{"title":"术前单次椎间孔神经阻滞术后呼吸窘迫的急性逆转。","authors":"Robert J Meulemans, Bastiaan M Gerritse","doi":"10.1136/rapm-2024-105728","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>Diaphragmatic paresis is a known complication of the interscalene block used for postoperative analgesia in shoulder surgery. A technique involving the injection of normal saline through the interscalene catheter to alleviate this condition has shown promise. This method, termed the \"washing-off\" technique, dilutes the local anesthetic around the phrenic nerve, mitigating respiratory symptoms.</p><p><strong>Case presentation: </strong>A 65-year-old male patient with multiple comorbidities (American Society of Anesthesiologists physical status classification 4) was scheduled for arteriovenous brachiocephalic fistula creation under regional anesthesia. Following an interscalene block with 32 mL of mepivacaine 1.5%, the patient experienced acute respiratory distress, with SpO<sub>2</sub> at 88% despite 6 L O<sub>2</sub> via nasal cannula. To avoid intubation, a 20 mL normal saline injection was administered through single-shot interscalene injection under ultrasound guidance. Within 5 min, respiratory distress markedly improved, allowing the patient to converse. Surgery proceeded without complications, maintaining SpO<sub>2</sub> at 99% with 6 L O<sub>2</sub>. Postoperatively, the patient remained stable, with SpO<sub>2</sub> at 98% on 2 L O<sub>2</sub>, and was discharged from the recovery room without additional oxygen requirements.</p><p><strong>Conclusions: </strong>The \"washing-off\" technique's mechanism may involve dilutional effects, pH changes or local sodium concentration alterations affecting the phrenic nerve. This case demonstrates its effectiveness in an acute setting, enabling surgery under regional anesthesia without intubation or any additional analgesia. The previously considered placebo effect appears unlikely here.</p>","PeriodicalId":54503,"journal":{"name":"Regional Anesthesia and Pain Medicine","volume":null,"pages":null},"PeriodicalIF":5.1000,"publicationDate":"2024-07-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Acute reversal of respiratory distress after a preoperative single-shot interscalene nerve block.\",\"authors\":\"Robert J Meulemans, Bastiaan M Gerritse\",\"doi\":\"10.1136/rapm-2024-105728\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Background: </strong>Diaphragmatic paresis is a known complication of the interscalene block used for postoperative analgesia in shoulder surgery. A technique involving the injection of normal saline through the interscalene catheter to alleviate this condition has shown promise. This method, termed the \\\"washing-off\\\" technique, dilutes the local anesthetic around the phrenic nerve, mitigating respiratory symptoms.</p><p><strong>Case presentation: </strong>A 65-year-old male patient with multiple comorbidities (American Society of Anesthesiologists physical status classification 4) was scheduled for arteriovenous brachiocephalic fistula creation under regional anesthesia. Following an interscalene block with 32 mL of mepivacaine 1.5%, the patient experienced acute respiratory distress, with SpO<sub>2</sub> at 88% despite 6 L O<sub>2</sub> via nasal cannula. To avoid intubation, a 20 mL normal saline injection was administered through single-shot interscalene injection under ultrasound guidance. Within 5 min, respiratory distress markedly improved, allowing the patient to converse. Surgery proceeded without complications, maintaining SpO<sub>2</sub> at 99% with 6 L O<sub>2</sub>. Postoperatively, the patient remained stable, with SpO<sub>2</sub> at 98% on 2 L O<sub>2</sub>, and was discharged from the recovery room without additional oxygen requirements.</p><p><strong>Conclusions: </strong>The \\\"washing-off\\\" technique's mechanism may involve dilutional effects, pH changes or local sodium concentration alterations affecting the phrenic nerve. This case demonstrates its effectiveness in an acute setting, enabling surgery under regional anesthesia without intubation or any additional analgesia. The previously considered placebo effect appears unlikely here.</p>\",\"PeriodicalId\":54503,\"journal\":{\"name\":\"Regional Anesthesia and Pain Medicine\",\"volume\":null,\"pages\":null},\"PeriodicalIF\":5.1000,\"publicationDate\":\"2024-07-16\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Regional Anesthesia and Pain Medicine\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://doi.org/10.1136/rapm-2024-105728\",\"RegionNum\":2,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q1\",\"JCRName\":\"ANESTHESIOLOGY\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Regional Anesthesia and Pain Medicine","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1136/rapm-2024-105728","RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"ANESTHESIOLOGY","Score":null,"Total":0}
引用次数: 0
摘要
背景:膈肌麻痹是肩部手术中用于术后镇痛的椎间孔阻滞的一种已知并发症。一种通过腋窝间导管注射生理盐水来缓解这种情况的技术已初见成效。这种方法被称为 "冲洗 "技术,可以稀释膈神经周围的局麻药,减轻呼吸道症状:一名 65 岁的男性患者患有多种并发症(美国麻醉医师协会身体状况分类 4 级),计划在区域麻醉下进行动静脉脑瘘造瘘术。使用 32 mL 1.5% 甲哌卡因进行椎间阻滞后,患者出现急性呼吸窘迫,尽管通过鼻插管输入了 6 L 氧气,但 SpO2 仍为 88%。为避免插管,在超声引导下通过腋下单次注射 20 mL 生理盐水。5 分钟内,患者的呼吸困难明显改善,可以进行交谈。手术顺利进行,没有出现并发症,在 6 L 氧气条件下,SpO2 保持在 99%。术后,患者病情保持稳定,使用 2 L 氧气时 SpO2 为 98%,出恢复室时无需额外供氧:结论:"冲洗 "技术的机制可能涉及影响膈神经的稀释效应、pH 值变化或局部钠浓度变化。本病例证明了该技术在急性环境下的有效性,使区域麻醉下的手术无需插管或额外的镇痛。以前认为的安慰剂效应在这里似乎不太可能出现。
Acute reversal of respiratory distress after a preoperative single-shot interscalene nerve block.
Background: Diaphragmatic paresis is a known complication of the interscalene block used for postoperative analgesia in shoulder surgery. A technique involving the injection of normal saline through the interscalene catheter to alleviate this condition has shown promise. This method, termed the "washing-off" technique, dilutes the local anesthetic around the phrenic nerve, mitigating respiratory symptoms.
Case presentation: A 65-year-old male patient with multiple comorbidities (American Society of Anesthesiologists physical status classification 4) was scheduled for arteriovenous brachiocephalic fistula creation under regional anesthesia. Following an interscalene block with 32 mL of mepivacaine 1.5%, the patient experienced acute respiratory distress, with SpO2 at 88% despite 6 L O2 via nasal cannula. To avoid intubation, a 20 mL normal saline injection was administered through single-shot interscalene injection under ultrasound guidance. Within 5 min, respiratory distress markedly improved, allowing the patient to converse. Surgery proceeded without complications, maintaining SpO2 at 99% with 6 L O2. Postoperatively, the patient remained stable, with SpO2 at 98% on 2 L O2, and was discharged from the recovery room without additional oxygen requirements.
Conclusions: The "washing-off" technique's mechanism may involve dilutional effects, pH changes or local sodium concentration alterations affecting the phrenic nerve. This case demonstrates its effectiveness in an acute setting, enabling surgery under regional anesthesia without intubation or any additional analgesia. The previously considered placebo effect appears unlikely here.
期刊介绍:
Regional Anesthesia & Pain Medicine, the official publication of the American Society of Regional Anesthesia and Pain Medicine (ASRA), is a monthly journal that publishes peer-reviewed scientific and clinical studies to advance the understanding and clinical application of regional techniques for surgical anesthesia and postoperative analgesia. Coverage includes intraoperative regional techniques, perioperative pain, chronic pain, obstetric anesthesia, pediatric anesthesia, outcome studies, and complications.
Published for over thirty years, this respected journal also serves as the official publication of the European Society of Regional Anaesthesia and Pain Therapy (ESRA), the Asian and Oceanic Society of Regional Anesthesia (AOSRA), the Latin American Society of Regional Anesthesia (LASRA), the African Society for Regional Anesthesia (AFSRA), and the Academy of Regional Anaesthesia of India (AORA).