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An unusual complication of interscalene brachial plexus catherization: delayed catheter migration. I
- Alain Borgeat, Hans Jutzi and Stephan Blumenthal (2 November 2005)
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Unusual complications of interscalene brachial plexus analgesia
- Olumuyiwa A Bamgbade (21 October 2005)
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Alain Borgeat, Chief-of-Staff Anesthesia Balgrist University Hospital Zurich, Hans Jutzi and Stephan Blumenthal
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Editor - We read with interest the article by Jenkins CR et al.1, describing a case of delayed intrapleural migration of an interscalene catheter. The authors explained the occurrence of interpleural location of the interscalene catheter by a delayed catheter migration. Perineural catheter migration is a very rare and probably overstated event. We think in the present case the catheter was from the beginning very close to – or partly in – the pleura as shown by the CT reconstruction. This was notrecog-nized by the authors for the following reasons. The effects of the first bolus (20 ml of bupi-vacaine 0.25%) were unfortunately not checked and the patient had general anaesthesia (including strong opioids and muscular relaxant), which has masked to some extent an incomplete interscalene block. Despite the presence of some residual block over the shoulder in the recovery room, there is no description of a fully efficient interscalene block. The presence of some pain at this time argues against a correctly placed interscalene block. Moreover, the volume needed to control the pain had to be subsequently increased until chest wall numbness became evident. The increased volume of local anaesthetics was the most likely reason to make pleural analgesia visible, a secondary migration seems very doubtful. In fact, this case represents most likely a postponed diagnosis of an incorrectly placed interscalene catheter. This case shares similarities with Souron's one.2 The occurrence of this complication emphasized the recommendation not to thread the catheter more than 2-3 cm past the tip of the stimulating needle. Threading the catheter more than that is unnecessary, increases the risks of complication and jeopardized the success of the block. H. Jutzi S. Blumenthal A. Borgeat Zurich, Switzerland E-mail: alain.borgeat@balgrist.ch 1 Jenkins CR, Karmakar MK. An unusual complication of interscalene brachial plexus catheterization: delayed catheter migration. Br J Anaesth 2005; 95: 535-7 2 Souron V, Reiland Y, De Traverse A, Delaunay L, Lafosse L. Interpleural migration of an interscalene catheter. Anesth Analg 2003; 97: 1200-1 Conflict of Interest:None declared |
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Olumuyiwa A Bamgbade, Attending Anesthesiologist University of Michigan Hospital, Ann Arbor, USA
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Editor- The article by Jenkins and Karmakar on delayed interpleural migration of interscalene block catheter was interesting[1]. The CT scan images of the confirmation of interpleural catheter location were very informative. The average complication rate of interscalene block insertion is 11%, but continuous blocks are associated with a higher complication rate of 14%, mostly from catheter displacement[2]. The complication of interpleural block following single-dose interscalene block without catheterisation is rare, but this author has encountered one classical case presenting with postoperative ipsilateral interpleural block. A further review of the literature revealed other forms of interscalene catheter misplacement[3,4]. Walter et al reported a case of total spinal anaesthesia secondary to intrathecal displacement of an interscalene catheter[3]. This is a serious complication which requires resuscitation and mechanical ventilatory support. Souron et al reported a case of continuous interscalene block with unilateral atelectasis, elevated hemidiaphragm and pleural effusion[4]. The pleural effusion may be the result of interpleural infusion of local anaesthetic and hemidiaphragm paresis. Hemidiaphragm paresis secondary to ipsilateral phrenic nerve palsy is an inevitable adverse effect of interscalene block[5]. It is usually asymptomatic and rarely impairs respiration significantly[5]. This author has encountered two uncommon cases of severe respiratory insufficiency secondary to hemidiaphragm paresis; confirmed by chest radiography. Both cases required non-invasive respiratory support and respiratory exercises for 6 hours after surgery. Their respiratory function on bedside spirometry normalised by 5-6 hours, although repeat chest radiographs showed no improvement of the elevated hemidiaphragm. Both patients were discharged home the same day, and follow-up telephone calls confirmed sustained improvement of respiratory function. Although this discussion highlights uncommon complications of interscalene brachial plexus block, it is important to emphasize that this nerve block provides effective perioperative analgesia and the continuous catheter technique aids post-surgical rehabilitation. References: 1-Jenkins CR, Karmakar MK. An unusual complication of interscalene brachial plexus catheterization: delayed catheter migration. Br J Anaesth 2005; 95: 535-7. 2-Koh DL, Lim BH. Postoperative continuous interscalene brachial plexus blockade for hand surgery. Ann Acad Med Singapore 1995; 24: 3-7. 3-Walter M, Rogalla P, Spies C, et al. Anaesthesist 2005; 54: 215-9. 4-Souron V, Reiland Y, Delaunay L. Pleural effusion and chest pain after continuous interscalene brachial plexus block. Reg Anesth & Pain Med 2003; 28: 535-8. 5-Urmey WF, Talts KH, Sharrock NE. One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography. Anesth Analg 1991; 72: 498- 503. Conflict of Interest:None declared |
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