Interpleural Migration of an Interscalene Catheter

Abstract

surgery, we noticed significant swelling of the right hand caused by extravasation of the intravenous fluids. The pulse oximeter on the right index finger showed damped wave form and the fingertips were "dusky" with delayed capillary refill. The peripheral arterial pulses were palpable, and the hand showed no motor or sensory deficits. Since warm compresses and elevation of the right hand did not improve the capillary circulation, we proceed to try hyaluronidase. We requested and obtained from the pharmacy 150 units of hyaluronidase, mixed in 10 mL of normal saline. Using a 25-gauge needle, multiple subcutaneous injections of 0.5-1.0 mL were performed around the periphery of the extravasation. The pulse oximeter was left in place, and a plastic surgery consult was called. The hand was examined every hour. The swelling diminished after 6 h and was completely resolved by the next day. The surgical service closely followed the uneventful resolution of swelling and felt no further intervention was necessary.It must be recognized that extravasation of even small amounts of hyperosmolar fluids, if untreated, could easily swell in size from drawing in free water and rapidly escalate to compartment syndrome. Mannitol is a potent osmotic fluid, and each 50 g of mannitol causes an intracellular to extracellular shift of 1 liter of water (2). Hence, early treatment with hyaluronidase of extravasation of hyperosmolar fluids/drugs such as mannitol, parenteral nutrition solution, 10% dextrose, and 30% urea could save the patient fasciotomy.While we cannot be sure that our treatment with hyaluronidase contributed to the positive outcome in our patient, it is worth mentioning as a low-risk treatment option in early stages of hyperosmolar solutions extravasation. The technique involves subcutaneous infiltration of hyaluronidase in a pin cushion fashion at 5-10 sites along the leading edge of the extravasation. Hyaluronidase may be diluted with normal saline or 1% lidocaine to provide a concentration of 10 -15 units per milliliter. The recommended total dose is 150 -900 units (3).

Analgesia after arthroscopic rotator cuff repair: Subacromial versus interscalene continuous infusion of ropivacaine

“…We used Xray control because we have previously observed several improper catheter placements into interpleural, mediastinal, and intravascular locations. 22 Moreover, spinal or epidural placements have been previously described. 23,24 Although interscalene block provided better postoperative analgesia, it was not devoid of side effects.…”

The Role of Continuous Peripheral Nerve Blocks

“…These seldom but possible complications include inaccurate catheter tip placement resulting too far from the target nerve and therefore lacking successful analgesia, [74] or in an undesirable position like intravascular [257], intrapleural [258], intraneural [259], epidural [260] or even intrathecal. [261–263].…”

An unusual complication of interscalene brachial plexus catheterization: delayed catheter migration

“…3 Interpleural migration of an interscalene catheter has been described previously by Souron and colleagues. 5 They injected (30 ml of ropivacaine 0.75%) through the needle that was used to locate the brachial plexus before advancing a catheter 8 cm beyond the needle tip. The resultant brachial plexus block, in conjunction with sedation (propofol), was effective for surgical anaesthesia (arthroscopic shoulder surgery).…”