Perioperative diaphragm point-of-care ultrasound as a prediction tool of postoperative respiratory failure in high-risk patients: A feasibility study and case series

Abstract

Introduction: Respiratory muscle function in the postoperative period is a key to whether a patient develops Postoperative Respiratory Failure (PRF) or not. PRF occurs when the gas exchange does not meet metabolic needs. Ipsilateral paralysis of the hemidiaphragm after interscalenic brachial plexus block (ISB) causes an acute reduction of respiratory muscle function. This reduction does not cause PRF when the contralateral hemidiaphragm generates enough gas exchange to meet metabolic demands.

Objectives: To study the evolution of hemidiaphragmatic muscle function during the perioperative period with diaphragmatic ultrasound (D-POCUS), and use it as an innovative tool to predict PRF, assessing the contralateral hemidiaphragm in the event of acute hemidiaphragm paralysis.

Methods: Patients considered high risk, scheduled for shoulder surgery with ISB are studied. Both hemidiaphragms were evaluated by ultrasound, before and after the procedure, measuring Thickening Fraction (TF) and Diaphragmatic Excursion (DE). PACU patients with PRF were registered.

Results: There was a significant reduction in the TF and DE of the ipsilateral hemidiaphragm in the six patients studied. Only 1/6 patients showed signs of PRF. The evaluation of the contralateral hemidiaphragm during the postoperative period showed that in the five patients without signs of PRF, there were no significant changes in the function of the contralateral hemidiaphragm. The patient, who showed a reduction in contralateral hemidiaphragm function, was the only one who suffered PRF.

Conclusions: In this case series, D-POCUS allows to know the perioperative function of the diaphragm in high-risk patients. All patients suffered an acute reduction of hemidiaphragm function after ISB; however, these patients did not develop PRF when the contralateral hemidiaphragm function was preserved.

Keywords: Bloqueo interescalénico del plexo braquial; Diaphragm evaluation; Evaluación diafragmática; Fallo ventilatorio postoperatorio; Hemidiaphragm palsy; Interscalene brachial plexus block; POCUS; Parálisis del nervio frénico; Parálisis hemidiafragmática; Phrenic nerve palsy; Postoperative respiratory failure.