title: Acute respiratory failure after deep cervical plexus block for carotid endarterectomy as a result of bilateral recurrent laryngeal nerve paralysis.
abstract: We report about a case of acute respiratory distress (73-year-old female), which occurred minutes after a deep cervical plexus block (40 ml ropivacaine 0.5%) for carotid endarterectomy (CEA) and required immediate endotracheal intubation of the patient's trachea and consecutive mechanical ventilation. Subsequently, CEA was performed under general anaesthesia (TIVA) with continuous monitoring by somatosensory-evoked potentials. After a period of 14 hours, the endotracheal tube could be removed, the patient being in fair respiratory, cardiocirculatory and neurological conditions. Retrospectively, acute respiratory distress was caused by a combination of ipsilateral plexus blockade-induced and pre-existing asymptomatic contralateral recurrent laryngeal nerve (RLN) paralysis confirmed by a postoperative ENT-check and related to previous thyroid surgery more than 50 years ago. RLN paralysis, often being asymptomatic, represents a typical complication of thyroid and other neck surgery with reported incidences of 0.5-3%. Therefore, a thorough preoperative airway check is advisable in all patients scheduled for a cervical plexus block. Particularly in cases with a history of respiratory disorders or previous neck surgery a vocal cord examination is recommended, and the use of a superficial cervical plexus block may lower the risk of respiratory complications. This may prevent a possibly life-threatening coincidence of ipsilateral plexus blockade-induced and pre-existing asymptomatic contralateral RLN paralysis.
authors.affiliation: Department of Anaesthesiology and Critical Care Medicine, University Hospital of Mannheim, Faculty of Clinical Medicine Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany. weissandreas@t-online.de
authors.forename: A
authors.initials: A
authors.lastname: Weiss
authors.forename: C
authors.initials: C
authors.lastname: Isselhorst
authors.forename: J
authors.initials: J
authors.lastname: Gahlen
authors.forename: S
authors.initials: S
authors.lastname: Freudenberg
authors.forename: H
authors.initials: H
authors.lastname: Roth
authors.forename: N
authors.initials: N
authors.lastname: Hammerschmitt
authors.forename: C
authors.initials: C
authors.lastname: Mattinger
authors.forename: H
authors.initials: H
authors.lastname: Kerger
mesh_terms: D000208:Acute Disease; D000368:Aged; D000768:Anesthesia, General; D000771:Anesthesia, Intravenous; D002572:Cervical Plexus; D016894:Endarterectomy, Carotid; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D009407:Nerve Block / Q000009:adverse effects*; D012121:Respiration, Artificial; D012131:Respiratory Insufficiency / Q000209:etiology*; D013965:Thyroidectomy / Q000009:adverse effects; D014826:Vocal Cord Paralysis / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy