• T Sivashanmugam, Indubala Maurya, Naveen Kumar, and Manoj K Karmakar.
• From the Department of Anesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Pillayarkuppam, Pondicherry, India (TS, IM, NK) and Department of Anaesthesia & Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China (MKK).
• Eur J Anaesthesiol. 2019 Oct 1; 36 (10): 787-795.

BackgroundThe costoclavicular brachial plexus block (BPB) produces faster onset of sensory motor blockade than the lateral sagittal approach. However, the incidence of phrenic nerve palsy (PNP) after a costoclavicular BPB is not known.ObjectivesThe current study compared the incidence of ipsilateral hemidiaphragmatic paresis, and thus PNP, between a supraclavicular and costoclavicular BPB.DesignRandomised observer blinded study.SettingOperating room.PatientsForty patients undergoing right-sided upper extremity surgery.InterventionAll patients received either a supraclavicular group or costoclavicular group BPB using 20 ml of an equal mixture of 0.5% bupivacaine and 2% lidocaine with 1 : 200 000 epinephrine.Main Outcome MeasuresMeasurements included ipsilateral hemidiaphragmatic excursion and peak expiratory flow rate (PEFR) taken before and at 30 min after the BPB. Diaphragmatic excursion was measured using M-mode ultrasound during normal breathing, deep breathing and with the sniff manoeuvre. Ipsilateral PNP was defined as a reduction in hemidiaphragmatic excursion by at least 50% during deep breathing at 30 min after the BPB.ResultsThe incidence of ipsilateral PNP was lower (P = 0.008) in the costoclavicular group (5%) than in the supraclavicular group (45%). Fewer (P = 0.04) patients in the costoclavicular group [1(5%)] exhibited a positive sniff test, with paradoxical movement of the diaphragm, than in the supraclavicular group [7(35%)]. PEFRs were similar (P = 0.09) between the groups. When ipsilateral hemidiaphragmatic paresis was present, the median reduction in PEFR was 32% (interquartile range 23.6 to 45.5%).ConclusionCostoclavicular BPB produces a lower incidence of ipsilateral PNP than a supraclavicular BPB.Name Of RegistryClinical Trial Registry of India.IdentifierCTRI/2017/09/009763.

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