Top

Published in:

01-08-2006 | Pediatric Original

Postoperative phrenic nerve palsy: early clinical implications and management

Authors: Julia Lemmer, Brigitte Stiller, Grit Heise, Michael Hübler, Vladimir Alexi-Meskishvili, Yuguo Weng, Matthias Redlin, Valerie Amann, Stanislav Ovroutski, Felix Berger

Published in: Intensive Care Medicine | Issue 8/2006

Abstract

Objective

We examined the clinical impact of diaphragmatic palsy (DP) as a result of phrenic nerve injury following cardiothoracic surgery, specifically its effects on morbidity and mortality, early regeneration capacity of the phrenic nerve, and role of surgical diaphragmatic plication.

Methods

A retrospective case control study was performed in 74 children with DP and 74 matched controls after cardiothoracic surgery within the past 14 years.

Results

Following 5,128 surgical procedures in children (aged under 18 years) we found an incidence of DP of 1.4%. There were no differences in mortality between the groups, and the cause of death was not related to DP or plication in any of the patients. However, patients with diaphragm impairment had significantly longer duration of mechanical ventilation (median 3 days vs. 1), ICU stay (7 days vs. 3.5), duration of hospital stay (16 days vs. 12), and for antibiotic treatment (16 days vs. 7). Because of prolonged respiratory problems 40 children (54%) underwent surgical diaphragmatic plication to flatten the diaphragm in its inspiratory position. In children with DP younger age was a strong predictor for plication (median 3.8 months vs. 12.1).

Conclusions

Especially in newborns and young infants with DP the length of mechanical ventilation, ICU stay, and hospital stay are prolonged. Early spontaneous recovery of the phrenic nerve is rare. In cases of respiratory impairment early transthoracic diaphragmatic plication is an effective means of treatment.

Schwartz MZ, Filler RM (1978) Plication of the diaphragm for symptomatic phrenic nerve paralysis. J Pediatr Surg 13:259–263PubMedCrossRef

Shoemaker R, Palmer G, Brown JW, King H (1981) Aggressive treatment of acquired phrenic nerve paralysis in infants and small children. Ann Thorac Surg 32:250–259PubMedCrossRef

Amin Z, McElhinney DB, Strawn JK, Kugler JD, Duncan KF, Reddy VM, Petrossian E, Hanley FL (2001) Hemidiaphragmatic paralysis increases postoperative morbidity after a modified Fontan operation. J Thorac Cardiovasc Surg 122:856–862PubMedCrossRef

Bandla HP, Hopkins RL, Beckerman RC, Gozal D (1999) Pulmonary risk factors compromising postoperative recovery after surgical repair for congenital heart disease. Chest 116:740–747PubMedCrossRef

Leeuw M de, Williams JM, Freedom RM, Williams WG, Shemie SD, McCrindle BW (1999) Impact of diaphragmatic paralysis after cardiothoracic surgery in children. J Thorac Cardiovasc Surg 118:510–517PubMedCrossRef

Mok Q, Ross-Russell R, Mulvey D, Green M, Shinebourne EA (1991) Phrenic nerve injury in infants and children undergoing cardiac surgery. Br Heart J 65:287–292PubMedCrossRef

van Onna IE, Metz R, Jekel L, Woolley SR, van de Wal HJ (1998) Post cardiac surgery phrenic nerve palsy: value of plication and potential for recovery. Eur J Cardiothorac Surg 14:179–184PubMedCrossRef

Tonz M, von Segesser LK, Mihaljevic T, Arbenz U, Stauffer UG, Turina MI (1996) Clinical implications of phrenic nerve injury after pediatric cardiac surgery. J Pediatr Surg 31:1265–1267PubMedCrossRef

Riccabona M, Sorantin E, Ring E (1998) Application of M-mode sonography to functional evaluation in pediatric patients. Eur Radiol 8:1457–1461PubMedCrossRef

10.

Mickell JJ, Oh KS, Siewers RD, Galvis AG, Fricker FJ, Mathews RA (1978) Clinical implications of postoperative unilateral phrenic nerve paralysis. J Thorac Cardiovasc Surg 76:297–304PubMed

11.

Watanabe T, Trusler GA, Williams WG, Edmonds JF, Coles JG, Hosokawa Y (1987) Phrenic nerve paralysis after pediatric cardiac surgery. Retrospective study of 125 cases. J Thorac Cardiovasc Surg 94:383–388PubMed

12.

Hamilton JR, Tocewicz K, Elliott MJ, de Leval M, Stark J (1990) Paralysed diaphragm after cardiac surgery in children: value of plication. Eur J Cardiothorac Surg 4:487–490PubMedCrossRef

13.

Andrews P, Azoulay E, Antonelli M, Brochard L, Brun-Buisson C, Dobb G, Fagon JY, Gerlach H, Groeneveld J, Mancebo J, Metnitz P, Nava S, Pugin J, Pinsky M, Radermacher P, Richard C, Tasker R, Vallet B (2005) Year in review in intensive care medicine, 2004. I. Respiratory failure, infection, and sepsis. Intensive Care Med 31:28–40PubMedCrossRef

14.

Salam A, Tilluckdharry L, Amoateng-Adjepong Y, Manthous CA (2004) Neurologic status, cough, secretions and extubation outcomes. Intensive Care Med 30:1334–1339PubMedCrossRef

15.

Kizilcan F, Tanyel FC, Hicsonmez A, Buyukpamukcu N (1993) The long-term results of diaphragmatic plication. J Pediatr Surg 28:42–44PubMedCrossRef

16.

Marcos JJ, Grover FL, Trinkle JK (1974) Paralyzed diaphragm-effect of plication on respiratory mechanics. J Surg Res 16:523–526PubMedCrossRef

17.

Takeda S, Nakahara K, Fujii Y, Matsumura A, Minami M, Matsuda H (1995) Effects of diaphragmatic plication on respiratory mechanics in dogs with unilateral and bilateral phrenic nerve paralyses. Chest 107:798–804PubMedCrossRef

18.

Muller NL, Bryan AC (1979) Chest wall mechanics and respiratory muscles in infants. Pediatr Clin North Am 26:503–516PubMed

19.

Penny DJ, Redington AN (1991) Doppler echocardiographic evaluation of pulmonary blood flow after the Fontan operation: the role of the lungs. Br Heart J 66:372–374PubMedCrossRef

20.

Redington AN, Penny D, Shinebourne EA (1991) Pulmonary blood flow after total cavopulmonary shunt. Br Heart J 65:213–217PubMedCrossRef

21.

Ovroutski S, Alexi-Meskishvili V, Stiller B, Ewert P, Abdul-Khaliq H, Lemmer J, Lange PE, Hetzer R (2005) Paralysis of the phrenic nerve as a risk factor for suboptimal Fontan hemodynamics. Eur J Cardiothorac Surg 27:561–565PubMedCrossRef

22.

Iverson LI, Mittal A, Dugan DJ, Samson PC (1976) Injuries to the phrenic nerve resulting in diaphragmatic paralysis with special reference to stretch trauma. Am J Surg 132:263–269PubMedCrossRef

23.

Ciccolella DE, Daly BD, Celli BR (1992) Improved diaphragmatic function after surgical plication for unilateral diaphragmatic paralysis. Am Rev Respir Dis 146:797–799PubMed

24.

Yellin A, Lieberman Y, Barzilay Z (1991) Postoperative unilateral diaphragmatic paralysis in children, a plea for early plication. Thorac Cardiovasc Surg 39:221–223PubMedCrossRef

25.

Joho-Arreola AL, Bauersfeld U, Stauffer UG, Baenziger O, Bernet V (2005) Incidence and treatment of diaphragmatic paralysis after cardiac surgery in children. Eur J Cardiothorac Surg 27:53–57PubMedCrossRef

26.

Affatato A, Villagra F, De Leon JP, Gomez R, Checa SL, Vellibre D, Sanchez P, Diez Balda JI, Brito JM (1988) Phrenic nerve paralysis following pediatric cardiac surgery. Role of diaphragmatic plication. J Cardiovasc Surg (Torino) 29:606–609

27.

Haller JA Jr, Pickard LR, Tepas JJ, Rogers MC, Robotham JL, Shorter N, Shermeta DW (1979) Management of diaphragmatic paralysis in infants with special emphasis on selection of patients for operative plication. J Pediatr Surg 14:779–785PubMedCrossRef

28.

Kunovsky P, Gibson GA, Pollock JC, Stejskal L, Houston A, Jamieson MP (1993) Management of postoperative paralysis of diaphragm in infants and children. Eur J Cardiothorac Surg 7:342–346PubMedCrossRef

Title: Postoperative phrenic nerve palsy: early clinical implications and management
Authors: Julia Lemmer
Brigitte Stiller
Grit Heise
Michael Hübler
Vladimir Alexi-Meskishvili
Yuguo Weng
Matthias Redlin
Valerie Amann
Stanislav Ovroutski
Felix Berger
Publication date: 01-08-2006
Publisher: Springer-Verlag
Published in: Intensive Care Medicine / Issue 8/2006
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-006-0208-4

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Postoperative phrenic nerve palsy: early clinical implications and management

Abstract

Objective

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Objective

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 8/2006

Persisting low monocyte human leukocyte antigen-DR expression predicts mortality in septic shock

Drotrecogin alfa in tropical infections and refractory multi-organ failure

Stress ulcer prophylaxis in mechanically ventilated patients: integrating evidence and judgment using a decision analysis

Is the measurement of monocytes HLA-DR expression useful in patients with sepsis?

Sedation and analgesia in German intensive care units: how is it done in reality? Results of a patient-based survey of analgesia and sedation

Sedation and analgesia in the PICU: many questions remain