Background and aims Bilateral brachial plexus blocks are rarely performed in modern anaesthesia practice due to concerns about local anesthetic toxicity, bilateral diaphragmatic paralysis and pneumothorax. However, with the use of ultrasound guidance and by spacing blocks apart in time, it may be considered in selected patients. We report a clinical scenario where this approach seemed appropriate.

Methods A 58-year-old female ASA II patient with a predicted difficult airway presented for a bilateral shoulder arthroplasty. Physical examination revealed a severe retrognatism, with a Class III Upper Lip Bite Test and a Class III Mallampati Score.

Results Under light sedation a left interscalene brachial plexus block was performed under direct echographic visualization, injecting 15cc of 0,75% Ropivacain. After 120 minutes the arthroplasty was completed and the block was repeated contralaterally, totalling 225 mg of Ropivacain (2,8 mg/kg). Both blocks worked adequately with minimal patient discomfort, without difficulty breathing and with stable vital signs during and after surgery.

Conclusions Bilateral brachial plexus blocks should be considered for simultaneous bilateral surgery when the risks of a general anaesthesia outweigh its benefits (low cardiovascular function or a predicted difficult airway), provided adequate pulmonary reserve is present. Ultrasound guidance can reduce the volume of local anaesthetic and the rate of phrenic nerve involvement. Spacing blocks apart in time helps to detect evolving signs of toxicity from the first block and ensures that peak absorption does not occur simultaneously. In this case report we found this technique to be effective and safe, with the added advantage of ensuring a prolonged postoperative analgesia.