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Dose–response relationship between local anesthetic volume and hemidiaphragmatic paresis following ultrasound-guided supraclavicular brachial plexus blockade
  1. Tiffany R Tedore1,
  2. Hannah X Lin1,
  3. Kane O Pryor1,
  4. Virginia E Tangel2,
  5. Daniel J Pak1,
  6. Michael Akerman1,
  7. David S Wellman3 and
  8. Hannah Oden-Brunson4
  1. 1Anesthesiology, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
  2. 2Anesthesiology, Cornell University Joan and Sanford I Weill Medical College, New York, New York, USA
  3. 3Orthopedic Surgery, Westchester Medical Center, Valhalla, New York, USA
  4. 4Baylor College of Medicine, Houston, Texas, USA
  1. Correspondence to Dr Tiffany R Tedore, Anesthesiology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA; tft9001{at}


Background There is no consensus regarding what volume of local anesthetic should be used to achieve successful supraclavicular block while minimizing hemidiaphragmatic paresis (HDP). This study investigated the dose–response relationship between local anesthetic volume and HDP after ultrasound-guided supraclavicular brachial plexus block.

Methods A dose escalation design was used to define the dose response curve for local anesthetic volume and incidence of HDP in subjects undergoing upper extremity surgery with supraclavicular block as the primary anesthetic. Dosing levels of 5, 10, 15, 20, 25, 30, 35 and 40 mL of local anesthetic were administered in cohorts of three subjects per dose. Diaphragm function was assessed with M-mode ultrasound before and after block. Secondary objectives included assessment of negative inspiratory force (NIF), oxygen saturation, subjective dyspnea and extent of sensory and motor blockade.

Results Twenty-one subjects completed the study. HDP was present at all doses, with an incidence of 33% at 5 mL to 100% at 30–35 mL. There was a significant decrease in NIF (7.5 cmH2O, IQR (22,0); p=0.01) and oxygen saturation on room air (1%, IQR (2,0); p=0.01) 30 min postblock in subjects experiencing HDP but not in those without HDP. There was no increase in dyspnea in subjects with or without HDP. No subject required respiratory intervention. Motor and sensory block improved with increasing dose, and subjects with HDP exhibited denser blocks than those without (p<0.01).

Conclusions There is no clinically relevant volume of local anesthetic at which HDP can be avoided when performing a supraclavicular block. In our subject population free of respiratory disease, HDP was well tolerated.

Trial registration number NCT03138577.

  • brachial plexus
  • ultrasonography
  • diagnostic techniques and procedures

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  • Contributors TT: responsible for conception and design of study; data acquisition and analysis, presentation and interpretation; drafting the manuscript; critical revision of the manuscript and final approval of version to be published. HXL: data acquisition, presentation; drafting and revision of manuscript. KOP: study design; drafting and revision of manuscript. VT: data analysis and figure preparation, drafting and revision of manuscript. DJP: study design; drafting and revision of manuscript. MA and DW: data acquisition; drafting and revision of manuscript. HO-B: data acquisition and management; drafting and revision of manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. For access to deidentified participant data, please contact: TT, M.D. Department of Anesthesiology, NewYork-Presbyterian/Weill Cornell Medicine525 E. 68th StreetBox 124NY, NY