Role of perioperative diaphragmatic point-of-care ultrasound in assessing postoperative pulmonary complications in brachial plexus repair surgeries with preexisting hemidiaphragm paresis: A prospective observational study

Abstract Background and Aims: A brachial plexus injury (BPI) with phrenic nerve involvement causes hemidiaphragm paresis and subclinical respiratory problems. Surgical traction and anesthetic agents employed during brachial plexus repair may further worsen diaphragm function, complicating extubation and increasing postoperative pulmonary complication (PPC) risk. Point-of-care ultrasound (POCUS) provides rapid, bedside assessment of diaphragm function but has not been evaluated in BPI repair surgery. Hence, this study evaluated the role of perioperative diaphragmatic POCUS (PDPOCUS) for determining PPC incidence as the primary objective in BPI repair surgeries with preexisting chronic hemidiaphragm paresis. Secondary objectives included assessment of diaphragm dysfunction contributing to PPC. Material and Methods: This prospective observational study recruited 60 patients with chronic hemidiaphragm paresis undergoing BPI repair surgeries under propofol-dexmedetomidine total intravenous anesthesia (TIVA) without muscle relaxants. PDPOCUS was employed to measure diaphragm excursion (DE), diaphragm thickness (DT), and diaphragm thickness fraction (DTF) bilaterally and to compare between the two sides and preoperative versus postoperative values. PPCs were followed till 3 postoperative days. Results: All 60 patients exhibited lower diaphragm parameters in the affected side than the normal side ( P < 0.05) (100% diaphragm dysfunction incidence) except for DT during expiration preoperatively, reflecting paresis. Postoperatively, the normal hemidiaphragm showed a significant fall in DE during deep breathing ( P = 0.042), DT during inspiration ( P = 0.001), and DTF ( P = 0.031) but remained near normal, implying no new dysfunction. Only two patients desaturated postoperatively within 24 hours and required oxygen support, indicating 3.33% incidence of PPC. Conclusions: PDPOCUS reliably assesses perioperative diaphragmatic dysfunction in brachial plexus repair surgeries with preexisting hemidiaphragm paresis. PPC incidence is low with propofol-dexmedetomidine TIVA and meticulous microsurgical techniques, which preserve diaphragm integrity and promote safe extubation under POCUS guidance, despite chronic paresis, but large trials are needed.