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

Abstract

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.