Users Online: 1347 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size  
Home | About us | Editorial board | Search | Ahead of print | Current issue | Archives | Submit article | Instructions | Subscribe | Contacts | Login 


RSACP wishes to inform that it shall be discontinuing the dispatch of print copy of JOACP to it's Life members. The print copy of JOACP will be posted only to those life members who send us a written confirmation for continuation of print copy.
Kindly email your affirmation for print copies to dranjugrewal@gmail.com preferably by 30th June 2019.

 

 
Table of Contents
LETTER TO EDITOR
Year : 2012  |  Volume : 28  |  Issue : 4  |  Page : 543-544

Pneumothorax following ultrasound guided supraclavicular brachial plexus block


Department of Anesthesia and Critical Care, V.M.M.C and Safdarjung Hospital, New Delhi, India

Date of Web Publication4-Oct-2012

Correspondence Address:
Kapil Gupta
Department of Anesthesia and Critical Care, V.M.M.C and Safdarjung Hospital, New Delhi
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.101962

Rights and Permissions

How to cite this article:
Gupta K, Bhandari S, Singhal D, Bhatia PS. Pneumothorax following ultrasound guided supraclavicular brachial plexus block. J Anaesthesiol Clin Pharmacol 2012;28:543-4

How to cite this URL:
Gupta K, Bhandari S, Singhal D, Bhatia PS. Pneumothorax following ultrasound guided supraclavicular brachial plexus block. J Anaesthesiol Clin Pharmacol [serial online] 2012 [cited 2019 Dec 13];28:543-4. Available from: http://www.joacp.org/text.asp?2012/28/4/543/101962

Sir,

Ultrasound is popular for the brachial plexus block, allowing real time visualization of the brachial plexus, pleura, blood vessels, needle and the local anesthetic spread. [1] Ultrasound guidance is the gold standard for the nerve blocks [2] and helps in detecting abnormal anatomy of the brachial plexus. [3] We report the occurrence of pneumothorax in a patient after administration of brachial plexus block under ultrasound guidance.

A 60 kg, 46-year-old man, a chronic smoker with chronic obstructive lung disease, suffered a fracture of the right radius. He was scheduled for open reduction and plate fixation, under the brachial plexus block. After initiating the monitoring and securing an 18G intravenous (IV) cannula, midazolam 1.5 mg was administered IV.

A 10 MHz, linear probe (Soneo, Kontron Medical, Plaisir, France) and a 22G, 4 cm stimulating needle were used for the brachial plexus block. Under all aseptic precautions, the probe was placed in the coronal oblique plane and the brachial plexus, first rib, sub clavian artery and the pleura identified in the supraclavicular area. The lateral to medial approach was used for insertion of the needle. Initially, the tip of the needle was not clearly visible. After adequate visualization, 25 mL of 0.25% Bupivacaine was injected into the sheath of the brachial plexus. The spread of the local anesthetic was observed during the injection.

After 10 minutes, the patient complained of dyspnea and became restless. The oxygen saturation decreased gradually from 98% to 78%. The air entry was decreased on the right side of the chest. After administration of oxygen via the ventimask, the oxygen saturation improved to 92%.The vitals remained stable during this period. A chest X-ray (CXR) anteroposterior (AP) view was taken revealed a right sided pneumothorax [Figure 1]. The chest wall to the lung margin distance was 2.5 cm. Under local anesthesia, chest tube was inserted in the second intercostal space and continuous air bubbles were seen in the fluid filled container. The oxygen saturation improved to 99%. The surgery was postponed and patient was shifted to the ICU for further management. Repeat CXR (AP view) confirmed the re-expansion of the lung with minimal residual pneumothorax. After two days, the chest tube was removed and the patient underwent the surgery under IV regional anesthesia.
Figure 1: Right Pneumothotrax

Click here to view


In this case, pleural puncture probably occurred during the transient loss of visualization while advancing the needle initially. The tip of the needle was wrongly visualized by the anesthesiologist, although he was experienced with the use of ultrasound guided brachial plexus block. The tip of the needle was actually more distal than its appearance on the image, because of the improper alignment of the probe with the needle. This transient loss of visualization of the tip of the needle is a potential cause of error for the beginners. [4] A continuous visualization of the tip of the needle and proper alignment of probe with the needle must be ensured and in addition the needle should be slowly advanced towards the brachial plexus to avoid complications.

There is higher risk of pneumothorax in chronic obstructive lung disease. [5] Our patient was a chronic cigarette smoker and had chronic obstructive lung disease. In order to improve visualization of the tip of the needle, hydrolocalization using 5% dextrose can be used. [6] An ultrasound machine with needle visualization enhancing technology, is advocated.

To conclude, despite using the correct technique and latest devices like the ultrasound, while performing the brachial plexus block, one should keep a high index of suspicion of pneumothorax.

 
  References Top

1.Klaastad O, Sauter AR, Dodgson MS. Brachial plexus block with or without ultrasound guidance. Curr Opin Anesthesiol 2009;22:655-60.  Back to cited text no. 1
[PUBMED]    
2.Sites BD, Brull R. Ultrasound guidance in peripheral regional anesthesia: Philosophy, evidence- based medicine, and technique. Curr Opin Anesthesiol 2006;19:630-9.  Back to cited text no. 2
[PUBMED]    
3.Chin KJ, Niazi A, Chan V. Anomalous brachial plexus anatomy in the supraclavicular region detected by ultrasound. Anesth Analg 2008;107:729-31.  Back to cited text no. 3
[PUBMED]    
4.Chin KJ, Perlas A, Chan VW, Brull R. Needle visualization in ultrasound -guided regional anesthesia: Challenges and solutions. Reg Anesth Pain Med 2008;33:532-4.  Back to cited text no. 4
[PUBMED]    
5.Cox JE, Chiles C, MacManus CM, Aquino SL, Chaplin RH. Transthoracic needle aspiration biopsy: Variables that affect the risk of pneumothorax. Radiology 1999;212:165-8.  Back to cited text no. 5
    
6.Macfarlane A, Brull R. Ultrasound guided supraclavicular block. J New York Sch Reg Anesth 2009;12:6-10.  Back to cited text no. 6
    


    Figures

  [Figure 1]


This article has been cited by
1 Incidence of clinically symptomatic pneumothorax in ultrasound-guided infraclavicular and supraclavicular brachial plexus block
A. Gauss,I. Tugtekin,M. Georgieff,A. Dinse-Lambracht,D. Keipke,G. Gorsewski
Anaesthesia. 2014; 69(4): 327
[Pubmed] | [DOI]
2 Ultrasound-guided supraclavicular brachial plexus block in upper limb surgery: outcomes and patient satisfaction
K. Gamo,K. Kuriyama,H. Higuchi,A. Uesugi,T. Nakase,M. Hamada,H. Kawai
The Bone & Joint Journal. 2014; 96-B(6): 795
[Pubmed] | [DOI]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
   References
   Article Figures

 Article Access Statistics
    Viewed1518    
    Printed59    
    Emailed0    
    PDF Downloaded294    
    Comments [Add]    
    Cited by others 2    

Recommend this journal