American Society of Regional Anesthesia and Pain Medicine November 2017 - 19
would steer me toward using a regional anesthesia technique in
some way if only to minimize her additional opiate requirement.
The use of dual antiplatelet therapy within 7 days does induce a
mild amount of anxiety, and the potential for a deep plexus in view
of her BMI may steer me more toward the peripheral techniques
(suprascapular nerve and axillary nerve).
The patient discusses with you her fear that her pain has
been incredibly poorly controlled with previous surgical
interventions and that this frightens her more than other
potential complications. The surgeon approaches you and
would very much prefer a catheter technique.
Would this impact your willingness to perform this technique,
and if so, how? Why?
Dr Auyong: The focus should be on what is best for the patient, not
the surgeon. I would plan on a continuous catheter technique after
discussing risks, benefits, and options with the patient.
Dr Maniker: Infraclavicular and suprascapular catheters are
reasonable to consider, given the patient's chronic pain and opioid
tolerance as well as her pulmonary disease, which would render
the negative respiratory effects of opioids particularly deleterious
for her in the postoperative period. This would require further
discussion with the patient as well as with the surgeon regarding
any interference of the catheters on the surgical field.
Dr Harrington: In my hands, the only effective catheter technique
under these circumstances would be a continuous interscalene
block. Because of the pulmonary risks involved, if an interscalene
catheter was considered necessary, I would insist that the
procedure be performed as an inpatient.
Dr Pawa: Clearly, my aim would always be to deal with the
patient's concerns and deliver the safest and most appropriate
anesthetic. I would establish which techniques had been used
before and why they had been ineffective. If I was sure that she had
understood the risks involved and this was clearly documented, I
would carefully perform a catheter technique. The only additional
advantage of a catheter technique in this context is that there has
been at least one case report where postoperative compromising
phrenic nerve palsy was reversed by administration of saline via
the interscalene catheter.
Following placement of an interscalene catheter, negative
test dose, and catheter dosing with 10 mL 0.5% bupivacaine,
the patient is brought to the operating theater. The patient
assumes a fully supine position while transferring to the
operating room table and describes significant chest
heaviness.
What is in your differential diagnosis?
Dr Auyong: The differential diagnosis is wide ranging and includes
cardiac, pulmonary, and neurologic issues. Top on the differential
is hemidiaphragm paralysis from phrenic nerve impairment. As
previously indicated, an interscalene catheter was placed and
dosed with a long-acting local anesthetic. Based on the time frame
to the onset of symptoms and the patient's position, I would be
most concerned about diaphragm paralysis.
Dr Maniker: Highest on the differential would be symptomatic
phrenic block. Other possibilities include myocardial infarction,
pulmonary embolism, anxiety, pneumothorax, and gastroesophageal
reflux disease.
Dr Harrington: The differential would include unilateral phrenic
nerve paresis, symptomatic coronary artery disease, and
pneumothorax.
Dr Pawa: In this scenario, the differentials would be cardiac chest
pain, phrenic nerve palsy, pneumothorax, and intrathecal spread of
local anesthetic.
American Society of Regional Anesthesia and Pain Medicine
2017
19
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