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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.56 no.5 Campinas Sept./Oct. 2006
Infraclavicular vertical brachial plexus blockade in patients with chronic obstructive pulmonary disease. Case report*
Bloqueo del plexo braquial, por vía infraclavicular vertical, en paciente con enfermedad pulmonar obstructiva crónica. Relato de caso
Diogo Brüggemann da Conceição, M.D.I; Pablo Escovedo Helayel, TSA, M.D.I; Fernanda Cecato, M.D.II
do CET Integrado de Anestesiologia da SES-SC. Membro do Núcleo de Ensino
e Pesquisa em Anestesia Regional do HGCR
IIME3 do CET Integrado de Anestesiologia da SES-SC
OBJECTIVES: Patients with Chronic Obstructive Pulmonary Disease (COPD) have
a higher risk of postoperative complications, especially when undergoing general
anesthesia. Brachial plexus blockade is an alternative for these patients when
they undergo upper limb surgeries. The objective of this report is to present
a case of infraclavicular brachial plexus blockade in patients with COPD and
a fractured elbow.
CASE REPORT: A female patient, 67 years old, 52 kg, physical status ASA III, with post-pneumonia bronchiectasis since nine years of age and an indication of osteosynthesis of the elbow. She presented productive cough regularly; after evaluation, her pneumologist cleared her for the surgery. The patient was monitored with non-invasive blood pressure. ECG, and pulse oximeter. Infraclavicular brachial plexus blockade with 0.5% ropivacaine 30 mL was performed, without intercurrences. The patient was discharged from the hospital the following day.
CONCLUSIONS: Infraclavicular brachial plexus blockade is an alternative for patients with COPD and fracture of the elbow, due to its lower morbidity when compared to general anesthetic.
Key Words: ANESTHETIC TECHNIQUES, Regional: brachial plexus blockade; SURGERY, Orthopedic: osteosynthesis.
Y OBJETIVOS: Los pacientes con enfermedad pulmonar obstructiva crónica
(DPOC) presentan riesgo mayor de complicaciones postoperatorias especialmente
cuando se les someten a la anestesia general. El bloqueo del plexo braquial
representa una alternativa para esos pacientes en intervenciones quirúrgicas
de miembros superiores. El objetivo de este relato fue el de presentar un caso
de bloqueo del plexo braquial, por vía infraclavicular vertical en paciente
con DPOC con fractura de codo.
RELATO DEL CASO: Paciente del sexo femenino, 67 años, 52 kg, estado físico ASA III, con indicación de osteosíntesis de codo, portadora de bronquiectasias desde los nueve años de edad después de una pneumonía. Presentaba una tos productiva habitualmente, y fue sometida a la evaluación de su neumólogo que la liberó para el procedimiento. Después de la instalación de monitorización con presión arterial no invasiva, ECG y oxímetro de pulso, se realizó un bloqueo del plexo braquial por vía infraclavicular vertical con 30 mL de ropivacaína a 0,5%. La intervención quirúrgica fue realizada sin incidencias. La paciente recibió alta hospitalaria al día siguiente del procedimiento quirúrgico.
CONCLUSIONES: El bloqueo del plexo braquial por vía infraclavicular vertical es una alternativa técnica para portadores de DPOC y fractura de codo, por su menor morbidez cuando se le compara a la anestesia general y a su vía supraclavicular.
Patients with chronic obstructive pulmonary disease (COPD) have a higher risk of postoperative complications, especially when undergoing general anesthesia 1. Regional anesthesia is an alternative for these patients.
Elbow fractures are a challenge for regional anesthesia due to the complex innervation of this region. Supraclavicular or combination, by the axillary and interscalene approaches, blocks for complete anesthesia of this region are frequently indicated. However, these approaches present a high incidence of phrenic nerve block and risk of pneumothorax.
The objective of this report is to present a case of infraclavicular vertical brachial plexus blockade in a patient with COPD and fractured elbow.
A female patient, 67 years old, 52 kg, 1.60 m, physical status ASA III, with an indication of osteosynthesis for a fractured elbow.
During the preanesthetic evaluation, the patient complained of productive cough since 9 years of age, after an episode of pneumonia, being a long-time user of corticosteroid, b2-adrenergic agonist, and antidepressant. On physical exam, the patient showed supraclavicular pulling, dyspnea, decreased breath sounds, and scattered rales. Laboratory tests did not show any changes; CT scan of the chest demonstrated brionchiectasis; lung function tests were consistent with moderate obstructive disturb. The pneumologist considered the patient fit to undergo the surgical procedure.
After the cardioscope, non-invasive blood pressure, and pulse oximeter were placed and the patient was sedated with diazepam (5 mg); infraclavicular vertical brachial plexus blockade was performed, as described by Kilka et al. 2. The patient was placed in the supine position, head turned to the contralateral side of the fracture, with the forearm placed on the abdome. A line was drawn from the ventral arm of the acromion to the jugular fossa. After anesthetizing the skin of the midpoint of this line, a 50 mm needle, isolated electrically and connected with a peripheral nerve stimulator (Stimuplex dig RC B. Braun), was introduced perpendicularly to the surgical table (Figure 1). After stimulating the median nerve, 30 mL of 0.5% ropivacaine were injected. The surgical procedure was performed without intercurrences. The patient was discharged from the hospital the following day.
Some advantages are attributed to regional anesthesia when compared to general anesthesia, for surgeries of the upper limb, especially in patients with COPD 1,4. The route chosen for the anesthesia is determined by the innervation of the place to be operated, by the experience of the anesthesiologist, and by the possible complications.
Cutaneous nerves of the arm (medial brachial cutaneous, lateral brachial cutaneous, and posterior brachial cutaneous) have to be anesthetized in surgical interventions of the elbow. These nerves leave the neurovascular compartment at the level of the fascicles.
Historically, the supraclavicular approach is considered the most effective one for brachial plexus blockade in surgery of the elbow. A complete anesthesia of the arm and forearm is accomplished with the injection of a relatively small volume of local anesthetic. However, the risks of pulmonary complication in the perioperative period make the supraclavicular approach contraindicated in patients with pulmonary disease. There is temporary paralysis of the phrenic nerve in 50% of the patients, while pneumothorax occurs in 5% to 6% of the patients after supraclavicular brachial plexus blockade.
The interscalene approach can also be used for these procedures; however, in general it does not produce total anesthesia of the ulnar nerve. This approach is also not indicated in patients who depend on the diaphragmatic function, since there the ipsilateral phrenic nerve is blocked in 100% of the cases 5.
Kilka et al. 2 described, after studies in cadavers, the infraclavicular vertical brachial plexus blockade. This technique blocks the brachial plexus in the beginning of the fascicle, reaching every nerve in the upper limb. The advantages of this approach include lower risk of pneumothorax (less than 1%) and low incidence of phrenic nerve block.
Neuburger et al. 3 concluded, after MRI in volunteers, that the infraclavicular vertical block, if performed with the right technique, is safe, as far as the risk of pneumothorax is concerned. We found only one report in the literature of phrenic nerve paralysis after infraclavicular vertical brachial plexus blockade 6; however, its precise incidence has yet to be determined.
Individualized evaluation regarding the risk-benefit ratio of each technique can decrease complications in high-risk patients.
01. Wong DH, Weber EC, Schell MJ et al Factors associated with postoperative pulmonary complications in patients with severe chronic obstructive pulmonary disease. Anesth Analg, 1995; 80:276-284. [ Links ]
02. Kilka HG, Geiger P, Mehrkens HH Infraclavicular vertical brachial plexus blockade. A new method for anesthesia of the upper extremity. An anatomical and clinical study. Anaesthesist, 1995;44:339-344. [ Links ]
03. Neuburger M, Kaiser H, Uhl M Biometric data on risk of pneumothorax from vertical infraclavicular brachial plexus block (VIP). A magnetic resonance imaging study. Anaesthesist, 2001;50:511-516. [ Links ]
04. Brown AR, Parker GC The use of a "reverse" axis (axillary-interscalene) block in a patient presenting with fractures of left shoulder and elbow. Anesth Analg, 2001;93:1618-1620. [ Links ]
05. Urmey WF, McDonald M Hemidiaphragmatic paresis during interscalene brachial plexus block: effects on pulmonary function and chest wall mechanics. Anesth Analg, 1992;74:352-357. [ Links ]
06. Stadlmeyer W, Neubauer J, Finkl RO et al Unilateral phrenic nerve paralysis after vertical infraclavicular plexus block. Anaesthesist, 2000;49:1030-1033. [ Links ]
07. Gusmão LCB, Lima JSB, Prates JC Bases anatômicas para o bloqueio anestésico do plexo braquial por via infraclavicular. Rev Bras Anestesiol, 2002;52:348-353. [ Links ]
Dr. Diogo Brüggemann da Conceição
Rua Germano Wendhausen, 32/401
88015-460 Florianópolis, SC
Submitted for publication
09 de novembro de 2005
Accepted for publication 21 de junho de 2006
* Received from Núcleo de Ensino e Pesquisa em Anestesia Regional do Hospital Governador Celso Ramos, CET Integrado de Anestesiologia da SES SC, Florianópolis, SC