Comparing ipsilateral hemidiaphragmatic paresis after supraclavicular & costoclavicular block (randomised observer-blinded study)

Introduction. Hemidiaphragmatic paresis (HDP) after brachial plexus block results from inadvertent involvement of the C3-C5 phrenic nerve roots. While brachial plexus block performed by supraclavicular approach (SC) is commonly associated with HDP, the incidence of this complica tion in brachial plexus block performed by costoclavicular approach (CC) remains unclear.

The objective was to compare the incidence of ipsilateral HDP between supraclavicular (SC) and costoclavicular (CC) blocks using ultrasound-assessed diaphragmatic excursion and peak expiratory flow rate (PEFR).

Materials and methods. In this prospective, observer-blinded, randomized study, 48 patients undergoing elective below-elbow surgery were allo cated to receive either SC-BPB (n = 24) or CC-BPB (n = 22). Patients received 30 ml of a 1:1 mixture of 0.5% bupivacaine and 2% lignocaine with adrenaline. Diaphragmatic excursion was measured via M-mode ultrasonography during normal inspiration, deep inspiration, and sniff manoeuvre, and PEFR was recorded pre-block and 30 minutes postoperatively. HDP was defined as a reduction in diaphragmatic excursion: > 50% as complete, 25-50% as partial, and < 25% as no palsy. Secondary outcomes included block onset time, total anesthesia-related time, and incidence of adverse events.

Results. HDP incidence was significantly higher in Group SC compared with Group CC across all respiratory manoeuvres. Post-block diaphrag matic excursion and PEFR declined more in Group SC (p < 0.05). Block onset and time to complete sensory and motor block were longer in Group CC, while no patient experienced clinical respiratory compromise or adverse events.

Conclusion. Ultrasound-guided costoclavicular brachial plexus block is associated with a lower incidence of ipsilateral HDP and better preserva tion of pulmonary function compared with the supraclavicular approach, despite a slightly slower onset of block.

1. Aliste J., Bravo D., Layera S. et al. Randomized comparison between interscalene and costoclavicular blocks for arthroscopic shoulder surgery. Regional Anesthesia & Pain Medicine, 2019, vol. 44, pp. 472–477. https://doi.org/10.1136/rapm-2018-100055.

2. Arcand G., Williams S. R., Chouinard P. et al. Ultrasound-guided infraclavicular versus supraclavicular block. Anesth Analg, 2005, vol. 101, pp. 886–890. https://doi.org/10.1213/01.ANE.0000159168.69934.CC.

3. Boussuges A., Gole Y., Blanc P. Diaphragmatic motion studied by M-mode ultrasonography: methods, reproducibility, and normal values. Chest, 2009, vol. 135, pp. 391–400. https://doi.org/10.1378/chest.08-1541.

4. Dullenkopf A., Blumenthal S., Theodorou P. et al. Diaphragmatic excursion and respiratory function after the modified Raj technique of the infraclavicular plexus block. Reg Anesth Pain Med, 2004, vol. 29, pp. 110–114 https://doi.org/10.1016/j.rapm.2003.12.001.

5. El-Sawy A., Mohamed N. N., Mansour M. A. et al. Ultrasound-guided supraclavicular versus infraclavicular brachial plexus nerve block in chronic renal failure patients undergoing arteriovenous fistula creation. Egypt J Anaesth, 2014, vol. 30, pp. 161–167.

6. Gentili M. E., Deleuze A., Estebe J. P. et al. Severe respiratory failure after infraclavicular block with 0.75% ropivacaine: a case report. J Clin Anesth, 2002, vol. 14, pp. 459–461. https://doi.org/10.1016/s0952-8180(02)00387-2.

7. Hong B., Lee S., Oh C. et al. Hemidiaphragmatic paralysis following costoclavicular versus supraclavicular brachial plexus block: a randomized controlled trial. Sci Rep, 2021, vol. 11, 18749. https://doi.org/10.1038/s41598-021-97843-x.

8. Hsu A. C., Tai Y. T., Lin K. H. et al. Infraclavicular brachial plexus block in adults: A comprehensive review based on a unified nomenclature system. J Anesth, 2019, vol. 33, no. 3, pp. 463–477. https://doi.org/10.1007/s00540-019-02638-0.

9. Karmakar M. K., Sala-Blanch X., Songthamwat B. et al. Benefits of the costoclavicular space for ultrasound-guided infraclavicular brachial plexus block: description of a costoclavicular approach. Reg Anesth Pain Med, 2015, vol. 40, pp. 287–288. https://doi.org/10.1097/AAP.0000000000000232.

10. Kessler J., Schafhalter-Zoppoth I., Gray A. T. An ultrasound study of the phrenic nerve in the posterior cervical triangle: implications for the interscalene brachial plexus block. Reg Anesth Pain Med, 2008, vol. 33, pp. 545–550. PMID: 19258969.

11. Khurana J., Gartner S. C., Naik L. et al. Ultrasound identification of diaphragm by novices using ABCDE technique. Reg Anesth Pain Med, 2018, vol. 43, no. 2, pp. 161–165. https://doi.org/10.1097/AAP.0000000000000718.

12. Kim B. G., Han J. U., Song J. H. et al. A comparison of ultrasound-guided interscalene and supraclavicular blocks for post-operative analgesia after shoulder surgery. Acta Anaesthesiol Scand, 2017, vol. 61, pp. 427–435. https://doi.org/10.1111/aas.12864.

13. Kirkwood B. R., Sterne J. A. Calculation of Required Sample Size. Essential Medical Statistics, Blackwell Science, Oxford, 2003, pp. 420–421.

14. Koscielniak-Nielsen Z. J., Frederiksen B. S., Rasmussen H. et al. A comparison of ultrasound-guided supraclavicular and infraclavicular blocks for upper extremity surgery. Acta Anaesthesiol Scand, 2009, vol. 53, pp. 620–626. https://doi.org/10.1111/j.1399-6576.2009.01909.x.

15. Li J. W., Songthamwat B., Samy W. et al. Ultrasound-guided costoclavicular brachial plexus block: sonoanatomy, technique, and block dynamics. Reg Anesth Pain Med, 2017, vol. 42, no. 2, pp. 233–240. https://doi.org/10.1097/AAP.0000000000000566.

16. Lloyd T., Tang Y. M., Benson M. D. et al. Diaphragmatic paralysis: the use of M mode ultrasound for diagnosis in adults. Spinal Cord, 2006, vol. 44, pp. 505–508. https://doi.org/10.1038/sj.sc.3101889.

17. Naik L. Y., Sondekoppam R. V., Jenkin Tsui J. et al. An ultrasound-guided ABCDE approach with a sniff test to evaluate diaphragmatic function without acoustic windows. Can. J. Anaesth, 2016, vol. 63, pp. 1199–1200. https://doi.org/10.1007/s12630-016-0685-z.

18. Neal J. M., Gerancher J. C., Hebl J. R. et al. Upper extremity regional anesthesia: essentials of our current understanding, 2008. Reg Anesth Pain Med, 2009, vol. 34, pp. 134–170. https://doi.org/10.1097/AAP.0b013e31819624eb.

19. Neumeister E. L., Beason A. M., Thayer J. A. et al. Perioperative pain management in hand and upper extremity surgery. Clin Plast Surg, 2020, vol. 47, № 2, pp. 323–334. https://doi.org/10.1016/j.cps.2019.12.004.

20. Oh C., Noh C., Eom H. et al. Costoclavicular brachial plexus block reduces hemidiaphragmatic paralysis more than supraclavicular brachial plexus block: retrospective, propensity score matched cohort study. Korean J Pain, 2020, vol. 33, pp. 144–152. https://doi.org/10.3344/kjp.2020.33.2.144.

21. Petrar S.D., Seltenrich M.E., Head S.J. et al. Hemidiaphragmatic paralysis following ultrasound-guided supraclavicular versus infraclavicular brachial plexus blockade: a randomized clinical trial. Reg Anesth Pain Med, 2015, vol. 40, № 2, pp. 133–138. https://doi.org/10.1097/AAP.0000000000000215.

22. Renes S. H., Rettig H. C., Gielen M. J. et al. Ultrasound-guided low-dose interscalene brachial plexus block reduces the incidence of hemidiaphragmatic paresis. Reg Anesth Pain Med, 2009, vol. 34, pp. 498–502. https://doi.org/10.1097/AAP.0b013e3181b49256.

23. Renes S. H., Spoormans H. H., Gielen M. J. et al. Hemidiaphragmatic paresis can be avoided in ultrasound-guided supraclavicular brachial plexus block. Reg Anesth Pain Med, 2009, vol. 34, pp. 595–599. https://doi.org/10.1097/aap.0b013e3181bfbd83.

24. Rettig H. C., Gielen M. J., Boersma E. et al. Vertical infraclavicular block of the brachial plexus: effects on hemidiaphragmatic movement and ventilatory function. Reg Anesth Pain, Med, 2005, vol. 30, pp. 529–535. https://link.springer.com/article/10.1007/s00540-019-02638-0.

25. Riazi S., Carmichael N., Awad I. et al. Effect of local anaesthetic volume (20 vs 5 mL) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block. Br J Anaesth, 2008, vol. 101, pp. 549–556. https://doi.org/10.1093/bja/aen229.

26. Ryu T., Kil B. T., Kim J. H. Comparison between ultrasound-guided supraclavicular and interscalene brachial plexus blocks in patients undergoing arthroscopic shoulder surgery: a prospective, randomized, parallel study. Medicine (Baltimore), 2015, vol. 94, e1726. https://doi.org/10.1097/MD.0000000000001726.

27. Sala-Blanch X., Reina M. A., Pangthipampai P. et al. Anatomic basis for brachial plexus block at the costoclavicular space: A cadaver anatomic study. Reg. Anesth. Pain Med, 2016, vol. 41, pp. 387–391. https://doi.org/10.1097/AAP.0000000000000393.

28. Saraswat R. K., Deganwa M., Verma K. et al. Diaphragmatic and pulmonary functions following an ultrasound-guided supraclavicular approach versus a costoclavicular approach of a brachial plexus block: a randomized study. Cureus, 2024, vol. 16, № 6, e62586. https://doi.org/10.7759/cureus.62586.

29. Sivashanmugam T., Maurya I., Kumar N. et al. Ipsilateral hemidiaphragmatic paresis after a supraclavicular and costoclavicular brachial plexus block: A randomised observer blinded study. Eur J Anaesthesiol, 2019, vol. 36, № 10, pp. 787–795. https://doi.org/10.1097/EJA.0000000000001069.

30. Songthamwat B., Karmakar M. K., Li J. W. et al. Ultrasound-guided infraclavicular brachial plexus block: Prospective randomized comparison of the lateral sagittal and costoclavicular approach. Reg. Anesth. Pain Med, 2018, vol. 43, pp. 825–831. https://doi.org/10.1097/AAP.0000000000000822.

31. Tran D. Q., Layera S., Bravo D. et al. Diaphragm-sparing nerve blocks for shoulder surgery, revisited. Regional Anesthesia & Pain Medicine, 2020, vol. 45, pp. 73–78. https://doi.org/10.1136/rapm-2019-100908.

32. Tran de Q. H., Russo G., Munoz L. et al. A prospective, randomized comparison between ultrasound-guided supraclavicular, infraclavicular, and axillary brachial plexus blocks. Reg Anesth Pain Med, 2009, vol. 34, pp. 366–371. https://doi.org/10.1097/AAP.0b013e3181ac7d18.

33. Tsui J. J., Tsui B. C. A novel systematic ABC approach to diaphragmatic evaluation (ABCDE). Can J Anaesth, 2016, vol. 63, pp. 636–637. https://doi.org/10.1007/s12630-015-0566-x.

34. Urmey W. F. Regional anesthesia and pain management: What’s new. European Journal of Pain Supplements, 2008, vol. 2, pp. 36–39. https://doi.org/10.1016/S1754-3207(08)70062-2.

35. Xing T., Ge L. Ultrasound-guided brachial plexus block by costoclavicular space approach: a narrative review. Med Sci Monit, 2023, vol. 29, e939920. https://doi.org/10.12659/MSM.939920.