PR2-166
A Case of Horner's Syndrome Following an Infraclavicular Nerve Block and Catheter Placement in a Two-year Old Female
McCambridge T, Lo C
Children's Hospital Los Angeles, Keck School of Medicine at USC, Los Angeles, CA, USA
Introduction: Horner’s syndrome results from ipsilateral paralysis of the cervical chain. Causes include compression, trauma, inadequate perioperative positioning, and local anesthetics. Horner’s syndrome usually results from interscalene and supraclavicular blocks. Few case reports of Horner’s exist following infraclavicular blocks in adults, but it has never been described in the pediatric literature (1,2).
Case Description: A 2 yo, 11.3kg female was scheduled for a left hand reconstruction. After induction of GA, an U/S-guided infraclavicular nerve block was performed. Forearm contractions using nerve stimulation were lost at 0.6 mA, and a nerve catheter was placed 7.5 cm from the skin. It was bolused with 3 mLs of 1% lidocaine, and 2.5 mLs of 0.15% ropivacaine, and an infusion of ropivacaine 0.15% at 2.5 mLs/hr was continued during the case and postoperatively. Shortly after surgery, the patient developed ipsilateral ptosis and miosis. The catheter did not migrate, and the patient did not complain of any side effects. Pain scores were adequate during the hospitalization, and the catheter was removed POD#3, and symptoms resolved.
Discussion: This case report is the first in the literature to describe an infraclavicular block causing Horner’s syndrome in the pediatric population.
The mechanism causing Horner’s syndrome following LA injection for a nerve block is related to the block type, the volume of LA, and the anatomy of the brachial plexus and surrounding sheaths. Local anesthetic spread remains mostly superior to the clavicle for supraclavicular and interscalene blocks, and below the clavicle for infraclavicular blocks (3).
Anatomic variations may explain the development of Horner’s syndrome after an infraclavicular block. Where one study showed that the brachial plexus is completely encased in a continuous sheath from the interscalene grove to the axilla, another showed that the connective tissue could be divided into two compartments (4, 5).
Literature describing Horner’s syndrome in the pediatric population is limited. Regarding our patient, we hypothesize that the spread of local anesthetic and the development of Horner’s syndrome may have been secondary to an anatomic variation. Other causes may have been a prolonged tourniquet time or catheter migration.
References:
1. Walid T et al. A Case of Horner's Syndrome following Ultrasound-Guided Infraclavicular Brachial Plexus Block. Case Rep Anesthesiol. 2012
2. Salengros JC et al. Delayed Horner's syndrome during a continuous infraclavicular brachial plexus block. J Clin Anesth. 2007 Feb; 19(1):57-9.
3. Rodriguez J et al. Restricted infraclavicular distribution of the local anesthetic solution after infraclavicular brachial plexus block. Reg Anesth Pain Med, 28 (2003)
4. Winnie AP. Interscalene brachial plexus block. Anesth Analg, 49 (1970)
5. Beck H et al. The dual compartment construction of the brachial plexus sheath: an anatomical study and its clinical implications. Reg Anesth, 15 (1990)
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