The edition · Anaesthesiology
After a proximal brachial plexus block, three in four patients lost over half their diaphragm function
A blinded ultrasound study of 99 shoulder blocks found major weakness was the rule, not the exception, with superior trunk as well as interscalene blocks. Plus the gap between glottic view and tube delivery on videolaryngoscopy.
The edition in brief
Today's anaesthesiology edition ends on the diaphragm. A prospective blinded ultrasound study of 99 patients having interscalene or superior trunk block for shoulder surgery found a median fall in diaphragmatic function of 42% to 82%, depending on block type, sex and measurement method; three in four patients had more than 50% weakness and one had complete paralysis. Interscalene block and female sex were associated with more weakness. Lateral zone-of-apposition ultrasound with a linear probe measured excursion in every patient, where the classic dome view failed on the left in about half. A 44-hospital observational study of 5,302 videolaryngoscopic intubations found that glottic view did not reliably predict tube delivery: 6.3% were difficult or failed despite an excellent view, and a quarter with a poor view were easy; a three-domain record of blade, view and delivery was reproducible. A pragmatic randomised trial of 7,294 patients with cognitive impairment found an AI-driven, non-interruptive decision support prompt did not change adherence to delirium best practices, and delirium assessment was documented in only 17%. A randomised trial of 160 laparoscopic cholecystectomies found 8 mmHg pneumoperitoneum did not significantly reduce 6-hour pain compared with 14 mmHg. The pearl is checking respiratory reserve before a proximal upper limb block.
A good glottic view on videolaryngoscopy did not guarantee an easy intubation
Record blade, view and ease of tube delivery after videolaryngoscopy; the view alone does not tell the next team how hard the intubation was.
An AI prompt for patients with cognitive impairment did not change delirium care
A passive electronic prompt did not change delirium care; build prevention into default pathways and screen for delirium routinely.
Low-pressure pneumoperitoneum did not significantly lower pain after laparoscopic cholecystectomy
Insufflating at 8 rather than 14 mmHg did not significantly reduce early pain after laparoscopic cholecystectomy.
Check respiratory reserve before any proximal upper limb block
Assess respiratory reserve before a proximal brachial plexus block, and choose a different approach if the patient cannot afford hemidiaphragm weakness.
Proximal brachial plexus blocks weakened the diaphragm by over half in three in four patients
Expect more than 50% hemidiaphragm weakness after most proximal brachial plexus blocks, and consider lateral ultrasound to measure it in patients with limited reserve.
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