-8651 UR - https://www.unboundmedicine.com/medline/citation/25650633/Hemidiaphragmatic_paralysis_following_ultrasound_guided_supraclavicular_versus_infraclavicular_brachial_plexus_blockade:_a_randomized_clinical_trial_ L2 - https://rapm.bmj.com/lookup/pmidlookup?view=long&pmid=25650633 DB - PRIME DP - Unbound Medicine ER -