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Peripheral nerve injury after peripheral nerve blockade in patients with previous systemic chemotherapy

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Perioperative Nerve Injury after Peripheral Nerve Blockade in Patients with Previous Systemic Chemotherapy

Arney S. Abcejo, M.D., Hans P. Sviggum, M.D., James R. Hebl, M.D., Adam K. Jacob, M.D.
Department of Anesthesiology

Mayo Clinic, Rochester, MN

Objectives:

•Identify perioperative nerve injury (PNI) in patients who have received peripheral nerve blockade (PNB) after receiving systemic chemotherapy
•Estimate the incidence of PNI in patients undergoing PNB after receiving systemic chemotherapy
 
Introduction:
•Several anesthetic, surgical, and patient-related factors, including PNB, may increase the risk for PNI
•Many chemotherapeutic drugs have been associated with peripheral neuropathy, though the pathophysiology for several drugs is unclear1
•Unknown if patients who received chemotherapy are at higher risk for PNI following PNB compared to patients that have not received chemotherapy
 
Methods:
•All adults who received systemic chemotherapy between January 2000 and April 2012 and subsequently underwent perioperative PNB at Mayo Clinic, Rochester MN, were retrospectively identified.
•Patients were excluded for incomplete records, primary neuraxial anesthesia, age <18 years
•Each electronic medical record was  searched for key terms relating to nerve injury, then manually reviewed to confirm  PNI
•Primary outcome was defined as the presence of new or worsened PNI within three months of the procedural date
•Each PNI graded as “possibly” or “unlikely” related to the PNB independently by 2 reviewers based on location of injury, EMG correlation (if obtained), and injury characteristics
 
Results:
•12,649 patients received ≥ 1 chemotherapeutic drugs during 12-year period
  •1,154 patients received a regional block (including neuraxial blockade)
  •968 patients met one or more exclusion criteria
•186 patients included for study analysis (Table 2)
•64 potential case of PNI were identified during the initial EMR search
•Upon review, 4 cases met criteria for new or worsening PNI (2.15%; 95%CI 0.84-5.40%) (Table 1)
  •Excellent agreement between the reviewers (96.9% agreement, kappa 0.786)
•2 cases were categorized as “possibly” related to the PNB (1.08%; 95%CI 0.30-3.84%)
 
Discussion:
•This study identified a PNI rate of 2.15% in patients with previous systemic chemotherapy exposure undergoing extremity surgery with PNB. This is comparable to previous large cohort studies using similar methodology.
•Incidence of PNI possibly attributable to PNB in this study (1.08%) is approximately 40 times higher than previous large scale studies1
•Study limitations: retrospective study design, limited sample size
 
Conclusions:
•PNI was possibly attributable to the PNB in 1.08% of patients, approximately 40 times higher than the previously reported incidence of PNI after PNB
•Potential increased risk for PNI in this population warrants a thoughtful discussion between patients and providers when contemplating the use of a peripheral regional anesthetic technique
 
References:
1.Auroy Y, et. al.  Major complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service. Anesthesiology. 2002; 97: 1274-80
2.Hebl JR, et al.  Diffuse brachial plexopathy after interscalene block in a patient receiving cisplatin chemotherapy: the pharmacologic double crush syndrome. Anes Analg.  2001; 92: 249-51
3.Sviggum HP, et al. Perioperative nerve injury after total shoulder arthroplasty: assessment of risk after regional anesthesia. Reg Anesth Pain Med. 2012; 37: 490-4
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