REVIEW

CURRENT
OPINION Diaphragm-sparing brachial plexus blocks: a
focused review of current evidence and their role
during the COVID-19 pandemic
Javier Cubillos a, Laura Girón-Arango b, and Felipe Muñoz-Leyva c

Purpose of review
Given that COVID-19 can severely impair lung function, regional anesthesia techniques avoiding phrenic
Downloaded from http://journals.lww.com/co-anesthesiology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 12/07/2020

nerve paralysis are relevant in the anesthetic management of suspected/confirmed COVID-19 patients
requiring shoulder and clavicle surgical procedures. The objective of this review is to provide an overview
of recently published studies examining ultrasound-guided diaphragm-sparing regional anesthesia
techniques for the brachial plexus (BP) to favor their preferent use in patients at risk of respiratory function
compromise.
Recent findings
In the last 18 months, study findings on various diaphragm-sparing regional anesthesia techniques have
demonstrated comparable block analgesic effectivity with a variable extent of phrenic nerve paralysis. The
impact of hemi-diaphragmatic function impairment on clinical outcomes is yet to be established.
Summary
Existing diaphragm-sparing brachial plexus regional anesthesia techniques used for shoulder and clavicle
surgery may help minimize pulmonary complications by preserving lung function, especially in patients
prone to respiratory compromise. Used as an anesthetic technique, they can reduce the risk of exposure of
healthcare teams to aerosol-generating medical procedures (AGMPs), albeit posing an increased risk for
hemi-diaphragmatic paralysis. Reducing the incidence of phrenic nerve involvement and obtaining opioid-
sparing analgesia without jeopardizing efficacy should be prioritized goals of regional anesthesia practice
during the COVID-19 pandemic.
Keywords
brachial plexus, COVID-19, diaphragm-sparing, nerve block, phrenic nerve, regional anesthesia

INTRODUCTION are greater than those reported for even the highest
Humanity is facing an unprecedented health crisis risk patients before the pandemic [7].
because of COVID-19 pandemic [1]. Concern has To date, the impact of COVID-19 in healthcare
been raised because of the fact that up to 80% of providers (HCP) and surgeries worldwide is still evolv-
COVID-19 positive patients are asymptomatic [2] ing, with many centers resuming elective procedures
yet can present ground-glass opacities in chest CT with variable rates of community spread worldwide.
scan [3], interstitial (i.e. ‘walking’) pneumonia [4] HCP are susceptible to viral contamination after
and significant hypoxemia [5], reflecting consider-
able (and mostly undiagnosed) underlying pulmo-
a
nary compromise. Unfortunately, up to 30% of Department of Anesthesia & Perioperative Medicine, Western University,
infected patients will be reported as free of the virus London Health Sciences Center, London, Ontario, Canada, bDepartment
of Anesthesia, Hospital Pablo Tobón Uribe, Medellı́n, Antioquia,
with recommended perioperative tests at present
Colombia and cDepartment of Anesthesiology & Pain Medicine, Univer-
[6]. According to a recent multinational observa- sity of Toronto, Toronto Western Hospital, University Health Network
tional cohort study involving 1128 patients who (UHN), Toronto, Ontario, Canada
had surgery in 24 countries, postoperative pulmo- Correspondence to Javier Cubillos, MD, 339 Windermere Road-Univer-
nary complications occur in half of the patients with sity Hospital, C3-127, London, ON N6A 5A5, Canada.
perioperative COVID-19 infection and are also asso- Tel: +1 519 685 8500; e-mail: [email protected]
ciated with high mortality. Of note and worrisome, Curr Opin Anesthesiol 2020, 33:685–691
these pulmonary complications and mortality rates DOI:10.1097/ACO.0000000000000911

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Regional anesthesia

phrenic nerve if the injection is not performed accu-

KEY POINTS rately in the proper subcutaneous plane and using
 In COVID 19 patients, regional anesthesia can be a low volumes [14]. Another option to avoid any risk of
valuable tool for surgical anesthesia and analgesia diaphragm involvement with SCPB will be to directly
management in shoulder and clavicle surgery to infiltrate the clavicle surrounding skin. Currently,
minimize the risk of pulmonary compromise. CPFP has been documented both as an analgesic
block and as an individual anesthetic technique in
 In COVID-19 patients, the choice of regional
anesthesia technique for shoulder and clavicle surgery isolated case reports [15,16]; however, diaphragm-
should always be preceded by careful individual risk– sparing potential and anesthetic/analgesic effective-
benefit analysis in conjunction with the surgical team. ness of this new block for clavicle surgery still need to
be evaluated in future randomized studies.
 ASNB, combined ICB with suprascapular nerve block,
CCB and STB are valid alternatives for analgesia as
part of a multimodal approach, while surgical
anesthesia has only been reported with STB.
IN SEARCH OF THE IDEAL BLOCK FOR
SHOULDER SURGERY
 Further research on the clinical impact of complete/ Shoulder surgery is related to severe postsurgical
partial phrenic nerve paralysis after the diaphragm-
pain with opioid requirements comparable to that
sparing brachial plexus regional anesthesia techniques
is needed. of a thoracotomy [17]. Regional anesthesia is asso-
ciated with lower pain scores and greater patient
satisfaction [18]. The 2019 procedure-specific post-
operative pain management (PROSPECT) approach
exposure to aerosol-generating medical procedures guidelines for rotator cuff repair surgery by Toma
(AGMPs), and recommendations to avoid airway man- et al. [19] recommend that the analgesic regimen for
agement procedures commonly performed in the peri- rotator cuff repair should include an arthroscopic
&
operative period have been issued [8 ]. Nevertheless, approach and the use of a regional anesthesia tech-
given that COVID-19 can also severely impair lung nique as a component of perioperative multimodal
function, regional anesthesia techniques avoiding analgesia that only includes opioids as rescue anal-
phrenic nerve paralysis may become increasingly rel- gesia. Continuous regional anesthesia techniques
evant in the anesthetic management of patients over a single shot approach and use of dexametha-
undergoing shoulder and clavicle surgery. This review sone are also discussed as highlighted recommen-
will focus on updating the most recent information on dations to contribute to prolonging analgesic
diaphragm-sparing regional anesthesia techniques benefits and preventing rebound pain.
that can be useful for these surgical procedures in The gold standard regional anesthesia technique
the context of the COVID-19 pandemic. for shoulder surgery is ISB [20]. However, it is related to
the highest incidence of transient (3.5/1000) and
permanent (2.5/1000) nerve damage [21]. Also, it is
ANALGESIA FOR CLAVICLE FRACTURES greatly associated with phrenic nerve block producing
Clavicle fractures are associated with severe pain [9] undesirable diaphragm paralysis [22]. Although this is
and surgical management is usually indicated [10]. usually not clinically significant in healthy individu-
Sensitive innervation of the clavicle and surround- als, it can lead to respiratory failure in patients with
ing skin is controversial. Contributions from the compromised pulmonary function. Paradoxically,
supraclavicular nerves not only from the superficial effective regional anesthesia analgesia with reduced
cervical plexus but also from the brachial plexus (BP) opioid consumption is highly desirable in these
via subclavian, suprascapular, long thoracic nerves, patients, thus posing a dilemma for clinicians.
and lateral pectoral nerve have been described Given the aforementioned risks, there is an
[11,12]. Therefore, interscalene block (ISB) comple- increased interest in finding a shoulder block that
mented with a superficial cervical plexus block offers a superior safety profile, capable of providing
(SCPB) has been classically suggested [11]. reliable and reproducible shoulder analgesia/anes-
Clavipectoral fascial plane (CPFP) block thesia comparable with ISB, but that also grants the
described by Valdés-Vilches et al. consists of an ultra- privilege of lung function preservation by its dia-
sound-guided infiltration using 10–15 ml of local phragm-sparing effect (Table 1).
anesthetic deep to the fascia that covers the clavicle
and separates it from the minor pectoral muscle,
blocking bone innervation to the clavicle [13]. Com- Superior trunk block
plementary SCPB is suggested to anesthetize the skin, Superior trunk block (STB) is performed where the
nevertheless, this block can potentially involve the C5 and C6 nerve roots are coming together to

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 Table 1. Summary of recent randomized controlled trials evaluating hemidiaphragmatic paralysis after single shot ultrasound-guided blocks for shoulder and upper
extremity surgery
Incidence of hemidiaph-
ragmatic paralysis
Reference Block type Surgery Complete Partial Injectate Observations

Kang et al. [28] Interscalene block Shoulder 72.5% 97.5% 0.5% ropivacaine, 15 ml Indicated either for analgesia or
arthroscopy surgical anesthesia as single
technique
Superior trunk block Shoulder 5.3% 76.3% 0.5% ropivacaine, 15 ml Similar to ISB analgesia. Surgical
arthroscopy anesthesia reported by Kim
et al.
&
Kim et al. [27 ] 4.8% N/A 0.5% bupivacaine, 15 ml
&
Abdallah et al. [31 ] Anterior suprascapular Shoulder N/A 0.5% ropivacaine, 15 ml Similar to ISB analgesia. Surgical
block Arthroscopy anesthesia not reported
&
Ferré et al. [33 ] Combined axillary nerve þ Shoulder Anterior 0.375% ropivacaine, Greater opioid-sparing analgesic
anterior and posterior arthroscopy 10 ml þ 2 mg effect with anterior approach.
suprascapular block dexamethasone Surgical anesthesia not
reported.
7% 33%
Posterior
2% 0%
&
Aliste et al. [38 ] Costoclavicular block Shoulder 0% N/A 0.5% Levobupivacaine, All patients received

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arthroscopy 20 ml supplementary ICPB. Similar to
ISB analgesia. Surgical
anesthesia not reported.
Sivashanmugam Distal upper 2.5–5% N/A 0.5% bupivacaine, 10 ml N/A
&
et al. [39 ]; extremity surgery, þ 2% lidocaine, 10 ml
Oh et al. [40] not shoulder
Taha et al. [43] Combined infraclavicular Shoulder N/A 5.6% 0.5% ropivacaine, 25 ml Similar to ISB analgesia. Surgical
þ suprascapular arthroscopy anesthesia not reported
(anterior approach for
Taha and posterior
approach for Aliste)
Aliste et al. [41] Shoulder 0% N/A 0.25% levobupivacaine, All patients received
arthroscopy 30 ml supplementary ICPB. Similar to
ISB analgesia after 30 min.

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Surgical anesthesia not
reported.

ICPB, intermediate cervical plexus block; ISB, interscalene block; N/A, not applicable.

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Diaphragm-sparing brachial plexus blocks Cubillos et al.

687
Regional anesthesia

conform the superior trunk, and very importantly, 2% with the PSNB (0% partial and 2% complete).
before the suprascapular nerve leaves the trunk [23]. The authors also describe higher opioid consump-
A careful approach to ultrasound-guided STB tion in the PSNB group, supporting previous studies
may prevent the possibility of potential injuries to reporting the analgesic inferiority of this approach
the dorsal scapular and long thoracic nerves by to ISB in the immediate period after arthroscopic
avoiding passing the needle close to them [24,25]. shoulder surgery [34,35].
Also, as it is performed where the trunk is already
formed, it reduces possible failures in patients with
anatomical C5 variability, which can be found in up Costoclavicular block
to 30–35% of the population [26]. Anatomically, This block was described by Karmakar et al. [36] as an
STB is performed further away from the phrenic alternative approach to infraclavicular block also
nerve, which has the theoretical advantage of mini- suitable for perineural catheter placement [37].
&
mizing the risk of nerve injury as there is more Aliste et al. [38 ] compared the costoclavicular bloc
epineurium at this level [23]. (CCB) to ISB for arthroscopic shoulder surgery using
Two studies report that STB is an effective 20 ml of local anesthetic, finding equivalent analge-
regional anesthesia alternative to the ISB in preserv- sia with complete diaphragm paralysis in 100% of
ing lung function while providing comparable sur- the ISB group versus 0% in the CCB group. Siva-
& &
gical anesthesia and analgesia. Kim et al. [27 ] shanmugam et al. [39 ] reported an incidence of 5%
performed STB and ISB for surgical anesthesia and of complete diaphragm paralysis with CCB using the
reported 71.4% full diaphragmatic paralysis for the same volume of 20 ml, despite that his study was
ISB versus only 4.8% for STB with no report of partial performed for upper arm surgery and not for shoul-
paralysis with STB. In the study by Kang et al. [28] der or clavicle procedures. Similarly, Oh et al. [40]
partial diaphragm compromise was reported in report an incidence of 2.5% of complete diaphragm
97.5% of ISB and 76.3% of STB, with full paresis paralysis with CCB.
in 72.5% of cases for the ISB versus only 5.3%
for STB.
Infraclavicular block with suprascapular
block
Anterior suprascapular nerve block Aliste et al. [41] compared ICB and PSNB with the
Described by Siegenthaler et al. [29], anterior supra- ISB, reporting a lower pain score at initial 30 min
scapular nerve block (ASNB) consists on blocking with ISB, and comparable analgesia thereafter. Nev-
the suprascapular nerve as it moves away from the ertheless, ISB was associated with lower opioid con-
superior trunk, posterior to the lower belly of the sumption. Diaphragmatic paralysis was found in
omohyoid muscle (subomohyoid approach) and 90% of ISB patients versus 0% in the ICB and PSNB.
before traveling to reach the supraspinous fossa of Of note, a previous study reported an incidence of
the scapula. Wiegel et al. [30] found comparable 3% complete hemidiaphragmatic paralysis when
analgesia to ISB with less motor function compro- using ICB [42].
&
mise. Abdallah et al. [31 ] compared subomohyoid Taha et al. [43] compared ISB with ICB and
ASNB versus ISB for shoulder arthroscopic surgery ASNB, finding no difference in analgesia duration,
finding noninferiority of ASNB in terms of achieved opioid consumption, or patient satisfaction. How-
postoperative pain control in the first 24 h. They ever, diaphragmatic paralysis was found in 88.9% of
also quantified the frequency of sensory-motor ISB versus 5.6% in ASNB. The usefulness of adding
block in C5-C6 dermatome finding a consistent ICB to ASNB is questionable as it has been shown
block of the superior trunk. Interestingly, a recent that ASNB alone produces comparable analgesia
cadaver study showed that after only 5 ml of dye to ISB.
injection, 20% of cases had phrenic nerve staining
[32]. They also found that 90% of the specimens had
dye staining the superior trunk, 80% of the middle Erector spinae plane block
trunk, and 30% of the lower trunk, which could also Case reports have described its use in shoulder sur-
explain the comparable analgesia to ISB. geries with the potential advantage of diaphragm-
&
Regarding phrenic nerve involvement, Ferré sparing [44,45,46 ]. Tsui et al. [47] reports using ESP
&
et al. [33 ] evaluated hemidiaphragmatic paralysis as continuous regional analgesia for shoulder sur-
following axillary nerve block with ASNB versus gery at the T2 level moving a stimulating catheter in
posterior suprascapular nerve block (PSNB) for a cephalic direction obtaining a deltoid response.
shoulder surgery, finding it in 41% of the patients Nevertheless, the impact of ESP block in hemidiaph-
with the ASNB (33% partial and 7% complete) and ragmatic function has not been established. The

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 Diaphragm-sparing brachial plexus blocks Cubillos et al.

analgesic role and safety profile of ESP block in most patients as it has the potential of reducing the
shoulder surgery is currently under active research. amount of opioid requirements to control postoper-
&
ative pain. For this, ASNB [31 ], combined ICB with
& &
suprascapular nerve [40], CCB [38 ] and STB [27 ,28]
REGIONAL ANESTHESIA may be considered valid alternatives for analgesia,
CONSIDERATIONS FOR SHOULDER whereas surgical anesthesia has only been reported
AND CLAVICLE SURGERY DURING THE &
with STB [27 ]. Regarding these blocks reporting sim-
COVID-19 PANDEMIC ilar analgesia to ISB, none of them ensure the absence
Anesthetic management strategies during the of phrenic nerve compromise. In the case of axillary
COVID-19 pandemic are a matter of ongoing dis- nerve block with PSNB (’shoulder block’), Ferré et al.
&
cussion. Given the fact that all patients (even those [33 ] reported a 2% incidence of complete diaphrag-
asymptomatic) during the mitigation phase should matic paralysis with an analgesic profile inferior to
&
be considered infected unless proven otherwise [8 ], ISB. This unexpected finding is surprising as the
expert opinion from the American Society of mechanisms by which such distal block could poten-
Regional Anesthesia and Pain Medicine (ASRA) tially cause diaphragmatic paralysis merits further
and European Society of Regional Anesthesia and research to rule out a potential reproducible pathway
Pain Therapy (ESRA) recommends the use of of local anesthetic dissemination versus a misplaced
regional anesthesia over general anesthesia when- injection of local anesthetic in the context of a block
ever feasible, to minimize the need of exposure of considered technically challenging. In the same way,
HCP to AGMPs and reduce the potential risk of future research on the role of ESP and clavipectoral
&&
perioperative pulmonary complications [48 ]. blocks for shoulder and clavicle surgery and their
Furthermore, different groups around the world impact on phrenic nerve function is warranted.
have published their practical considerations for per- Careful reasoning and interdisciplinary collabo-
forming regional anesthesia during the COVID-19 ration with the surgical team is essential to balance
pandemic [49–51] emitting expert opinion based on the benefits and potential risks of aiming for an
available context-specific scientific evidence. Inno- anesthetic block, as its failure will need an emer-
vative recommendations have been wisely suggested gency conversion to general anesthesia. This unde-
and they might contribute to developing effective sirable scenario will defeat the initial purpose of
and adaptable anesthetic plans under high standards using regional anesthesia to reduce the possibility
of efficiency, while strictly preserving HCP and of exposure during AGMPs, and perhaps, may even
patient safety. Some of these recommendations increase the risk of HCP contamination as airway
include individualizing each clinical scenario; plan- management will be approached under suboptimal,
ning of human resources giving high priority to uncomfortable, and stressful conditions.
expertise; adapting the clinical environment to
enhance safety; preparing necessary and suitable
equipment and drugs in advance; selecting and assur- CONCLUSION
ing appropriate personal protective equipment (PPE) COVID-19 pandemic has become an opportunity for
for HCP; providing adequate oxygen therapy with regional anesthesia to stand up as an essential tool
pertinent sedation without increasing risk of contam- for anesthesiologists. Recent developments in dia-
ination; planning for safely performing regional phragm-sparing nerve blocks for shoulder and clav-
anesthesia procedures; and, monitoring during the icle surgery acquire increased relevance in patients
conduct of anesthesia and postanesthetic care. with respiratory compromise as they may help min-
Individualizing patient care after risk/benefit imize deleterious respiratory effects of phrenic nerve
consideration of regional anesthesia techniques is paralysis. Opioid-sparing effective perioperative
paramount. For shoulder and clavicle surgery, analgesia added to lung function preservation capa-
regional anesthesia techniques like ISB can be con- bility is also of utmost importance. Unfortunately,
sidered for surgical anesthesia in COVID-19 negative an optimal approach remains elusive.
patients without respiratory compromise, but in the In the context of suspected/confirmed COVID-
context of patients with clinical signs of respiratory 19 patients, meticulous individualized breakdown
involvement (i.e. dry cough, shortness of breath, of risks and benefits should be debated. Except for
decreased SpO2) and scheduled for an urgent proce- STB, all regional anesthesia techniques discussed
dure, a diaphragmatic-sparing technique needs to be have been studied only for analgesia and not for
ensured if at all to be used. On the other hand, even if surgical anesthesia, reporting various degrees of
regional anesthesia is performed only as an adjunct to phrenic nerve involvement, and their use is recom-
general anesthesia for analgesic purposes, a block mended as part of a multimodal analgesic approach
with phrenic nerve-sparing qualities is desirable for that includes general anesthesia. Further research

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Regional anesthesia

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