Clinical Reports
585
Total anesthetic gas flow was increased from 5 L to 8 L/min, resulting in adequate filling of the bag and sufficient chest excursion. Heart and breath sounds were audible through the stethoscope. The operation proceeded without difficulty. Because continiious mechanical ventilation in the ICU was needed for this patient, there was no plan for extubation a t the conclusion of operation. Prior to transfer, the stethoscope required considerable force for removal, resulting in concomitant extubation of the endotracheal tube with the cuff still inflated. The patient was immediately reintubated without difficulty.
Case 3.-This was a 36-year-old mail who was to have a nephrectomy. Intubation with a #36 endotracheal tube was facilitated by succinylcholine, the cuff was inflated. and breath sounds were equal bilaterally. A 24gauge esophageal stethoscope was then inserted blindly. However, the position of the stethoscope was not checked. Soon after, manual ventilation became totally inadequate even with complete closure of the popoff valve. An increase in anesthetic gas flow failed to provide adequate ventilation. Examination of the anesthesia circuit revealed no leakage in the system up to the endotracheal tube. The endotracheal-tube cuff was maximally inflated in an unsuccessful
attempt to eliminate the leakage. Finally, difficulty in advancement or withdrawal of the stethoscope was noted. The endotrachael-tube cuff was deflated and the stethoscope was easily removed.
DISCUSSION The esophageal stethoscope is a simple and very useful monitoring device. However, because of its popularity and ease in using, one tends to frequently forget the possibility of misplacement and the complications that may result. Misplacement of the stethoscope could not always be prevented by inserting it after inflation of the endotracheal-tube cuff. As shown in cases 1 and 2, being able to hear the heart and breath sounds alone does not confirm its proper position. Regardless of what technic is used for its placement, advancing or withdrawing it is important to obtain optimum positioning. Unless it is inadvertently placed within the trachea and trapped between the tracheal wall and the endotracheal tube, it should be freely movable.
REFERENCE 1. Nicholson MJ, Crehan JP: Cardiac monitoring in clinical anesthesia: current status. Anesth Analg 43:109-115, 1964
Hoarseness and Horner’s Syndrome After I ntersca lene Brac h ia I PIbxus Block JOSEPH L. SELTZER, M D *
A
for shoulder operations can be obtained by a single-injection brachial plexus block.’ The interscalene approach to the brachial and cervical plexuses is based on the concept of a continuous fascia1 sheath which extends from the cervical vertebrae to the axilla and contains elements of both the cervical and brachial plexuses. As the subclavian artery passes between the anterior and middle scalene muscles, it enters this sheath and continues NESTHESIA
distally within the sheath as the axillary arterv. This reDort describes the onset of hoarseness and a Horner’s syndrome ( ptosis of the upper eyelid, miosis, and enophthalmos) secondary to stellate ganglion block after a cervicobrachial plexus block using a single interscalene injection.
REPORT OF A CASE A healthy 29-year-old man was scheduled for elective repair of an acromioclavicular
*Assistant Clinical Professor, Department of Anesthesiology, Wright State University School of Medicine; Staff Anesthesiologist, USAF Medical Center, Wright-Patterson APB, Ohio 45433. Present address: Department of Anesthesiology, State University Hospital, Upstate Medical Center, 750 East Adams Street, Syracuse, New York 13210. Paper received: 8/12/76 Accepted for publication: 11/28/76
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ANESTHESIA AND ANALGESIA . . . Current Researches VOL. 56, No. 4, JULY-AUGUST, 1977
joint meniscus tear of the right shoulder. The history, physical examination, and laboratory data were normal except for the orthopedic injury. He was given 15 mg of diazepam by mouth 1 hour before arriving in the operating room. After the right side of the neck and supraclavicular area were prepared, a 22-gauge, 4-cm needle attached to a segment of I V extension tubing (forming an “immobile needle”2) was introduced into the groove between the anterior and middle scalene muscles at the level of the cricoid cartilage. The patient report,ed a paresthesia to the right shoulder. The anesthesiologist’s hand holding the needle was fixed in this position and the index finger of the other hand was used to place firm pressure on the area of the interscalene groove below the needle. With the paresthesia still present, a second anesthesiologist performed the aspiration and injected 40 ml of 0.5 percent bupivacaine. The distal pressure was released and the needle withdrawn. Cervical and brachial plexus anesthesia resulted and the operation was carried out uneventfully, the patient requiring an additional 5 mg of diazepam IV for sedation. With the onset of anesthesia, the patient became hoarse and developed a Horner’s syndrome. These symptoms resolved when plexus functions returned to normal. The patient required his first analgesic medication approximately 9 hours after the block.
COMMENT Moore3 describes a multiple-injection technic of cervical plexus block, citing block of the recurrent laryngeal nerve and Horner’s syndrome as possible complications. He states that the recurrent laryngeal nerve block is probably the result of too deep infiltration along the posterior border of
the sternocleidomastoid muscle and occurs in 2 to 3 percent of cases. Moore also reports a 5 to 8 percent rate of recurrent laryngeal nerve block associated with steIlate ganglion block. LiiPstrom4 also reports these complications with a multiple-needle technic of cervical plexus block. In our case, the needle was firmly fixed, and the success of the surgical procedure under regional anesthesia confirmed its proper position. As a result of the large volume of solution used and the digital pressure applied to the distal aspect of the interscalene groove, it is possible that some of the solution tracted along the subclavian artery to reach the recurrent laryngeal nerve and stellate ganglion. The right recurrent laryngeal nerve courses back around the subclavian artery on its way to the larynx. While Horner’s syndrome produced no great discomfort in this patient, block of the recurrent laryngeal nerve in a heavily sedated patient with paralysis of the contralateral vocal cord might produce some impairment to ventilation. This case confirms previous reports that recurrent laryngeal nerve and stellate ganglion block should be considered as possible complications of interscalene injections.
REFERENCES 1. Winnie All: Tnterscalene brachial plexus block.
Anesth Analg 49:455-466, 1970 2. Winnie AP: An “immobile needle” for nerve blocks. Anesthesiology 31 :577-578, 1969
3. Moore DC: Regional Block, A Handbook for Use in the Clinical Practice of Medicine and Surgery, 4th ed. Springfield, Illinois, Charles C Thomas, Publisher, 1973, p 120 4. Lofstriim B: Cervical nerve block, Handbook in Local Anaesthesia. Edited by E Eriksson. Chicago, Year Book Medical Publishers, Inc, 1969, pp 73-74
585
Total anesthetic gas flow was increased from 5 L to 8 L/min, resulting in adequate filling of the bag and sufficient chest excursion. Heart and breath sounds were audible through the stethoscope. The operation proceeded without difficulty. Because continiious mechanical ventilation in the ICU was needed for this patient, there was no plan for extubation a t the conclusion of operation. Prior to transfer, the stethoscope required considerable force for removal, resulting in concomitant extubation of the endotracheal tube with the cuff still inflated. The patient was immediately reintubated without difficulty.
Case 3.-This was a 36-year-old mail who was to have a nephrectomy. Intubation with a #36 endotracheal tube was facilitated by succinylcholine, the cuff was inflated. and breath sounds were equal bilaterally. A 24gauge esophageal stethoscope was then inserted blindly. However, the position of the stethoscope was not checked. Soon after, manual ventilation became totally inadequate even with complete closure of the popoff valve. An increase in anesthetic gas flow failed to provide adequate ventilation. Examination of the anesthesia circuit revealed no leakage in the system up to the endotracheal tube. The endotracheal-tube cuff was maximally inflated in an unsuccessful
attempt to eliminate the leakage. Finally, difficulty in advancement or withdrawal of the stethoscope was noted. The endotrachael-tube cuff was deflated and the stethoscope was easily removed.
DISCUSSION The esophageal stethoscope is a simple and very useful monitoring device. However, because of its popularity and ease in using, one tends to frequently forget the possibility of misplacement and the complications that may result. Misplacement of the stethoscope could not always be prevented by inserting it after inflation of the endotracheal-tube cuff. As shown in cases 1 and 2, being able to hear the heart and breath sounds alone does not confirm its proper position. Regardless of what technic is used for its placement, advancing or withdrawing it is important to obtain optimum positioning. Unless it is inadvertently placed within the trachea and trapped between the tracheal wall and the endotracheal tube, it should be freely movable.
REFERENCE 1. Nicholson MJ, Crehan JP: Cardiac monitoring in clinical anesthesia: current status. Anesth Analg 43:109-115, 1964
Hoarseness and Horner’s Syndrome After I ntersca lene Brac h ia I PIbxus Block JOSEPH L. SELTZER, M D *
A
for shoulder operations can be obtained by a single-injection brachial plexus block.’ The interscalene approach to the brachial and cervical plexuses is based on the concept of a continuous fascia1 sheath which extends from the cervical vertebrae to the axilla and contains elements of both the cervical and brachial plexuses. As the subclavian artery passes between the anterior and middle scalene muscles, it enters this sheath and continues NESTHESIA
distally within the sheath as the axillary arterv. This reDort describes the onset of hoarseness and a Horner’s syndrome ( ptosis of the upper eyelid, miosis, and enophthalmos) secondary to stellate ganglion block after a cervicobrachial plexus block using a single interscalene injection.
REPORT OF A CASE A healthy 29-year-old man was scheduled for elective repair of an acromioclavicular
*Assistant Clinical Professor, Department of Anesthesiology, Wright State University School of Medicine; Staff Anesthesiologist, USAF Medical Center, Wright-Patterson APB, Ohio 45433. Present address: Department of Anesthesiology, State University Hospital, Upstate Medical Center, 750 East Adams Street, Syracuse, New York 13210. Paper received: 8/12/76 Accepted for publication: 11/28/76
586
ANESTHESIA AND ANALGESIA . . . Current Researches VOL. 56, No. 4, JULY-AUGUST, 1977
joint meniscus tear of the right shoulder. The history, physical examination, and laboratory data were normal except for the orthopedic injury. He was given 15 mg of diazepam by mouth 1 hour before arriving in the operating room. After the right side of the neck and supraclavicular area were prepared, a 22-gauge, 4-cm needle attached to a segment of I V extension tubing (forming an “immobile needle”2) was introduced into the groove between the anterior and middle scalene muscles at the level of the cricoid cartilage. The patient report,ed a paresthesia to the right shoulder. The anesthesiologist’s hand holding the needle was fixed in this position and the index finger of the other hand was used to place firm pressure on the area of the interscalene groove below the needle. With the paresthesia still present, a second anesthesiologist performed the aspiration and injected 40 ml of 0.5 percent bupivacaine. The distal pressure was released and the needle withdrawn. Cervical and brachial plexus anesthesia resulted and the operation was carried out uneventfully, the patient requiring an additional 5 mg of diazepam IV for sedation. With the onset of anesthesia, the patient became hoarse and developed a Horner’s syndrome. These symptoms resolved when plexus functions returned to normal. The patient required his first analgesic medication approximately 9 hours after the block.
COMMENT Moore3 describes a multiple-injection technic of cervical plexus block, citing block of the recurrent laryngeal nerve and Horner’s syndrome as possible complications. He states that the recurrent laryngeal nerve block is probably the result of too deep infiltration along the posterior border of
the sternocleidomastoid muscle and occurs in 2 to 3 percent of cases. Moore also reports a 5 to 8 percent rate of recurrent laryngeal nerve block associated with steIlate ganglion block. LiiPstrom4 also reports these complications with a multiple-needle technic of cervical plexus block. In our case, the needle was firmly fixed, and the success of the surgical procedure under regional anesthesia confirmed its proper position. As a result of the large volume of solution used and the digital pressure applied to the distal aspect of the interscalene groove, it is possible that some of the solution tracted along the subclavian artery to reach the recurrent laryngeal nerve and stellate ganglion. The right recurrent laryngeal nerve courses back around the subclavian artery on its way to the larynx. While Horner’s syndrome produced no great discomfort in this patient, block of the recurrent laryngeal nerve in a heavily sedated patient with paralysis of the contralateral vocal cord might produce some impairment to ventilation. This case confirms previous reports that recurrent laryngeal nerve and stellate ganglion block should be considered as possible complications of interscalene injections.
REFERENCES 1. Winnie All: Tnterscalene brachial plexus block.
Anesth Analg 49:455-466, 1970 2. Winnie AP: An “immobile needle” for nerve blocks. Anesthesiology 31 :577-578, 1969
3. Moore DC: Regional Block, A Handbook for Use in the Clinical Practice of Medicine and Surgery, 4th ed. Springfield, Illinois, Charles C Thomas, Publisher, 1973, p 120 4. Lofstriim B: Cervical nerve block, Handbook in Local Anaesthesia. Edited by E Eriksson. Chicago, Year Book Medical Publishers, Inc, 1969, pp 73-74
