• Jiaxin Lang, Xulei Cui, Jia Zhang, and Yuguang Huang.
• Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
• Medicine (Baltimore). 2022 Jan 14; 101 (2): e28525e28525.

RationaleHemidiaphragmatic paralysis (HDP) is a frequent complication of the brachial plexus block, caused by unintentional blockade of ipsilateral phrenic nerve. HDP did not rise enough alarm and attention to most anesthesiologists, because most patients with no coexisting comorbid diseases are asymptomatic and able to tolerate it. However, it may cause severe respiratory complication for patients with preexisting compromised cardiorespiratory function.Patient ConcernsA 67-year-old woman with morbidly obesity was planned to receive opening reduction and internal fixation of right humeral shaft fracture under regional anesthesia considering less respiratory and cardiovascular system interference compared with general anesthesia.DiagnosesAfter ultrasound guided supraclavicular brachial plexus block, the patient developed severe hypoxia and hypercapnia.Unintentional block of phrenic nerve and diaphragm paralysis was diagnosed by diaphragm ultrasound, which was considered as the main reason of severe hypoxia.InterventionsIt led to a conversion from regional anesthesia to general anesthesia with endotracheal intubation for patient's safety and smooth operation.OutcomesThe unintentional phrenic nerve block leads to a prolonged ventilation time, length of stay in intensive care unit and length of stay in hospital.LessonsThis case report highlights the risk of diaphragm paralysis in morbidly obese patients. Though new diaphragm sparing brachial plexus block (BPB) methods were developed intended to reduce the risk of HDP, no approaches could absolutely spare phrenic nerve involvement. Therefore, clinicians should always consider the risk of HDP associated with BPBs. For each individual, a detailed preoperative evaluation and sufficient preparation are paramount to avoid serious complications.Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.

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