Kronik Pulmoner Problemli Hastalarda Kostoklavikular Brakial Pleksus Bloğu􏰁nun􏰁 Diyafram Hareketi ve Analjeziye Etkileri: Retrospektif Analiz

Year 2023, , 148 - 153, 23.03.2023

Gökçen Emmez , İrfan Güngör Ulunay Kanatlı

https://doi.org/10.18663/tjcl.1255472

Abstract

Amaç: ÇeşitIi seviyeIerden yapıIan Brakial pIeksus bIokIarı, postoperatif analjezi için artroskopik omuz cerrahisinde yaygın olarak kullanılmaktadır. Ancak, bloğun uygulandığı seviyeyle ilişkili yüksek hemidiyafragmatik paralizi insidansı, pulmoner fonksiyon bozukluğu olan hastalarda kullanımı sınırlamaktadır. Paradoksal olarak, pulmoner patolojili hastalarda analjezi için kullanılacak sistemik opioidlerin oksijenasyonu bozabileceği düşünüldüğünde analjezi yönetimleri özellikli hastalardır. Son araştırmalar frenik siniri koruyucu brakial pleksus blok yaklaşım alternatiflerini araştırmaktadır. Bu retrospektif çalışma ile, ultrason eşliğinde uygulanan kostoklavikular bloğun bilinen pulmoner patolojisi olan hastalardaki analjezik etkinliğinin ve diyafram fonksiyonlarına etkisinin araştırılması amaçlanmıştır.
Gereç ve Yöntemler: Çalışmaya Ocak 2020-Temmuz 2022 tarihleri arasında, kronik puImoner probIemi oIan, kostokIavikuIar bIok ve geneI anestezi kombinasyonu iIe anestezi yönetimIeri gerçekIeştiriIen artroskopik omuz cerrahisi geçiren vakaIar dahiI ediIdi. Demografik veriler, cerrahi endikasyonlar, uygulanan genel anestezi yöntemi, komplikasyonlar/yan etkiler, VAS skorları, analjezi süreleri, uygulanan anestezi tekniği için hasta ve cerrah memnuniyeti ile diyafram fonksiyonları retrospektif olarak kayıtlardan incelendi. Blok uygulanan tarafta hemi- diyafram fonksiyonları; diyafram tutulumunun derecesi; > %75 ise “tam”, %25,1-74,9 ise “kısmi diyafram paralizisi” ve < %25 ise “paralizi yok” olarak değerlendirildi.
Bulgular: Çalışmaya dahil edilen 21 hastanın dördü Bankart diğerleri rotator kaf rüptürü endikasyonuyla opere edilmişti. Hastalarda komplikasyon gözlenmedi. Anestezi tekniğiyle ilgili hem hasta (%71,4) hem cerrah (%100) memnuniyet oranları yüksekti. Diyafragma ekskürsiyon oranları %25’ten düşüktü ve dolayısıyla hemi-diyafragma paralizisinin gerçekleşmediği görüldü. Kostoklavikular blokla ortalama 470 dakika postoperatif analjezi sağlandı.
Sonuçlar: Kostoklavikular blok, diyafram fonksiyonunu korurken etkin cerrahi ve postoperatif analjezi sağlamıştır. Bu nedenle pulmoner patolojisi olan artroskopik omuz cerrahisi geçirecek hastalarda geleneksel interskalen bloğa bir alternatif olarak düşünülebilir.
Anahtar kelimeler: brakial pleksus blok; diyafram; analjezi; akciğer hastalıklarıAbstract
Aim: Brachial plexus blocks are widely used for post-operative analgesia in shoulder surgery. The high risk of hemidiaphragmatic paralysis limits its use in patients with pulmonary dysfunction. In patients with pulmonary diseases, the management of pain requires special approaches since systemic opioids may also decrease oxygenation. Latest studies search for alternative methods for phrenic nerve preserving brachial plexus block. This retrospective study aim to analyze the analgesic efficacy and diaphraghmatic effects of ultrasonography guided costoclavicular block in patients with pulmonary diseases.
Material and Methods: The study includes patients with pulmonary diseases who undergone arthroscopic shoulder surgery under the combination of costoclavicular block and general anesthesia between January 2020 and July 2022. The demographic data, surgical indications, general anesthesia method, complications, VAS scores, the duration of analgesia, diaphragm functions, patient and surgeon satisfaction survey was collected from the records and analyzed retrospectively. The diaphragm functions were evaluated as complete  75%, partial 25.1-74.9%, no paralysis  25%.
Results: Four of the 21 patients in the research underwent Bankart surgery, while the others were operated on for rotator cuff rupture. No complications were observed in the patients. Patient (71.4%) and surgeon (100%) satisfaction about the anesthesia method was high. Since the diaphragm excursion rates were below 25%, it was observed that hemidiaphragmatic paralysis did not occur. An average of 470 minutes of postoperative analgesia was achieved with costoclavicular block.
Conclusion: While preserving diaphragmatic function, a costoclavicular block provided effective surgical and postoperative analgesia. As a result, it can be regarded as an alternative to conventional interscalene block in pulmonary pathology patients undergoing arthroscopic shoulder surgery.
Key words: brachial plexus block; diaphragm; analgesia; lung diseases

Keywords

brakial pleksus blok, diyafram, analjezi, akciğer hastalıkları

References

• 1. Paxton ES, Backus J, Keener J, Brophy RH. Shoulder arthroscopy: basic principles of positioning, anesthesia, and portal anatomy. J Am Acad Orthop Surg. 2013 Jun;21(6):332-42.
• 2. Chen Q, Shen P, Zhang B, Chen Y, Zheng C. Treatment outcomes of tendinitis of long head of the biceps brachii tendon by different surgeries based on the concept of enhanced recovery after surgery. Jt Dis Relat Surg. 2023;34(1):24-31.
• 3. Gungör I, Emmez G, Kaptan AB, Gunaydin B, Kanatli U. Retrospective evaluation of the effects of traditional interscalene block alone versus combined with superior truncus block-associated diaphragm paralysis during arthroscopic shoulder surgery. Jt Dis Relat Surg 2023;34(2):i-vi.
• 4. Singelyn FJ, Lhotel L, Fabre B. Pain relief after arthroscopic shoulder surgery: a comparison of intraarticular analgesia, suprascapular nerve block, and interscalene brachial plexus block. Anesth Analg. 2004 Aug;99(2):589-92, table of contents.
• 5. Riazi S, Carmichael N, Awad I, Holtby RM, McCartney CJ. Effect of local anaesthetic volume (20 vs 5 ml) on the efficacy and respiratory consequences of ultrasound-guided interscalene brachial plexus block. Br J Anaesth. 2008 Oct;101(4):549-56.
• 6. Rose M, Ness TJ. Hypoxia following interscalene block. Reg Anesth Pain Med. 2002 Jan-Feb;27(1):94-6.
• 7. Erickson JM, Louis DS, Naughton NN. Symptomatic phrenic nerve palsy after supraclavicular block in an obese man. Orthopedics. 2009 May;32(5):368.
• 8. Gentili ME, Deleuze A, Estèbe JP, Lebourg M, Ecoffey C. Severe respiratory failure after infraclavicular block with 0.75% ropivacaine: a case report. J Clin Anesth. 2002 Sep;14(6):459-61.
• 9. Karmakar MK, Sala-Blanch X, Songthamwat B, Tsui BC. Benefits of the costoclavicular space for ultrasound-guided infraclavicular brachial plexus block: description of a costoclavicular approach. Reg Anesth Pain Med. 2015 May-Jun;40(3):287-8.
• 10. Sala-Blanch X, Reina MA, Pangthipampai P, Karmakar MK. Anatomic Basis for Brachial Plexus Block at the Costoclavicular Space: A Cadaver Anatomic Study. Reg Anesth Pain Med. 2016 May-Jun;41(3):387-91.
• 11. Tinoco J, Eloy A, Regufe R. Costoclavicular brachial plexus block: A review of current evidence. Rev Esp Anestesiol Reanim (Engl Ed). 2022 Dec;69(10):649-653.
• 12. Beh ZY, Hasan MS. Ultrasound-guided costoclavicular approach infraclavicular brachial plexus block for vascular access surgery. J Vasc Access. 2017 Sep 11;18(5):e57-e61.
• 13. Silva GR, Borges DG, Lopes IF, Ruzi RA, Costa PRRM, Mandim BLDS. Ultrasound-guided costoclavicular block as an alternative for upper limb anesthesia in obese patients. Braz J Anesthesiol. 2019 Sep-Oct;69(5):510-513.
• 14. Hogan QH. Phrenic nerve function after interscalene block revisited: now, the long view. Anesthesiology. 2013 Aug;119(2):250-2.
• 15. Kaufman MR, Elkwood AI, Rose MI et al. Surgical treatment of permanent diaphragm paralysis after interscalene nerve block for shoulder surgery. Anesthesiology. 2013 Aug;119(2):484-7.
• 16. Kang R, Jeong JS, Chin KJ et al. Superior Trunk Block Provides Noninferior Analgesia Compared with Interscalene Brachial Plexus Block in Arthroscopic Shoulder Surgery. Anesthesiology. 2019 Dec;131(6):1316-1326.
• 17. Kim DH, Lin Y, Beathe JC et al. Superior Trunk Block: A Phrenic-sparing Alternative to the Interscalene Block: A Randomized Controlled Trial. Anesthesiology. 2019 Sep;131(3):521-533.
• 18. Burckett-St Laurent D, Chan V, Chin KJ. Refining the ultrasound-guided interscalene brachial plexus block: the superior trunk approach. Can J Anaesth. 2014 Dec;61(12):1098-102.
• 19. Kessler J, Schafhalter-Zoppoth I, Gray AT. An ultrasound study of the phrenic nerve in the posterior cervical triangle: implications for the interscalene brachial plexus block. Reg Anesth Pain Med. 2008 Nov-Dec;33(6):545- 50. PMID: 19258969.
• 20. Qaiser M, Khan N, Jain A. Ultrasonographic Assessment of Diaphragmatic Excursion and its Correlation with Spirometry in Chronic Obstructive Pulmonary Disease Patients. Int J Appl Basic Med Res. 2020 Oct-Dec;10(4):256-259.
• 21. Georgiadis PL, Vlassakov KV, Patton ME et al. Ultrasound-guided supraclavicular vs. retroclavicular block of the brachial plexus: comparison of ipsilateral diaphragmatic function: A randomised clinical trial. Eur J Anaesthesiol. 2021 Jan;38(1):64-72.
• 22. Li JW, Songthamwat B, Samy W, Sala-Blanch X, Karmakar MK. Ultrasound-Guided Costoclavicular Brachial Plexus Block: Sonoanatomy, Technique, and Block Dynamics. Reg Anesth Pain Med. 2017 Mar/Apr;42(2):233-240.
• 23. Cesur S, Yayık AM, Daş AN, Ahıskalıoğlu A. A randomized comparison between ultrasound-guided costoclavicular and infraclavicular block for upper extremity surgery. Turk J Med Sci. 2021 Aug 30;51(4):1883-1888.
• 24. Sivashanmugam T, Maurya I, Kumar N, Karmakar MK. Ipsilateral hemidiaphragmatic paresis after a supraclavicular and costoclavicular brachial plexus block: A randomised observer blinded study. Eur J Anaesthesiol. 2019 Oct;36(10):787-795
• 25. Carioca F, Silva M, Bispo C, Mafra J, Cenicante T. Costoclavicular brachial plexus block in paediatric anaesthesia: A retrospective pilot study. J Clin Anesth. 2021 May;69:110113.
• 26. Hong B, Lee S, Oh C et al. Hemidiaphragmatic paralysis following costoclavicular versus supraclavicular brachial plexus block: a randomized controlled trial. Sci Rep. 2021 Sep 21;11(1):18749.
• 27. Lee JH, Cho SH, Kim SH et al. Ropivacaine for ultrasound-guided interscalene block: 5 mL provides similar analgesia but less phrenic nerve paralysis than 10 mL. Can J Anaesth. 2011 Nov;58(11):1001-6.