American Society of Regional Anesthesia and Pain Medicine November 2017 - 21

Is there anything you could have changed regarding this
patient's care that may have reduced the probability of this
outcome?
Dr Auyong: These are the things I would have done rather than
placing an interscalene catheter with bupivacaine: (1) anterior
approach suprascapular catheter, (2) dosing of the catheter with
short-acting local anesthetic (lidocaine or chloroprocaine), (3)
small-volume, intermittent dosing of catheter (<5 mL).
Dr Maniker: Interscalene block could have been avoided to prevent
phrenic nerve blockade.
Dr Harrington: Although it may not have made any difference,
I would not use a high concentration of local anesthetic (0.25%
bupivacaine would probably be as effective as 0.5%). Furthermore,
I would use a shorter-acting local anesthetic agent, such as
mepivacaine or lidocaine, so that if severe pulmonary compromise
ensues, it will be shorter lived.
Dr Pawa: Potentially, I could have used a slow, incremental loading
of the catheter with a lower concentration of local anesthetic
(assuming regional anaesthesia was being used as the sole mode
of anesthesia). If the interscalene catheter was being used for
analgesia only, I would avoid a bolus dose and start the local
anesthetic infusion alone without bolus.
An electrocardiogram and chest x-ray fail to demonstrate
any significant abnormalities other than an elevated left
hemidiaphragm. The patient is more comfortable with the head
of the bed elevated and with the provision of supplemental
oxygen.

If the patient was expecting a general anesthetic, I would induce
anesthesia.
The surgical procedure is uncomplicated, and no additional
intraoperative opioids are required. At the conclusion of
the case, the patient is extubated and transferred to the
postanesthesia care unit, where her oxygen saturation is noted
to be 88% on 2 L nasal cannula. The patient is asymptomatic,
but her oxygen saturation fails to improve over the course of
3 hours.
The procedure was planned to be performed on an ambulatory
basis. With the removal of supplemental oxygen, the patient's
oxygen saturation falls to 86%.
Would you be comfortable discharging the patient home?
Dr Auyong: First, I would check the patient's preoperative
oxygenation. Next, if these oxygen saturation values are
significantly lower than her preoperative baseline, I would give
the patient some time, incentive spirometry, and better positioning
(sitting upright or standing) to improve her oxygenation. However,
in the setting of this patient's multiple comorbidities and lack
of improvement in her postoperative course with time, I would
recommend the patient be admitted overnight.
Dr Maniker: This depends on the patient's baseline oxygen
saturation. If it is close to baseline, I would recommend temporarily
increasing the supplemental oxygen and discharge with close
watch by a family member or caretaker. If this is a significant
change from the patient's baseline and does not improve with
increased supplemental oxygen, I would have the patient admitted
for observation overnight.

Would you proceed and induce general anesthesia?
Dr Auyong: Yes, I would proceed with induction of a general
anesthetic. Hemidiaphragmatic paralysis is a known side effect
of brachial plexus regional anesthesia. If the patient was clinically
unstable, I would consider an infusion or bolus of saline through
the catheter to dilute the local anesthetic already delivered to help
decrease the duration and severity of the side effects related to the
block.
Dr Maniker: If the patient was hemodynamically stable and
oxygenating appropriately, I would proceed.
Dr Harrington: Yes. Although I generally do these cases with a
laryngeal mask airway, I would intubate this patient.
Dr Pawa: If the patient was expecting awake surgery, and
assuming the block is effective, I would attempt the use of a CPAP
mask or of high-flow, humidified nasal oxygen, and proceed.

Dr Harrington: No. As previously stated, I would not be comfortable
doing this case at an ambulatory center if an interscalene block
was planned.
Dr Pawa: No.
Would you be comfortable initiating an infusion of local
anesthetic through the interscalene catheter?
Dr Auyong: No, because bupivacaine was already dosed and no
additional opioids have been required, I would not elect to initiate a
continuous infusion of local anesthetic via the interscalene catheter
at this time. Because the patient has hemidiaphragmatic paralysis,
additional dosing may delay her improvement in pulmonary function
and postpone her discharge further. Continuous infusion of local
anesthetic is similarly associated with phrenic nerve impairment as
a single-injection bolus at the interscalene level. I would, however,
leave the catheter intact for future dosing.

American Society of Regional Anesthesia and Pain Medicine
2017

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