Background and Objectives. During interscalene block, ipsilateral hemidiaphragmatic paresis occurred in all patients who received > 34 ml of local anesthetic in the authors' previous studies. This study was done to determine whether diaphragmatic function could be spared by a smaller local anesthetic volume.
Methods. Twenty patients were randomly assigned to receive either a 45 ml or 20 ml interscalene brachial plexus block. For all blocks, 1.5% mepivacaine with added epinephrine and bicarbonate was used. Baseline serial measurements and those over a 30-minute test period before surgery were analyzed for significant differences between groups in onset or final change in any of the following measured variables: cephalad dermatomal extent of sensory anesthesia, clinically assessed upper extremity motor function, ipsilateral hemidiaphragmatic excursion during maximal sniff (inspiratory), and pulmonary function.
Results. There were no clinically significant differences between groups in any of the measured variables. Large reductions in routine pulmonary function tests were measured in all patients in both groups at 2 minutes after injection. At 30 minutes, baseline forced vital capacity (FVC) had diminished by 40.9 ± 11.7% in the 45 ml group and 32.0 ± 8.9% in the 20 ml group. One patient with pre-existing chronic obstructive pulmonary disease had a decrease in FVC from 1.83 l to 0.59 l, a 68% decrement from the baseline measurement, both measured in the supine position.
Conclusion. Reducing the volume of local anesthetic to 20 ml did not prevent the 100% incidence of diaphragmatic paresis or significantly lessen the compromise in pulmonary function that had been reported to occur during interscalene brachial plexus anesthesia.
- Interscalene block
- pulmonary function
- local anesthetic
- injection volume
- phrenic nerve.
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The authors thank Dr. Nigel Sharrock for his careful review of the manuscript and Ms. Marianne McDonald for technical assistance.