Management of postoperative paralysis of diaphragm in infants and children

Abstract

During an 8-month period, 86 consecutive infants and children under 2 years of age underwent palliative or corrective cardiac surgery, of whom 11 subsequently developed phrenic nerve injury (PNI). This was seen most frequently following classic or modified Blalock-Taussig shunts. The diagnosis was established by ultrasound screening of the diaphragm, and patients were initially managed expectantly with ventilatory support. In nine patients no further management was necessary with demonstrated return of diaphragmatic function. The remaining two patients underwent plication of the diaphragm. The mean time to diaphragmatic recovery was 40.8 days and was more prolonged in patients with paradoxical, as opposed to absent, diaphragmatic movement. There were no deaths in the series. A further retrospective review of 241 patients of similar age undergoing similar surgery over the preceding 2 years revealed evidence of PNI in 11 (4.6%). Recovery of diaphragmatic function was documented in all except one patient who died. Based on these results we believe that although PNI is associated with considerable morbidity, and frequently a long stay in Intensive Care, there is evidence of spontaneous recovery of diaphragmatic function in 90% of the patients. Consequently, plication of the diaphragm can usually be avoided. Ultrasound scanning is extremely useful in establishing the diagnosis and offers assistance in predicting prognosis and deciding management.

Incidence and treatment of diaphragmatic paralysis after cardiac surgery in children

“…In our retrospective analyses the 5.4% incidence of DP after cardiac surgery is comparable to other retrospective studies that showed an incidence of 0.3-5.7% [3,[8][9][10]. In prospective studies the reported incidence varies from 0.5 up to 12.8% which may indicate a substantial number of undiagnosed patients or difficulties in diagnosis [3,9,11,12].…”

“…In recent years an increasing number of phrenic nerve injuries associated with thoracic surgical procedures has been reported [4][5][6][7][8][9]. Today, it is the most common cause of DP in children with an incidence of 0.3-12.8% [3,5,10,11]. DP may present with respiratory distress, atelectasis, recurrent pneumonia or inability in weaning from ventilator.…”

Laparoscopic diaphragmatic plication: long-term results of a novel surgical technique for postoperative phrenic nerve palsy

“…Another important advantage of the laparoscopic approach is the option to avoid single-lung ventilation, which is always required with thoracoscopy. Postoperative ventilation time and outcome as reported here compare well with the literature [10,13,19,22]. Our patients remain free of respiratory dysfunction during a mean follow-up period of 7 years after surgery, which has also been confirmed by others [19,22].…”

Diaphragmatic paralysis after cardiac surgery in children: incidence, prognosis and surgical management

“…These procedures sometimes require harvesting of autologous pericardium and/or wide exposure of the great vessels. Thymus resection for a clear surgical view, and exposure to the cold solutions have also been associated with phrenic injury [3,6,8,10,11,14,17]. The mean age of the patients who were plicated were found to be significantly young when compared with patients who did not undergo plication due to DP.…”

“…It is accepted that procedures in congenital cardiac surgery are the major causes of DP with an incidence ranging from 0.3 to 12.8% [2,[10][11][12].…”