Acute respiratory failure after deep cervical plexus block for carotid endarterectomy as a result of bilateral recurrent laryngeal nerve paralysis

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Abstract
We report about a case of acute respiratory distress (73‐year‐old female), which occurred minutes after a deep cervical plexus block (40 ml ropivacaine 0.5%) for carotid endarterectomy (CEA) and required immediate endotracheal intubation of the patient's trachea and consecutive mechanical ventilation. Subsequently, CEA was performed under general anaesthesia (TIVA) with continuous monitoring by somatosensory‐evoked potentials. After a period of 14 hours, the endotracheal tube could be removed, the patient being in fair respiratory, cardiocirculatory and neurological conditions. Retrospectively, acute respiratory distress was caused by a combination of ipsilateral plexus blockade‐induced and pre‐existing asymptomatic contralateral recurrent laryngeal nerve (RLN) paralysis confirmed by a postoperative ENT‐check and related to previous thyroid surgery more than 50 years ago. RLN paralysis, often being asymptomatic, represents a typical complication of thyroid and other neck surgery with reported incidences of 0.5–3%. Therefore, a thorough preoperative airway check is advisable in all patients scheduled for a cervical plexus block. Particularly in cases with a history of respiratory disorders or previous neck surgery a vocal cord examination is recommended, and the use of a superficial cervical plexus block may lower the risk of respiratory complications. This may prevent a possibly life‐threatening coincidence of ipsilateral plexus blockade‐induced and pre‐existing asymptomatic contralateral RLN paralysis.