超声诊断臂丛神经阻滞下肩关节松解术中膈神经麻痹1例

One Case of Phrenic Nerve Palsy Diagnosed by Ultrasound during Shoulder Joint Release under Brachial Plexus Nerve Block

摘要: 目的：报告一例右锁骨上臂丛神经阻滞术后并发膈神经麻痹的病例，探讨其诊断流程与治疗方法，并强调床旁超声在快速鉴别诊断中的关键价值。方法：详细描述一例48岁男性患者在接受0.33%罗哌卡因 + 0.67%利多卡因共30 ml右锁骨上臂丛神经阻滞及肩关节松解术后，出现急性呼吸困难、SpO₂下降至91%的诊疗经过。通过床旁肺部超声初步排除气胸后，利用膈肌超声确诊右侧膈肌运动消失，明确诊断为右侧膈神经麻痹。结果：确诊后立即予患者吸氧、咪达唑仑镇静及严密生命体征监测。患者症状于6小时内缓解，48小时后完全恢复，膈肌运动及上肢功能均恢复正常，胸片检查未见异常。结论：锁骨上臂丛神经阻滞是膈神经麻痹的高危因素。当患者术后出现急性呼吸困难时，床旁膈肌超声是一种无创、快速、精准的诊断工具，能有效鉴别膈神经麻痹与其他并发症(如气胸)，对指导临床处理、避免误诊具有重要意义。

Abstract: Objective: To report a case of phrenic nerve palsy after right supraclavicular brachial plexus block surgery, explore its diagnostic process and treatment methods, and emphasize the key value of bedside ultrasound in rapid differential diagnosis. Methods: A detailed description of the diagnosis and treatment process of a 48-year-old male patient who developed acute dyspnea and SpO₂ decreased to 91% after receiving a total of 30 ml of 0.33% ropivacaine + 0.67% lidocaine right supraclavicular brachial plexus nerve block and shoulder joint release. After initially ruling out pneumothorax through bedside lung ultrasound, diaphragmatic ultrasound was used to confirm the disappearance of right diaphragmatic movement, and the diagnosis was clearly right phrenic nerve palsy. Result: Immediately after diagnosis, the patient was given oxygen, sedated with midazolam and closely monitored for vital signs. The patient’s symptoms were relieved within 6 hours and fully recovered after 48 hours. The diaphragm movement and upper limb function both returned to normal, and no abnormalities were found in the chest X-ray examination. Conclusion: Supraclavicular brachial plexus block is a high-risk factor for phrenic nerve palsy. When patients experience acute dyspnea after surgery, bedside diaphragmatic ultrasound is a non-invasive, rapid and accurate diagnostic tool, which can effectively distinguish phrenic nerve palsy from other complications (such as pneumothorax), and is of great significance for guiding clinical management and avoiding misdiagnosis.