PNEUMOTHORAX AFTER SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK: a CASE REPORT Dr

ISSN- 2394-5125 VOL 7, ISSUE 19, 2020 PNEUMOTHORAX AFTER SUPRACLAVICULAR BRACHIAL PLEXUS BLOCK: A CASE REPORT Dr. Deepak Gupta1, Dr Vijay Chandak2, Dr. Amol Singham3 1Junior resident, Department of anaesthesia, JNMC, DMIMS, Sawangi, Wardha 2Associate professor, Department of anaesthesia, JNMC, DMIMS, Wardha 3Head of department, Department of anaesthesia, JNMC, DMIMS, Wardha

E-mail: [email protected], [email protected], [email protected] Received: 14 April 2020 Revised and Accepted: 8 August 2020 ABSTRACT:BACKGROUND: Pneumothorax is a complication which is observed oftenly when supraclavicular block is performed using paresthesia technique. It is also observed when the procedure is performed using nerve stimulator technique. CASE REPORT: We report a case of 45 year old male patient posted for distal end radius fracture with ASA grade 2. Supraclavicular block was performed using nerve stimulator and paresthesia technique after taking multiple pricks. CONCLUSION: Multimodal approach diagnosis is superior to single method for diagnosing pneumothorax. Suspected cases should be monitored for at least 24 hours for early identification and intervention. Brachial plexus block is the most preferred technique for upper limb surgeries[1]. One of the commonest complication following supraclavicular approach is pneumothorax[2,3]. Other less frequent complication includes hematoma, phrenic nerve block, horner syndrome[4]. The pneumothorax can aggravate suddenly especially when patient is under general anaesthesia with nitrous oxide and sevoflurane used as volatile anaesthetics[5]. Here the case is presented in which the patient developed symptoms of pneumothorax 12 hours after the procedure of supraclavicular block.

I. CASE REPORT: A 45 year old male patient with a weight of 65kg posted for open reduction and internal fixation for the fracture of distal end radius. Preanaesthetic check-up was done with a history of cigarette smoking for 10 years. Patient had stopped smoking since 3 months. There was no history of any abdominal trauma, chest injury and head injury. Intravenous assess was secured. Monitors were attached to patient and vitals like BP, heart rate, oxygen saturation were monitored. All aseptic precaution were taken. Supraclavicular block using nerve stimulator and paresthesia technique was performed. Patient was auscultated with clear sounds of air entry. X ray was performed which shows no signs of pneumothorax. Surgery was performed within two and half hours. In recovery room, patient was monitored where he developed breathlessness and chest pain after 6 hours. Vitals were normal with 95 percent oxygen saturation. Patient was provided with adequate oxygenation. There was slight increase in heart rate. Chest x ray was performed 12 hours after procedure which was suggestive of pneumothorax with the absence of vascular markings on the right right side of the lung along with the margin of collapsed lung. On auscultation, air entry was reduced sharply on right side[6]. Chest drain was inserted in right intercoastal space on day 2. Patient was provided with adequate oxygenation and adequate analgesia. Chest drain was removed on day 2 and the patient was discharged on day 3.

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ISSN- 2394-5125 VOL 7, ISSUE 19, 2020

FIGURE 1: CHEST X RAY SHOWING PNEUMOTHORAX OVER RIGHT SIDE LUNG.

II. DISCUSSION: Pneumothorax is the common complication after supraclavicular block[7]. Proper technique, multimodal diagnostic approach will be beneficial in case of pneumothorax management. The apex of the lung, the slope of first rib and cupola of pleura are closely associated with each other behind the first rib. Any puncture in pleura could produce the clinical presentation of sudden chest pain, dyspnoea, cough[8,9]. Repeated coughing during placement of the block and aspiration of air were the initial clinical signs observed[10]. On physical examination, there will be increased resonance on percussion, decreased breath sounds on auscultation[6]. Chest x rays are useful in detecting the pneumothorax most times[11]. But sometimes pneumothorax go undetected in chest x rays[8]. Here forth, we require another modality such as CT scan and ultrasound to reach to a final conclusion of pneumothorax[12]. The site of puncture in pneumothorax gets sealed if it is small and it becomes asymptomatic[13]. But if the site of puncture is multiple and large, it produces clinical presentation[14]. Chest x ray alone sometimes be inadequate to diagnose pneumothorax[15]. Ct scan, usg along with chest x rays on multiple days will be useful to trace pneumothorax[16]. The suspected patients of pneumothorax should kept under observation in hospital for at least 2-3 days postoperatively and should be monitored by means of clinical examination, pulse oximetery, thoracic sonography. To further confirm the diagnosis, gold standard technique of chest CT scan can be used to rule out the pneumothorax.

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ISSN- 2394-5125 VOL 7, ISSUE 19, 2020 III. REFERENCES: [1] O.E. Etta, S.G. Akpan, C.S. Eyo, C.U. Inyang, "J. West African Coll. Surg." vol. 5 (2015) pp. 76–87. [2] R. Gehlot, R.K. Paliwal, S. Singh, L.K. Raiger, "Natl. J. Med. Dent. Res." vol. 5 (2017) pp. 278–281. [3] A. Gauss, I. Tugtekin, M. Georgieff, A. Dinse-Lambracht, D. Keipke, G. Gorsewski, "Anaesthesia" vol. 69 (2014) pp. 327–336. [4] B.D. Bowden, W.A. Williams, L.A. Stumpo, S.P. Stephens, R.M. DeCoons, "JSES Int." (2020) pp. 13– 16. [5] S.L. CROFTS, G.L. HUTCHISON, "Anaesthesia" vol. 46 (1991) pp. 192–194. [6] M. Sarkar, I. Madabhavi, N. Niranjan, M. Dogra, "Ann. Thorac. Med." vol. 10 (2015) pp. 158–168. [7] K. Gupta, S. Bhandari, D. Singhal, P.S. Bhatia, "J. Anaesthesiol. Clin. Pharmacol." vol. 28 (2012) pp. 543–544. [8] V.S. Karkhanis, J.M. Joshi, "Open Access Emerg. Med." vol. 4 (2012) pp. 31–52. [9] J. Pester M., V. Matthew, Brachial Plexus Block Techniques, 2020. [10] World Health Organization, "WHO Libr. Cat. Data World" (2013) pp. 125–143. [11] Y.-H. Chan, Y.-Z. Zeng, H.-C. Wu, M.-C. Wu, H.-M. Sun, "J. Healthc. Eng." vol. 2018 (2018) pp. 11. [12] L.F. Husain, L. Hagopian, D. Wayman, W.E. Baker, K.A. Carmody, "J. Emerg. Trauma. Shock" vol. 5 (2012) pp. 76–81. [13] A. Sharma, P. Jindal, "J. Emerg. Trauma. Shock" vol. 1 (2008) pp. 34–41. [14] W. Il Choi, "Tuberc. Respir. Dis. (Seoul)." vol. 76 (2014) pp. 99–104. [15] A. MacDuff, A. Arnold, J. Harvey, "Thorax" vol. 65 (2010) pp. ii18 LP-ii31. [16] E. Paramasivam, A. Bodenham, "Contin. Educ. Anaesthesia, Crit. Care Pain" vol. 8 (2008) pp. 204–209.

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