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Grocott HP, Clark JA, Homi HM, Sharma A. “Other” Neurologic Complications After Cardiac Surgery. Semin Cardiothorac Vasc Anesth 2016; 8:213-26. [PMID: 15375481 DOI: 10.1177/108925320400800304] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Compared to the neurologic morbidity of stroke and cognitive dysfunction, “other” neurologic complications involving injuries to the brachial plexus, phrenic nerve, cranial nerves, other peripheral nerves, as well as the visual pathways, have been disproportionately underrepresented in the cardiac surgery and anesthesiology literature. These injuries are often missed in the early postoperative period when attention is focused principally on recovery from the acute trespass of cardiac surgery and cardiopulmonary bypass. However, when these problems do become apparent, they can cause considerable discomfort and morbidity. An overview of the current concepts of injury mechanisms/etiology, diagnosis, prognosis, and when possible, prevention of these injuries is presented.
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Affiliation(s)
- Hilary P Grocott
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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Chen HY, Chen HC, Lin MC, Liaw MY. Bilateral Diaphragmatic Paralysis in a Patient With Critical Illness Polyneuropathy: A Case Report. Medicine (Baltimore) 2015; 94:e1288. [PMID: 26252301 PMCID: PMC4616567 DOI: 10.1097/md.0000000000001288] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Bilateral diaphragmatic paralysis (BDP) manifests as respiratory muscle weakness, and its association with critical illness polyneuropathy (CIP) was rarely reported. Here, we present a patient with BDP related to CIP, who successfully avoided tracheostomy after diagnosis and management.A 71-year-old male presented with acute respiratory failure after sepsis adequately treated. Repeated intubation occurred because of carbon dioxide retention after each extubation. After eliminating possible factors, septic shock-induced respiratory muscle weakness was suspected. Physical examination, a nerve conduction study, and chest ultrasound confirmed our impression.Pulmonary rehabilitation and reconditioning exercises were arranged, and the patient was discharged with a diagnosis of BDP.The diagnosis of BDP is usually delayed, and there are only sporadic reports on its association with polyneuropathy, especially in patients with preserved limb muscle function. Therefore, when physicians encounter patients that are difficult to wean from mechanical ventilation, CIP associated with BDP should be considered in the differential diagnosis.
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Affiliation(s)
- Hsuan-Yu Chen
- From the Department of Physical Medicine and Rehabilitation (H-YC), Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine (M-YL), Department of Physical Medicine and Rehabilitation, Chang Gung University College of Medicine; and Division of Pulmonary and Critical Care Medicine (H-CC, M-CL), Chang Gung Memorial Hospital-Kaohsiung Medical Center, Department of Internal Medicine, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Carvalho M, Matias T, Evangelista T, Pinto A, Luís MS. Bilateral phrenic nerve neuropathy in a diabetic patient; TO THE EDITOR. Eur J Neurol 2011. [DOI: 10.1111/j.1468-1331.1996.tb00257.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Matsumoto H, Nakayama T, Hamaguchi H, Nakamori T, Ikagawa T, Oda T, Imafuku I. Diaphragmatic paralysis in a patient with spinal cord infarction. Intern Med 2009; 48:1763-6. [PMID: 19797834 DOI: 10.2169/internalmedicine.48.2334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
This report describes the rare case of a 72-year-old woman with spinal cord infarction who presented with persistent diaphragmatic paralysis. Her neurological examination showed tetraplegia, sensory loss to pain and thermal stimulations, and paradoxical abdominal movement. Chest X-ray and diaphragmatic fluoroscopy revealed absent diaphragmatic movement. A cervical magnetic resonance image showed bilateral anterior spinal cord lesions from the level of the second to the fifth cervical vertebrae. Diaphragmatic paralysis should be recognized as a clinical sign of cervical spinal cord infarction. Particular attention must be given to paradoxical abdominal movement during respiration in this disorder.
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Abstract
We report an anatomic variation of the phrenic nerve. During a routine gross anatomical dissection course at our medical university, we found an unusual loop of the left phrenic nerve around the internal thoracic artery, about 1 cm from the take-off of the left subclavian artery. The phrenic nerve is close to the internal thoracic artery and is easily injured when dissecting the internal thoracic artery for coronary artery bypass conduit. Therefore, we suggest that the anatomic relationship of the phrenic nerve and internal thoracic artery is important in preventing incidental injury of the phrenic nerve.
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Merino-Ramirez MA, Juan G, Ramón M, Cortijo J, Rubio E, Montero A, Morcillo EJ. Electrophysiologic evaluation of phrenic nerve and diaphragm function after coronary bypass surgery: Prospective study of diabetes and other risk factors. J Thorac Cardiovasc Surg 2006; 132:530-6, 536.e1-2. [PMID: 16935106 DOI: 10.1016/j.jtcvs.2006.05.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2006] [Revised: 04/19/2006] [Accepted: 05/12/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Phrenic neuropathy after coronary artery bypass grafting has been related to various risk factors with conflicting results. The aim of this study was to assess the incidence, characteristics, and clinical consequences of phrenic neuropathy and the influence of diabetes and other risk factors. METHODS We conducted an observational, prospective study of parallel groups including 94 consecutive patients subjected to coronary artery bypass grafting, half of them with diabetes and associated polyneuropathy. Electrophysiologic study of phrenic nerve conduction as the reference method, chest radiography, diaphragm ultrasound, and functional respiratory tests were performed 24 to 48 hours before and 7 days after surgery. In those patients showing phrenic neuropathy, explorations were repeated, including needle diaphragmatic electromyography, at 1, 3, 6, 9, 12, 18, and 24 months or until recovery. RESULTS Fifteen of the 94 patients (16%) had phrenic neuropathy, 9 in the left side, 3 on the right, and 3 bilateral. Nine (60%) of the affected patients had diabetes, but diabetes did not represent a greater risk of neuropathy (relative risk 1.5, 95% confidence interval 0.6-3.9). Multivariate analysis showed no association of phrenic nerve injury with age, sex, ejection fraction, diabetes, use of internal thoracic artery, or number of grafts as risk factors. Phrenic neuropathy did not result in greater morbidity, and most patients recovered in less than 1 year. CONCLUSIONS None of the risk factors studied, including diabetes, influenced the appearance of phrenic neuropathy, thus indicating a role for nerve damage during surgery. Low morbidity and relatively rapid recovery were observed.
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Deng Y, Sun Z, Ma J, Paterson HS. Semi-skeletonized internal mammary grafts and phrenic nerve injury: Cause-and-effect analysis. ACTA ACUST UNITED AC 2006; 26:455-9. [PMID: 17120747 DOI: 10.1007/s11596-006-0420-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Phrenic nerve injury after cardiac surgery increases postoperative pulmonary complications. The purpose of this study was to analyze the causes and effects of phrenic nerve injury after cardiac surgery. Prospectively collected data on 2084 consecutive patients who underwent cardiac surgery from Jan. 1995 to Feb. 2002 were analyzed. Twenty-eight preoperative and operation related variables were subjected to logistic analysis with the end point being phrenic nerve injury. Then phrenic nerve injury and 6 perioperative morbidities were included in the analysis as variables to determine their independent predictive value for perioperative pulmonary morbidity. An identical approach was used to identify the independent risk factors for perioperative mortality. There were 53 phrenic nerve injuries (2.5%). There was no phrenic nerve injury in non-coronary surgery or coronary surgery using conduits other than the internal mammary artery. The independent risk factors for phrenic nerve injury were the use of internal mammary artery (Odds ratio (OR) = 14.5) and thepresence of chronic obstructive pulmonary disease (OR = 2.9). Phrenic nerve injury was an independent risk factor (OR = 8.1) for perioperative pulmonary morbidities but not for perioperative mortality. Use of semi-skeletonized internal mammary artery harvesting technique and drawing attention to possible vascular or mechanical causes of phrenic nerve injury may reduce its occurrence. Unilateral phrenic nerve injury, although rarely life-threatening, is an independent risk factor for postoperative respiratory complications. When harvesting internal mammary arteries, it should be kept in mind avoiding stretching, compromising, or inadvertently dissecting phrenic nerve is as important as avoiding damage of internal mammary artery itself.
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Affiliation(s)
- Yongzhi Deng
- Department of Cardiothoracic Surgery, The Second Teaching Hospital of Shanxi Medical University, Taiyuan 030001, China
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Moideen I, Nair SG, Shivaprakasha K, Anil R. Bilateral Phrenic Nerve Palsy in a Neonate Following Complex Congenital Cardiac Surgery. J Cardiothorac Vasc Anesth 2006; 20:76-9. [PMID: 16458219 DOI: 10.1053/j.jvca.2004.11.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2004] [Indexed: 11/11/2022]
Affiliation(s)
- Ijas Moideen
- Department of Anesthesia, Division of Cardiac Anaesthesia, Amrita Institute of Medical Sciences and Research Center, Kerala, India
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Tokuda Y, Matsumoto M, Sugita T, Nishizawa J. Nasal mask bilevel positive airway pressure ventilation for diaphragmatic paralysis after pediatric open-heart surgery. Pediatr Cardiol 2004; 25:552-3. [PMID: 15136909 DOI: 10.1007/s00246-003-0575-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
A 2-year-old boy underwent surgical repair of tetralogy of Fallot. Topical cooling of the heart with ice slush was used during the operation. Diaphragmatic paralysis occurred after the operation, inducing severe respiratory distress. To avoid repeated intubation and tracheostomy, the patient was placed on nasal mask bilevel positive airway pressure (BiPAP) ventilation. After ventilatory support with BiPAP for 40 days, the patient recovered spontaneously from the paralysis. No sedation was required during this time. This report illustrates the usefulness of BiPAP for a pediatric patient with diaphragmatic paralysis after cardiac surgery.
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Affiliation(s)
- Y Tokuda
- Department of Cardiovascular Surgery, Tenri Hospital, 200 Mishima, Tenri 632-8552, Japan.
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Canbaz S, Turgut N, Halici U, Balci K, Ege T, Duran E. Electrophysiological evaluation of phrenic nerve injury during cardiac surgery--a prospective, controlled, clinical study. BMC Surg 2004; 4:2. [PMID: 14723798 PMCID: PMC320489 DOI: 10.1186/1471-2482-4-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2003] [Accepted: 01/14/2004] [Indexed: 11/20/2022] Open
Abstract
Background According to some reports, left hemidiaphragmatic paralysis due to phrenic nerve injury may occur following cardiac surgery. The purpose of this study was to document the effects on phrenic nerve injury of whole body hypothermia, use of ice-slush around the heart and mammary artery harvesting. Methods Electrophysiology of phrenic nerves was studied bilaterally in 78 subjects before and three weeks after cardiac or peripheral vascular surgery. In 49 patients, coronary artery bypass grafting (CABG) and heart valve replacement with moderate hypothermic (mean 28°C) cardiopulmonary bypass (CPB) were performed. In the other 29, CABG with beating heart was performed, or, in several cases, peripheral vascular surgery with normothermia. Results In all patients, measurements of bilateral phrenic nerve function were within normal limits before surgery. Three weeks after surgery, left phrenic nerve function was absent in five patients in the CPB and hypothermia group (3 in CABG and 2 in valve replacement). No phrenic nerve dysfunction was observed after surgery in the CABG with beating heart (no CPB) or the peripheral vascular groups. Except in the five patients with left phrenic nerve paralysis, mean phrenic nerve conduction latency time (ms) and amplitude (mV) did not differ statistically before and after surgery in either group (p > 0.05). Conclusions Our results indicate that CPB with hypothermia and local ice-slush application around the heart play a role in phrenic nerve injury following cardiac surgery. Furthermore, phrenic nerve injury during cardiac surgery occurred in 10.2 % of our patients (CABG with CPB plus valve surgery).
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Affiliation(s)
- Suat Canbaz
- Department of Cardiovascular Surgery, Trakya University, Medical Faculty, Edirne, Turkey
| | - Nilda Turgut
- Department of Neurology, Trakya University, Medical Faculty, Edirne, Turkey
| | - Umit Halici
- Department of Cardiovascular Surgery, Trakya University, Medical Faculty, Edirne, Turkey
| | - Kemal Balci
- Department of Neurology, Trakya University, Medical Faculty, Edirne, Turkey
| | - Turan Ege
- Department of Cardiovascular Surgery, Trakya University, Medical Faculty, Edirne, Turkey
| | - Enver Duran
- Department of Cardiovascular Surgery, Trakya University, Medical Faculty, Edirne, Turkey
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Deng Y, Byth K, Paterson HS. Phrenic nerve injury associated with high free right internal mammary artery harvesting. Ann Thorac Surg 2003; 76:459-63. [PMID: 12902085 DOI: 10.1016/s0003-4975(03)00511-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The right phrenic nerve is at risk of injury during high mobilization of the right internal mammary artery (RIMA). The incidence and implications of this injury have not been previously defined. METHODS Prospectively collected data on all patients who underwent RIMA harvesting between January 1995 and February 2002 were analyzed. Thirty-one patients with right phrenic nerve injury were identified and the medical charts reviewed. Phrenic nerve injury was diagnosed when a postoperative chest roentgenogram showed the right hemidiaphragm to be two or more intercostal spaces higher than the left, or transection of the nerve was seen intraoperatively. Investigations included fluoroscopy and spirometry in upright and supine positions. Diaphragm plication was offered for symptom control. Subsequent follow-up was undertaken to determine the incidence of spontaneous recovery of diaphragm function and the benefits of diaphragm plication. RESULTS Seven hundred and eighty-three patients underwent high mobilization of the RIMA with proximal detachment for use as a free graft. Thirty-one patients with right hemidiaphragm dysfunction were identified in the postoperative period providing an injury incidence of 4% (confidence interval, 2.6% to 5.3%). Of these, 12 patients underwent diaphragm plication (4 early and 8 late), 14 patients achieved spontaneous recovery, and 5 patients were lost to follow-up. The supine to upright forced vital capacity ratios at the time of phrenic nerve dysfunction, after diaphragm plication, and after spontaneous recovery were 0.79, 0.90, and 0.96 respectively. CONCLUSIONS The incidence of phrenic nerve injury associated with high RIMA harvesting was 4% but spontaneous recovery may be anticipated in two thirds (14 of 22) of patients in whom the injury is identified postoperatively. High RIMA harvesting should be used with caution in patients with preoperative pulmonary dysfunction in whom phrenic nerve injury would be poorly tolerated.
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Affiliation(s)
- Yongzhi Deng
- Department of Cardiothoracic Surgery, Westmead Hospital, Westmead, New South Wales, Australia
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Tokuda Y, Matsumoto M, Sugita T, Nishizawa J, Matsuyama K, Yoshida K, Matsuo T. Bilateral diaphragmatic paralysis after aortic surgery with topical hypothermia: Ventilatory assistance by means of nasal mask bilevel positive pressure. J Thorac Cardiovasc Surg 2003; 125:1158-9. [PMID: 12771892 DOI: 10.1067/mtc.2003.297] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Yoshiyuki Tokuda
- Departments of Cardiovascular Surgery, Tenri Hospital, Nara, Japan.
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Miñambres E, García García A, Rodriguez Borregan J, Antolínez Eizaguirre X, Gutiérrez Morlote J, San José Garagarza J. [Bilateral diaphragm paralysis after cardiac surgery]. Arch Bronconeumol 2001; 37:454-6. [PMID: 11734128 DOI: 10.1016/s0300-2896(01)75117-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report two cardiac surgery patients on whom local hypothermia with slushed ice for myocardial protection was used. Bilateral diaphragm paralysis with respiratory failure occurred. In both cases, neurophysiologic studies have been used for the diagnosis. Prolonged ventilatory support was required for several weeks and they were totally recovered after months.
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Affiliation(s)
- E Miñambres
- Departamento de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria.
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Sharma AD, Parmley CL, Sreeram G, Grocott HP. Peripheral nerve injuries during cardiac surgery: risk factors, diagnosis, prognosis, and prevention. Anesth Analg 2000; 91:1358-69. [PMID: 11093980 DOI: 10.1097/00000539-200012000-00010] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- A D Sharma
- Department of Anesthesiology, Duke University Medical Center, and Durham Veterans Affairs Medical Center, Durham, North Carolina 27710, USA
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van Onna IE, Metz R, Jekel L, Woolley SR, van de Wal HJ. Post cardiac surgery phrenic nerve palsy: value of plication and potential for recovery. Eur J Cardiothorac Surg 1998; 14:179-84. [PMID: 9755004 DOI: 10.1016/s1010-7940(98)00147-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVES Evaluation of an aggressive policy for the treatment of phrenic nerve palsy (PNP), following cardiac operations, with emphasis on early diaphragmatic plication. Attention was given to the incidence and predisposing factors for PNP and the potential for recovery following plication. METHODS From 1 June 1991 to 1 January 1996 we prospectively screened patients for PNP following cardiac surgery. The diagnosis was suspected if difficulty was experienced in weaning the child from the ventilator. If abnormal elevation of the hemidiaphragm was present diaphragmatic plication was performed. Echocardiography was used to assess subsequent return of diaphragmatic function. RESULTS Seventeen children (nine boys, eight girls), out of 867 (1.9%) children younger than 16 years of age, undergoing cardiac operations were found to have PNP. The mean age was 66 days (range 1-17 months) with 16 patients below 1 year out of a total of 285 patients (incidence 5.6%) and one patient 17 months old. The incidence following open procedures was 11/190, following closed procedures 2/95 and following reoperation 4/83. PNP was diagnosed from 2 to 44 days (mean 14 days) following surgery. It was present on the right side in seven cases, the left in nine and was bilateral in one patient. Two patients were extubated at the time of diagnosis, one patient could be extubated shortly thereafter. Fourteen children underwent diaphragmatic plication, at a median 5 days post diagnosis. Extubation was possible 1-60 days (mean 4 days) after plication. Mean follow-up was 19 +/- 5 months. Subsequent recovery of diaphragmatic movement was documented in seven (41%) children. Time to recovery following plication was 16 months, without plication 38 months. CONCLUSION Prospective screening for PNP revealed an incidence in children younger than 1 year of 6%. Early plication substantially reduces the duration of ventilation, with its associated reduced morbidity and ICU stay.
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Affiliation(s)
- I E van Onna
- Paediatric Heart Center, Wilhelmina Children's Hospital, Utrecht University, The Netherlands
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Dimopoulou I, Daganou M, Dafni U, Karakatsani A, Khoury M, Geroulanos S, Jordanoglou J. Phrenic nerve dysfunction after cardiac operations: electrophysiologic evaluation of risk factors. Chest 1998; 113:8-14. [PMID: 9440560 DOI: 10.1378/chest.113.1.8] [Citation(s) in RCA: 90] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND STUDY OBJECTIVE Phrenic nerve injury may occur after cardiac surgery; however, its cause has not been extensively investigated with electrophysiology. The purpose of this study was to determine by electrophysiologic means the importance of various possible risk factors in the development of phrenic nerve dysfunction after cardiac surgical operations. DESIGN A prospective study was conducted. SETTING A tertiary teaching hospital provided the background for the study. PATIENTS Sixty-three cardiac surgery patients on whom surgical operations were performed by the same surgical team constituted the study group. Mean (+/-SD) age and ejection fraction were 63+/-5 years and 50+/-10%, respectively. INTERVENTIONS Measurement of phrenic nerve conduction latency time after transcutaneous stimulation preoperatively and at 24 h and 7 and 30 days postoperatively. RESULTS Thirteen patients had abnormal phrenic nerve function postsurgery, 12 on the left side and one bilaterally. Logistic regression analysis revealed that among the potential risk factors investigated, use of ice slush for myocardial preservation was the only independent risk factor related to phrenic nerve dysfunction (p=0.01), carrying an 8-fold higher incidence for this complication. In contrast, age, ejection fraction of the left ventricle, operative/bypass/aortic cross-clamp time, left internal mammary artery use, and diabetes mellitus were not found to be associated with phrenic neuropathy. The postoperative outcome of patients who received ice slush compared with that of those who had cold saline solution did not differ in terms of early morbidity and mortality. CONCLUSION Among the risk factors investigated, only the use of ice slush was significantly associated with postoperative phrenic nerve dysfunction. Therefore, ice should be avoided in cardiac surgery, since it does not seem to provide additional myocardial protection.
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Affiliation(s)
- I Dimopoulou
- Second Cardiac Surgery Department, Onassis Cardiac Surgery Center, Athens, Greece
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Mazzoni M, Solinas C, Sisillo E, Bortone F, Susini G. Intraoperative phrenic nerve monitoring in cardiac surgery. Chest 1996; 109:1455-60. [PMID: 8769493 DOI: 10.1378/chest.109.6.1455] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Left hemidiaphragmatic paralysis due to phrenic nerve lesion is a frequent complication of hypothermic cardiopulmonary bypass. Although this is believed to be caused by cold injury to the phrenic nerve, its exact cause is still not clear. STUDY OBJECTIVE To assess feasibility, safety, and usefulness of intraoperative phrenic nerve function monitoring. SETTING Elective cardiac surgery in a university hospital. PATIENTS Consenting patients scheduled for myocardial revascularization surgery with the use of the left internal mammary artery. DESIGN Intraoperative monitoring of compound diaphragmatic action potentials (CDAPs) through transcutaneous stimulation of phrenic nerves. INTERVENTIONS Patients were divided in two groups. Group 1 received intracoronary cold St. Thomas's solution as the only cardioplegic method. Group 2 received topical cardiac cooling with ice-cold solutions in addition to intracoronary cardioplegia. RESULTS In all group 1 patients, function of phrenic nerves was maintained throughout the surgical procedure. Group 2: in two patients, bilateral, and in one patient, left phrenic nerve conduction was abolished after submersion of the heart in ice-cold solution. In two of them, the action potential of the left hemidiaphragm was absent by the end of surgery. In one, nerve conduction recovered with rewarming of the patient. DISCUSSION Intraoperative monitoring of CDAP was safe and easily obtained in the intraoperative setting. It allowed us to observe changes in phrenic nerve conduction occurring during surgery and as a result of cold cardioplegia. Cryogenic lesion of phrenic nerve might explain our findings. However, nerve ischemia cannot be ruled out and it may worsen axonal damage or delay its recovery. COMMENT This monitoring method allowed us to predict postoperative diaphragmatic dysfunction. Also, surgeons can be warned of the damaging effects of excessive cooling of the pericardium and surrounding structures; thus, preventive measures can be taken.
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Affiliation(s)
- M Mazzoni
- Department of Anesthesia and Intensive Care Unit, IRCCS Centro Cardiologico Fondazione Italo Monzino, Milano, Italy
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Abstract
We report the case of a 51-year-old man who presented with breathlessness on exertion and orthopnoea in association with Type 2 diabetes mellitus. Investigation showed bilateral diaphragmatic paralysis due to phrenic neuropathy. There was no evidence of neuropathy or microvascular disease elsewhere. Phrenic neuropathy may be an important, albeit rare, complication of diabetes and diaphragmatic function should be considered in any patient with unexplained breathlessness and orthopnoea.
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Affiliation(s)
- J E White
- Department of Respiratory Medicine, Freeman Hospital, Newcastle upon Tyne, England
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Gordon PC, Bateman ED, Linton DM. Bilateral phrenic nerve palsy following cardiac surgery in a diabetic patient. Anaesth Intensive Care 1992; 20:511-4. [PMID: 1463185 DOI: 10.1177/0310057x9202000423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- P C Gordon
- Department of Anaesthesia, University of Cape Town, South Africa
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