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Abstract
This article aims to review the current anaesthetic management of tracheal resections.Apart from the "traditional" approach of induction of general anaesthesia with conventional tracheal intubation and cross-field intubation or jet ventilation during the resection phase, there has lately been a trend towards less invasive techniques.Regional anaesthesia, laryngeal mask airways and preservation of spontaneous ventilation are among the new anaesthetic approaches. Current data suggest potential advantages compared with conventional tracheal intubation.Extracorporeal membrane oxygenation may provide adequate gas exchange and/or cardiovascular support for complex resections and reconstructions. In addition, it may serve as a reliable "backup" technique, in case of oxygenation difficulties with the use of other devices.Given the vast spectrum of different anaesthetic approaches to tracheal surgery, interdisciplinary planning is essential to identify the optimal technique on a case-by-case basis. During that process, the localisation and consistency of the airway lesion, comorbidities and the functional status of the respiratory system and specific surgical approach need to be taken into account.As there is a lack of high-quality data, evidence-based comparisons of different anaesthetic techniques are not possible.
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Affiliation(s)
- Marc Schieren
- Klinik für Anästhesiologie und operative Intensivmedizin, Kliniken der Stadt Köln gGmbH, Köln, Deutschland
| | - Erich Stoelben
- Thoraxklinik Köln, St. Hildegardis Krankenhaus, Köln, Deutschland
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Coral G, Ayala M. Cervical Epidural Anesthesia Combined with Sedation for Neck Cancer Surgery: A Case Report. A A Pract 2024; 18:e01775. [PMID: 38572891 DOI: 10.1213/xaa.0000000000001775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
Cervical epidural anesthesia (CEA) is a well-established technique and is suitable for various surgeries, including carotid, thyroid, airway, neck cancer, breast, and upper limb procedures. We report the case of an elderly woman with a recurrent neck mass secondary to metastatic papillary thyroid carcinoma causing neurovascular compression, who underwent surgery under CEA. Five milliliters of 0.5% bupivacaine and 5 mL of 2% lidocaine (total 10 mL) were administered into the cervical epidural space. Combined with sedation, CEA in our case provided optimal anesthetic conditions, maintaining spontaneous ventilation, preventing airway collapse, ensuring patient comfort, and facilitating surgery.
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Affiliation(s)
- Gina Coral
- From the Department of Anesthesiology, Hospital Universitario San José Infantil, University Foundation Health Sciences, Bogotá, Colombia
| | - Marcela Ayala
- Department of Anesthesiology, University Foundation Health Sciences, Bogotá, Colombia
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Schieren M, Wappler F, Defosse J. Anesthesia for tracheal and carinal resection and reconstruction. Curr Opin Anaesthesiol 2022; 35:75-81. [PMID: 34873075 DOI: 10.1097/aco.0000000000001082] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to provide an overview of current anesthetic management of tracheal and carinal resection and reconstruction. RECENT FINDINGS In addition to the traditional anesthetic approach using conventional tracheal intubation after induction of general anesthesia and cross-field intubation or jet-ventilation once the airway has been surgically opened, there is a trend toward less invasive anesthetic procedures. Regional anesthetic techniques and approaches focusing on the maintenance of spontaneous respiration have emerged. Especially for cervical tracheal stenosis, laryngeal mask airways appear to be an advantageous alternative to tracheal intubation.Extracorporeal support can ensure adequate gas exchange and/or perfusion during complex resections and reconstructions without interference of airway devices with the operative field. It also serves as an effective rescue technique in case other approaches fail. SUMMARY The spectrum of available anesthetic techniques for major airway surgery is immense. To find the safest approach for the individual patient, comprehensive interdisciplinary planning is essential. The location and anatomic consistency of the stenosis, comorbidities, the functional status of respiratory system, as well as the planned reconstructive technique need to be considered. Until more data is available, however, a reliable evidence-based comparison of different approaches is not possible.
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Affiliation(s)
- Mark Schieren
- University Witten/Herdecke, Medical Centre Cologne-Merheim, Department of Anesthesiology and Intensive Care Medicine, Cologne, Germany
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Cho H, Kwon H, Song S, Yoo J, Kim M, Park S, Chung J, Kim S, Park S, Ok S. Quality of postoperative recovery after upper-arm vascular surgery for hemodialysis in patients with end-stage renal disease: A prospective comparison of cervical epidural anesthesia vs general anesthesia. Medicine (Baltimore) 2020; 99:e18773. [PMID: 32011469 PMCID: PMC7220058 DOI: 10.1097/md.0000000000018773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cervical epidural anesthesia (CEA) is generally not used during upper-arm vascular surgery for hemodialysis in end-stage renal disease (ESRD) patients, despite its advantages. The Quality of Recovery-40 questionnaire (QOR-40) has been validated as a tool for assessing the degree of recovery after surgery. We hypothesized that CEA could provide a better outcome on the QOR-40 than general anesthesia after upper-arm vascular surgery for hemodialysis in ESRD patients.We divided anesthetic methods into general anesthesia and CEA. The QOR-40 was administered to 70 patients on the night before surgery and at 24 hours after surgery. Additional data, including consumption of opioid analgesics, occurrence of postoperative nausea and vomiting, and scores on a numeric rating scale (NRS) were collected.The total QOR-40 scores of the two groups differed significantly (P = .024) on postoperative day 1. Opioid consumption (P = .005) and occurrence of postoperative nausea (P = .019) in the post-anesthesia care unit (PACU) were significantly lower in the CEA group, whose NRS scores were significantly lower in the PACU (P < .001) and at postoperative day 1 (P = .016).Assessment of postoperative quality of recovery after upper-arm vascular surgery in ESRD patients showed that the CEA group had significantly better total QOR-40 and NRS scores. CEA could be used as an alternative anesthetic technique for upper-arm vascular surgery for hemodialysis in ESRD patients to improve the quality of recovery.
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Affiliation(s)
- Hobum Cho
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul,
| | - Hyerim Kwon
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul,
| | - Sanghoon Song
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul,
| | - Jaehwa Yoo
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul,
| | - Mungyu Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul,
| | - Sunyoung Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul,
| | - Jiwon Chung
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul,
| | - Sangho Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul,
| | - Suyeon Park
- Department of Biostatistics, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Siyoung Ok
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Hospital Seoul,
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Stillman MW, Whittaker AL. Use and Efficacy of Analgesic Agents in Sheep ( Ovis aries) Used in Biomedical Research. JOURNAL OF THE AMERICAN ASSOCIATION FOR LABORATORY ANIMAL SCIENCE 2019; 58:755-766. [PMID: 31604483 DOI: 10.30802/aalas-jaalas-19-000036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Sheep (Ovis aries) are widely used as large animal models in biomedical research. However, current literature on the use of analgesics in sheep generally focuses on an industry or farm level of use. This structured review evaluates use and efficacy of analgesics administered to sheep in a biomedical research setting. Electronic databases were searched with terms related to analgesia in research sheep. After application of exclusion criteria, 29 peer-reviewed publications were evaluated from 1995 to 2018. Drugs used for analgesia in sheep include opioids, α₂ agonists, NSAID, local anesthetics, NMDA receptor antagonists, and calcium channel blockers. Opioid agonists have previously been considered short acting and of questionable efficacy in sheep, but newer modalities may provide effective analgesia. NSAID may exhibit an analgesic effect only when inflammatory pain is present and may not be beneficial for use in acute pain models. α₂ agonists provide effective yet short-lived analgesia; however, side effects are of concern. Local anesthetics were previously widely used as stand-alone agents, as alternatives to the use of general anesthetics in sheep. These agents have since fallen out of favor as sole agents. Despite this, they provide a valuable analgesic effect when used as adjuncts to general anesthetic regimes. The NMDA antagonist ketamine provided good analgesia and is likely underutilized as an analgesic agent in sheep. Future controlled studies should further evaluate the analgesic properties of ketamine in sheep.
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Affiliation(s)
- Mark W Stillman
- School of Animal and Veterinary Sciences, University of Adelaide, Adelaide, Australia
| | - Alexandra L Whittaker
- School of Animal and Veterinary Sciences, University of Adelaide, Adelaide, Australia;,
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Monnig A, Budhrani G. Anesthesia for Carotid Endarterectomy. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Schieren M, Böhmer A, Dusse F, Koryllos A, Wappler F, Defosse J. New Approaches to Airway Management in Tracheal Resections-A Systematic Review and Meta-analysis. J Cardiothorac Vasc Anesth 2017; 31:1351-1358. [PMID: 28800992 DOI: 10.1053/j.jvca.2017.03.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Although endotracheal intubation, surgical crossfield intubation, and jet ventilation are standard techniques for airway management in tracheal resections, there are also reports of new approaches, ranging from regional anesthesia to extracorporeal support. The objective was to outline the entire spectrum of new airway techniques. DESIGN The literature databases PubMed/Medline and the Cochrane Library were searched systematically for prospective and retrospective trials as well as case reports on tracheal resections. SETTING No restrictions applied to hospital types or settings. PARTICIPANTS Adult patients undergoing surgical resections of noncongenital tracheal stenoses with end-to-end anastomoses. INTERVENTIONS Airway management techniques were divided into conventional and new approaches and analyzed regarding their potential risks and benefits. MEASUREMENTS AND MAIN RESULTS A total of 59 publications (n = 797 patients) were included. The majority of publications (71.2%) describe conventional airway techniques. Endotracheal tube placement after induction of general anesthesia and surgical crossfield intubation after incision of the trachea were used most frequently without major complications. A total of 7 new approaches were identified, including 4 different regional anesthetic techniques (25 cases), supraglottic airways (4 cases), and new forms of extracorporeal support (25 cases). Overall failure rates of new techniques were low (1.8%). Details on patient selection and procedural specifics are provided. CONCLUSIONS New approaches have several theoretical benefits, yet further research is required to establish criteria for patient selection and evaluate procedural safety. Given the low level of evidence, it currently is impossible to compare methods of airway management regarding outcome-related risks and benefits.
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Affiliation(s)
- Mark Schieren
- Department of Anesthesiology and Intensive Care Medicine, University Witten/Herdecke, Medical Centre Cologne-Merheim, Cologne, Germany.
| | - Andreas Böhmer
- Department of Anesthesiology and Intensive Care Medicine, University Witten/Herdecke, Medical Centre Cologne-Merheim, Cologne, Germany
| | - Fabian Dusse
- Department of Anesthesiology and Intensive Care Medicine, University Witten/Herdecke, Medical Centre Cologne-Merheim, Cologne, Germany
| | - Aris Koryllos
- Department of Thoracic Surgery, University Witten/Herdecke, Medical Centre Cologne-Merheim, Cologne, Germany
| | - Frank Wappler
- Department of Anesthesiology and Intensive Care Medicine, University Witten/Herdecke, Medical Centre Cologne-Merheim, Cologne, Germany
| | - Jerome Defosse
- Department of Anesthesiology and Intensive Care Medicine, University Witten/Herdecke, Medical Centre Cologne-Merheim, Cologne, Germany
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Parua S, Choudhury D, Nath MP. Giant Haemangioma Excision Under Cervical Epidural Anaesthesia: A Viable Alternative to General Anaesthesia. J Clin Diagn Res 2016; 10:UD01-UD02. [PMID: 28050481 PMCID: PMC5198434 DOI: 10.7860/jcdr/2016/22674.8857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 08/06/2016] [Indexed: 11/24/2022]
Abstract
The cervical epidural anaesthesia is a safe anaesthetic technique with minimal morbidity and early postoperative recovery. Cervical epidural anaesthesia can be effectively used for neck, upper arm and chest surgeries. The technique avoids the adverse effects of general anaesthetics and airway instrumentation, especially in patients with cardio respiratory disorders. We preferred CEA for giant haemangioma neck excision in an adult female patient, having an associated laryngeal haemangioma, 10ml of 0.5% ropivacaine with 50μg Fentanyl (total 11 ml) was administered into the cervical epidural space through a 20G epidural catheter introduced via a 18G Tuohy needle at the level of C7-T1 space. Following initial dose a top up dose of 4ml 0.5% Ropivacaine was given after 60 minutes. The surgery lasted for 75 minutes. The cervical epidural anaesthesia allowed our patient to stay awake but comfortable, with stable haemodynamics and excellent postoperative pain relief with a continuous cervical epidural infusion of 0.25% Ropivacaine and 2μg/ml Fentanyl @ 2ml/h was achieved.
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Affiliation(s)
- Samit Parua
- Student, Department of Anaesthesiology and Critical Care, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Dipika Choudhury
- Professor and Head, Department of Anaesthesiology and Critical Care, Gauhati Medical College and Hospital, Guwahati, Assam, India
| | - Mridu Paban Nath
- Assistant Professor, Department of Anaesthesiology and Critical Care, Gauhati Medical College and Hospital, Guwahati, Assam, India
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Abstract
The authors present 25 cases and an in-depth 4-minute video of fully awake aesthetic breast reduction, which was made possible by thoracic epidural anesthesia. There are obvious and important advantages to this technique. Not only does this allow for intraoperative patient cooperation (i.e., patient self-positioning and opinion for comparison of breasts), meaning a shorter and more efficient intraoperative time, there also is a reduction in postoperative pain, complications, recovery, and discharge times. The authors have also enjoyed great success and no complications with this technique in over 150 awake abdominoplasty/total body lift patients. The authors feel that the elimination of the need for general anesthesia by thoracic epidural sensorial-only anesthesia is a highly effective and efficient technique, with very few disadvantages/complications, providing advantages to both patients and surgeons. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Shanthanna H, Mendis N, Goel A. Cervical epidural analgesia in current anaesthesia practice: systematic review of its clinical utility and rationale, and technical considerations. Br J Anaesth 2016; 116:192-207. [PMID: 26787789 DOI: 10.1093/bja/aev453] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Cervical epidural analgesia (CEA) is an analgesic technique, potentially useful for surgeries involving the upper body. Despite the inherent technical risks and systemic changes, it has been used for various surgeries. There have been no previously published systematic reviews aimed at assessing its clinical utility. This systematic review was performed to explore the perioperative benefits of CEA. The review was also aimed at identifying the rationale of its use, reported surgical indications and the method of use. We performed a literature search involving PubMed and Embase databases, to identify studies using CEA for surgical indications. Out of 467 potentially relevant articles, 73 articles were selected. Two independent investigators extracted data involving 5 randomized controlled trials, 17 observational comparative trials, and 51 case reports (series). The outcomes studied in most comparative studies were on effects of local anaesthetics and other agents, systemic effects, and feasibility of CEA. In one randomized controlled study, CEA was observed to decrease the resting pain scores after pharyngo-laryngeal surgeries. In a retrospective study, CEA was shown to decrease the cancer recurrence after pharyngeal-hypopharyngeal surgeries. The limited evidence, small studies, and the chosen outcomes do not allow for any specific recommendations based on the relative benefit or harm of CEA. Considering the potential for significant harm, in the face of better alternatives, its use must have a strong rationale mostly supported by unique patient and surgical demands. Future studies must aim to assess analgesic comparator effectiveness for clinically relevant outcomes.
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Affiliation(s)
- H Shanthanna
- Department of Anaesthesiology, St Joseph's Hospital, McMaster University, Hamilton, ON, Canada
| | - N Mendis
- Resident, Department of Anaesthesiology, University of Ottawa, Ottawa, ON, Canada
| | - A Goel
- Resident, Department of Anesthesiology, University of Toronto, Toronto, ON, Canada
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Kim JY, Song KS, Kim WJ, Park YH, Kang H, Woo YC, Shin HY. Analgesic efficacy of two interscalene blocks and one cervical epidural block in arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc 2016; 24:931-9. [PMID: 26063452 DOI: 10.1007/s00167-015-3667-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 05/29/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE Despite its effectiveness in other surgeries, studies on continuous epidural block in upper-extremity surgery are rare because of technical difficulties and potential complications. This study compared postoperative analgesic efficacy and safety of ultrasound-guided continuous interscalene brachial plexus block (UCISB) and fluoroscopy-guided targeted continuous cervical epidural block (FCCEB) in arthroscopic rotator cuff repair (ARCR). METHODS Seventy-five patients were randomly and equally assigned to groups FCCEB (0.2%), UCISB75 (0.75%), and UCISB20 (0.2%) according to the initial ropivacaine dose (8 ml). The background infusion (0.2% ropivacaine at 5 ml/h), bolus (3 ml of 0.2% ropivacaine), and lockout time (20 min) were consistent. Respiratory effects [respiratory discomfort (modified Borg scale), ventilatory function, and hemidiaphragmatic excursion (ultrasound)], analgesic quality [pain severity at rest and motion attempt (VAS-R and -M), number of boluses, analgesic supplements, and sleep disturbance], neurologic effects, procedural discomfort, satisfaction, and adverse effects were evaluated preprocedurally and up to 72 h postoperatively. RESULTS FCCEB caused less respiratory depression and sensorimotor block, but had less analgesic efficacy than UCISBs (P < 0.05). FCCEB caused nausea, vomiting, and dizziness more frequently (P < 0.05) and had lower patient satisfaction than UCISBs (P < 0.05). UCISB75 can cause severe respiratory distress in patients with lung disorders. Other variables were not significantly different between the groups. CONCLUSIONS UCISB20 may provide superior postoperative analgesia and is the most recommendable postoperative analgesic method in ARCR. LEVEL OF EVIDENCE Randomized controlled trials, Therapeutic study, Level I.
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Affiliation(s)
- Jae-Yoon Kim
- Department of Orthopedic Surgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Kwang-Sup Song
- Department of Orthopedic Surgery, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Won-Joong Kim
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Yong-Hee Park
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Young-Cheol Woo
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea
| | - Hwa-Yong Shin
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, College of Medicine, Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul, Republic of Korea.
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Mantha S, Jonnavithala N, Mohammad R, Padhy N, Kanithi G. Cervical epidural block in emergency hand surgery for a patient with untreated severe hypothyroidism. J Anaesthesiol Clin Pharmacol 2015; 31:424-5. [PMID: 26330740 PMCID: PMC4541208 DOI: 10.4103/0970-9185.161737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Srinivas Mantha
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Nirmala Jonnavithala
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Rahamathullah Mohammad
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Narmada Padhy
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Geetha Kanithi
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
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Samanta S, Samanta S, Panda N, Haldar R. A unique anesthesia approach for carotid endarterectomy: Combination of general and regional anesthesia. Saudi J Anaesth 2014; 8:290-3. [PMID: 24843351 PMCID: PMC4024695 DOI: 10.4103/1658-354x.130753] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Carotid endarterectomy (CEA), a preventable surgery, reduces the future risks of cerebrovascular stroWke in patients with marked carotid stenosis. Peri-operative management of such patients is challenging due to associated major co-morbidities and high incidence of peri-operative stroke and myocardial infarction. Both general anesthesia (GA) and local regional anesthesia (LRA) can be used with their pros and cons. Most developing countries as well as some developed countries usually perform CEA under GA because of technical easiness. LRA usually comprises superficial, intermediate, deep cervical plexus block or a combination of these techniques. Deep block, particularly, is technically difficult and more complicated, whereas intermediate plexus block is technically easy and equally effective. We did CEA under a combination of GA and LRA using ropivacaine 0.375% with 1 mcg/kg dexmedetomidine (DEX) infiltration. In LRA, we gave combined superficial and intermediate cervical plexus block with infiltration at the incision site and along the lower border of mandible. We observed better hemodynamics in intraoperative as well as postoperative periods and an improved postoperative outcome of the patient. So, we concluded that combination of GA and LRA is a good anesthetic technique for CEA. Larger randomized prospective trials are needed to support our conclusion.
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Affiliation(s)
- Sukhen Samanta
- Department of Anesthesia and Critical Care (Trauma Centre), JPNA Trauma Centre, AIIMS, New Delhi, India
| | - Sujay Samanta
- Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Nidhi Panda
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rudrashish Haldar
- Department of Anesthesia and Critical Care, Gain Sagar Medical College, Punjab, India
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Atkinson CJ, Ramaswamy K, Stoneham MD. Regional anesthesia for vascular surgery. Semin Cardiothorac Vasc Anesth 2013; 17:92-104. [PMID: 23327951 DOI: 10.1177/1089253212472985] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Vascular surgical patients are a diverse group of patients who tend to be elderly, with multiple comorbidities, while vascular procedures may involve significant blood loss and ischemia of tissues beyond the arterial obstruction. Regional anesthesia techniques may offer benefits to patients undergoing vascular surgery because of their cardiorespiratory comorbidities. However, this group of patients is commonly receiving multiple medications, including anticoagulants, so regional techniques are not without risks. This review will discuss this topic based around 3 fundamental revascularization procedures, carotid, abdominal aortic aneurysm repair, and infrainguinal surgery, discussing the clinical applications of regional techniques relevant to each key area.
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Jain G, Bansal P, Garg GL, Singh DK, Yadav G. Comparison of three different formulations of local anaesthetics for cervical epidural anaesthesia during thyroid surgery. Indian J Anaesth 2012; 56:129-34. [PMID: 22701202 PMCID: PMC3371486 DOI: 10.4103/0019-5049.96306] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: To compare the efficacy and safety of local anaesthetics under cervical epidural anaesthesia (CEA) using lignocaine (1%), bupivacaine (0.25%) and ropivacaine (0.5%) for thyroid surgery. Methods: In a prospective, randomized fashion, 81 patients were selected for thyroid surgery under CEA. They were assigned to one of three groups: Group L, B and R to receive 10 mL of 1% lignocaine, 0.25% bupivacaine and 0.5% ropivacaine, respectively. We compared their efficacy in terms of pulmonary and haemodynamic parameters, blockade quality and complications. Results: Of the total, 74 patients completed the study successfully. Sensory block attained the median dermatomal range of C2-T4/T5 in all the groups. Motor block was more pronounced in the ropivacaine group. Cardiorespiratory parameters decreased significantly in all the groups; however, none of the patients had any major complications except for bradycardia in two patients. Among the measured variables, the decrease in heart rate and peak expiratory force was more in the lignocaine group while forced vital capacity and forced expiratory volume at 1 sec declined to a greater extent in the ropivacaine group. The lignocaine group required significantly more epidural top-ups compared with the other two groups. Conclusion: We conclude that cervical epidural route can be safely used for surgery on thyroid gland in patients with normal cardiorespiratory reserve, using either of local anaesthetics chosen for our study. Under the selected dose and concentrations, the decrease in cardiorespiratory parameters was lesser with bupivacaine.
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Affiliation(s)
- Gaurav Jain
- Department of Anaesthesia, Teerthankar Mahaveer Medical College, Moradabad, India
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DeRossi R, Pagliosa R, Módolo TC, Maciel FB, Macedo GG. Thoracic epidural analgesia via the lumbosacral approach using multiport catheters with a low concentration of bupivacaine and morphine in sheep. Vet Anaesth Analg 2012; 39:306-14. [PMID: 22405079 DOI: 10.1111/j.1467-2995.2011.00689.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To determine the analgesic and systemic effects of thoracic epidural administration of bupivacaine (BP) and morphine (MP) in conscious sheep. STUDY DESIGN Randomized, crossover, experimental study. ANIMALS Six healthy castrated sheep weighing between 40 and 50 kg. METHODS Each sheep received, via the lumbosacral approach, BP (0.5 mg kg(-1)), MP (0.1 mg kg(-1)), and BP plus MP (BPMP; 0.25 mg kg(-1) + 0.05 mg kg(-1)) in a randomized order. Heart rate, blood pressure, respiratory rate, blood gas analysis, skin temperature, rectal temperature, analgesia, sedation, and motor blockade were determined before treatment and at predetermined intervals until analgesia had disappeared. RESULTS The main areas of complete analgesia for the BP and BPMP treatments were the thorax and forelimb bilaterally. The median duration of analgesia was shorter with MP treatment (45 minutes; score 2) than with BP treatment (70 minutes) and BPMP treatment (140 minutes; p < 0.05). The BP and BPMP treatments caused motor block, and MP and BPMP treatments showed mild sedation. Significant decreases in systolic and diastolic arterial blood pressures were observed only with the BP treatment (p < 0.05). Epidural MP combined with the BP local anesthetic depressed ventilation but within acceptable limits in these clinically healthy sheep. CONCLUSIONS Thoracic epidural administration of BPMP to sheep resulted in longer duration of analgesia of the thorax and forelimbs bilaterally in conscious sheep than the administration of MP or BP alone. The incidence of complications was low, but side-effects such as depressed ventilation and muscle paralysis occurred and require appropriate management. CLINICAL RELEVANCE This technique should be considered as another method for the relief of postoperative pain after thoracic surgery in sheep.
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Affiliation(s)
- Rafael DeRossi
- Department of Veterinary Medicine, Surgery and Anesthesiology, Faculty of Veterinary Medicine and Animal Science, Federal University of Mato Grosso do Sul, Campo Grande, Brazil.
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Singh RP, Shukla A, Verma S. Giant cervical lipoma excision under cervical epidural anesthesia: A viable alternative to general anesthesia. Anesth Essays Res 2011; 5:204-6. [PMID: 25885390 PMCID: PMC4173388 DOI: 10.4103/0259-1162.94781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The technique of Cervical Epidural Anesthesia (CEA) was first described by Dogliotti in 1933 for upper thoracic procedures. Administration of local anesthetic into cervical epidural space results in anesthesia of the neck, upper extremity, and upper thoracic region. CEA provides high-quality analgesia and anesthesia of above dermatomes and, at the same time, it has favorable effect on hemodynamic variable by blocking sympathetic innervation of the heart. CEA is not practiced routinely because of its potential complications. We selected this technique of CEA for excision of giant cervical lipoma on the back of the neck in an adult patient, as the patient was unwilling for general anesthesia. CEA was induced with 10 ml of 1% lignocaine-adrenaline mixture administered into C7-T1 space through 18G Tuohy needle. Our patient maintained vital parameters throught the procedure. The added advantage of epidural anesthesia was that the patient was awake and comfortable throughout the procedure.
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Affiliation(s)
- Ram Pal Singh
- Department of Anaesthesiology and Intensive Care, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India
| | - Aparna Shukla
- Department of Anaesthesiology and Intensive Care, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India
| | - Satyajeet Verma
- Department of Surgery, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India
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Yepes Temiño MJ, Lillo Cuevas M. [Anesthesia for carotid endarterectomy: a review]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2011; 58:34-41. [PMID: 21348215 DOI: 10.1016/s0034-9356(11)70695-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Cardiovascular diseases are associated with high rates of morbidity and mortality. Carotid artery stenosis causes between 20% and 25% of ischemic strokes, especially when an embolism is the underlying cause. Carotid endarterectomy is the treatment of choice when stenosis exceeds 60%. It is important to have an understanding of how to manage perioperative factors that can decrease the risk of stroke, infarction, and death. In contrast to the findings of earlier meta-analyses, the recent GALA trial of general versus local anesthesia concluded that the rates of stroke, myocardial infarction, and mortality during or soon after surgery are similar for both types of anesthesia.
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Affiliation(s)
- M J Yepes Temiño
- Departamento de Anestesiología y Reanimación de la Clínica Universidad de Navarra, Clínica Universidad de Navarra, Pamplona.
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Awake Upper Airway Surgery. Ann Thorac Surg 2010; 89:387-90; discussion 390-1. [DOI: 10.1016/j.athoracsur.2009.10.044] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2009] [Revised: 10/15/2009] [Accepted: 10/16/2009] [Indexed: 11/20/2022]
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21
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Ryoo SH, Kim TJ, Ok SY, Kim SH, Park W, Song D, Moon C. Cervical Epidural Anesthesia for Arteriovenous Bridge Graft at Upper Arm in Chronic Renal Failure Patients. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2010. [DOI: 10.4174/jkss.2010.79.6.486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Seung Hwa Ryoo
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Tae Joon Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Si Young Ok
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Sang Ho Kim
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Wook Park
- Department of Anesthesiology and Pain Medicine, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Dan Song
- Department of General Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Chul Moon
- Department of General Surgery, Soonchunhyang University Seoul Hospital, Seoul, Korea
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Ok SY, Ryoo SH, Baek YH, Kim SH, Kim SI, Kim SC, Park W, Song D. Drip infusion method as a useful indicator for identification of the epidural space. Korean J Anesthesiol 2009; 57:181-184. [PMID: 30625854 DOI: 10.4097/kjae.2009.57.2.181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cervical epidural anesthesia (CEA) is used for pain control and surgical procedures of the head and neck or upper arm areas. However, the failure rate of CEA is reported to be high, is the failure rate being quite higher than other sites, because of the anatomical differences of the cervical spine. We hypothesized that the loss of resistance (LOR) method combined with the drip infusion method for confirmation of the cervical epidural space can reduce the failure rate. This study investigated the usefulness of the drip infusion method. METHODS One hundred chronic renal failure patients undergoing arteriovenous bridge graft for hemodialysis at the upper arm under cervical epidural anesthesia were recruited for this study. In the cervical epidural puncture, we identified the cervical epidural space using a combination of the LOR method with the drip infusion method. After confirmation of the epidural space with LOR method, we decided it was the true epidural space when fluid dripping to the space was present. Otherwise, if fluid dripping was not present, we designated it was pseudo LOR, and we found the true epidural space using the drip infusion method only. RESULTS In all cases, the combined LOR with drip infusion method, identify the epidural space. CONCLUSIONS Combined LOR with drip infusion method is an efficacious method for the confirmation of the cervical epidural space.
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Affiliation(s)
- Si Young Ok
- Department of Anesthesiology and Pain Medicine, College of Medicine, Soonchunhyang University, Seoul, Korea.
| | - Seung Hwa Ryoo
- Department of Anesthesiology and Pain Medicine, College of Medicine, Soonchunhyang University, Seoul, Korea.
| | - Young Hee Baek
- Department of Anesthesiology and Pain Medicine, College of Medicine, Soonchunhyang University, Seoul, Korea.
| | - Sang Ho Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Soonchunhyang University, Seoul, Korea.
| | - Soon Im Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Soonchunhyang University, Seoul, Korea.
| | - Sun Chong Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Soonchunhyang University, Seoul, Korea.
| | - Wook Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, Soonchunhyang University, Seoul, Korea.
| | - Dan Song
- Department of Anesthesiology and Pain Medicine, College of Medicine, Soonchunhyang University, Seoul, Korea.
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Kang KS, Kim CW, Ahn KR, Kim CS, Yoo S, Chung JH, Chung JW, Kim SH. A comparison of cervical epidural analgesia and intravenous patient-controlled analgesia after mastectomy with immediate latissimus dorsi flap breast reconstruction. Korean J Anesthesiol 2009; 56:669-674. [PMID: 30625808 DOI: 10.4097/kjae.2009.56.6.669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Breast reconstruction following mastectomy has become increasingly popular in recent years. The purpose of this study was to compare the efficacy of cervical epidural patient-controlled analgesia (CEA) and intravenous patient-controlled analgesia (IV-PCA) for controlling the postoperative pain and the side effects after mastectomy with immediate Latissimus dorsi (LD) flap breast reconstruction. METHODS Sixty patients who were to undergo mastectomy with immediate LD flap breast reconstruction were randomly assigned to receive CEA [Group CEA, (n = 30), 0.15% ropivacaine + fentanyl 4 microg/ml] or IV-PCA [Group IV-PCA (n = 30) fentanyl 20 microg/kg + ketorolac 3 mg/kg] for postoperative pain control via a PCA pump (basal rate: 2 ml/h, bolus: 2 ml, lock out interval: 15 min) after their operation. Before general anesthesia, an epidural catheter was inserted at the cervical (C)7-thoracic (T)1 level in the patients of the CEA group. The resting visual analogue scale (VAS) for pain, the systolic blood pressure, the heart rate and the side effects were recorded for 48 hours after operation. RESULTS The VAS at rest was significantly lower in the CEA group than that in the IV-PCA group at 16 hours after surgery. The CEA group required less additional analgesics as compared with the group IV- PCA. There were no significant differences in the systolic blood pressure, the heart rate and the incidence of side effects between the two groups. CONCLUSIONS We conclude that cervical epidural analgesia, as compared with intravenous patient-controlled analgesia, provides effective pain control and it shows a similar incidence of side effects after mastectomy with immediate LD flap breast reconstruction.
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Affiliation(s)
- Kyu Sik Kang
- Department of Anesthesiology and Pain Medicine, College of Medicine, University of Soonchunhyang Hospital, Cheonan, Korea.
| | - Chang Won Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, University of Soonchunhyang Hospital, Cheonan, Korea.
| | - Ki Ryang Ahn
- Department of Anesthesiology and Pain Medicine, College of Medicine, University of Soonchunhyang Hospital, Cheonan, Korea.
| | - Chun Sook Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, University of Soonchunhyang Hospital, Cheonan, Korea.
| | - Siehyeon Yoo
- Department of Anesthesiology and Pain Medicine, College of Medicine, University of Soonchunhyang Hospital, Cheonan, Korea.
| | - Jin Hun Chung
- Department of Anesthesiology and Pain Medicine, College of Medicine, University of Soonchunhyang Hospital, Cheonan, Korea.
| | - Ji Won Chung
- Department of Anesthesiology and Pain Medicine, College of Medicine, University of Soonchunhyang Hospital, Cheonan, Korea.
| | - Sang Ho Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, University of Soonchunhyang Hospital, Cheonan, Korea.
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Gil S, Pretel M, Madrazo M, Redondo J, Sarabia R, Bernal G. [Brachial plexus block for minimally invasive parathyroidectomy: report of 3 cases]. ACTA ACUST UNITED AC 2008; 55:508-12. [PMID: 18982789 DOI: 10.1016/s0034-9356(08)70635-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The brachial plexus block, either deep or superficial, is one of the anesthetic techniques used in parathyroidectomy. The block is easy to perform and has few hemodynamic side effects. Surgery can be carried out in an awake patient. We describe 3 cases of patients with primary hyperparathyroidism (parathyroid adenoma) who underwent unilateral minimally invasive parathyroidectomy under regional anesthesia and sedation with 2 mg of midazolam plus remifentanil at dosages ranging from 0.6 to 0.1 microg kg(-1) min(-1). To provide a deep cervical block, we administered 15 mL of 0.75% ropivacaine. For a superficial block, 15 mL of 0.2% ropivacaine was used. The procedure could be completed in all 3 patients under regional anesthesia. The latency time for the block ranged from 21 to 30 minutes, and remifentanil dosages from 0.05 to 0.09 microg kg(-1) min(-1) were administered for procedures that lasted 30 to 45 minutes. No patient required postoperative opioids or antiemetics, although a local anesthetic had to be used at the moment of incision for 1 patient. All 3 patients were discharged the same day. We wish to underline the utility of the brachial plexus block for parathyroid surgery. The technique is easy to perform, safe, and effective; as a result, surgery can be carried out on an outpatient basis.
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Affiliation(s)
- S Gil
- Departamento de Anestesiología y Reanimación, Hospital General de Ciudad Real
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Hakl M, Michalek P, Sevcík P, Pavlíková J, Stern M. Regional anaesthesia for carotid endarterectomy: an audit over 10 years. Br J Anaesth 2007; 99:415-20. [PMID: 17621600 DOI: 10.1093/bja/aem171] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The aim of this retrospective study was to compare the failure rates and the frequency of anaesthesia-related complications of two different methods of regional anaesthesia used for carotid endarterectomy--cervical epidural (CE) anaesthesia and cervical plexus block (CPB). METHODS The study included 1828 carotid endarterectomies performed in 1455 patients between 1996 and 2006. A combination of deep and superficial CPB was used for 1166 procedures, whereas in 662 cases surgery was performed under CE anaesthesia. RESULTS The failure rate of CPB was 3% compared with 6.9% for CE anaesthesia (P < 0.0001). The reasons for failure of the anaesthetic techniques were (1) technical failure, (2) insufficient analgesia, (3) non-compliant patients, and (4) anaesthetic complications. The incidence of complications resulting from CE anaesthesia was significantly higher than with CPB; life-threatening complications--2% compared with 0.3% (P < 0.0001); other anaesthesia-related complications 5.7 vs 4.7%. Serious complications included inadvertant injection into the subarachnoid space or vertebral artery. The frequency of shunt insertion, perioperative stroke, and death from any cause was similar in both groups of patients. CONCLUSIONS Both methods of regional anaesthesia are acceptable for carotid artery surgery. CPB is associated with a significantly lower frequency of anaesthesia-related complications and should therefore be considered the anaesthetic of choice. CE anaesthesia should not be performed except in extenuating circumstances such as variant anatomy or the requirement for more extensive surgery.
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Affiliation(s)
- M Hakl
- Department of Anaesthesiology and Intensive Care, St Anńs Teaching Hospital in Brno, Pekarská 53, 656 91 Brno, The Czech Republic.
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Pandit JJ, Satya-Krishna R, Gration P. Superficial or deep cervical plexus block for carotid endarterectomy: a systematic review of complications †. Br J Anaesth 2007; 99:159-69. [PMID: 17576970 DOI: 10.1093/bja/aem160] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Carotid endarterectomy is commonly conducted under regional (deep, superficial, intermediate, or combined) cervical plexus block, but it is not known if complication rates differ. We conducted a systematic review of published papers to assess the complication rate associated with superficial (or intermediate) and deep (or combined deep plus superficial/intermediate). The null hypothesis was that complication rates were equal. Complications of interest were: (1) serious complications related to the placement of block, (2) incidence of conversion to general anaesthesia, and (3) serious systemic complications of the surgical-anaesthetic process. We retrieved 69 papers describing a total of 7558 deep/combined blocks and 2533 superficial/intermediate blocks. Deep/combined block was associated with a higher serious complication rate related to the injecting needle when compared with the superficial/intermediate block (odds ratio 2.13, P = 0.006). The conversion rate to general anaesthesia was also higher with deep/combined block (odds ratio 5.15, P < 0.0001), but there was an equivalent incidence of other systemic serious complications (odds ratio 1.13, P = 0.273; NS). We conclude that superficial/intermediate block is safer than any method that employs a deep injection. The higher rate of conversion to general anaesthesia with the deep/combined block may have been influenced by the higher incidence of direct complications, but may also suggest that the superficial/combined block provides better analgesia during surgery.
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Affiliation(s)
- J J Pandit
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford OX3 9DU, UK.
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Abstract
Carotid endarterectomy (CEA) is performed to prevent embolic stroke in patients with atheromatous disease at the carotid bifurcation. There is now substantial evidence to support early operation in symptomatic patients, ideally within 2 weeks of the last neurological symptoms. Thus, the anaesthetist may be faced with a high risk patient in whom there has been limited time for preoperative preparation. The operation may be performed under local or general anaesthesia. The advantages and disadvantages of both are explored in this review. Carotid shunting may offer a degree of cerebral protection, but carries its own risks and has not been proved to reduce morbidity and mortality. The use of carotid shunts is based on clinical judgement, awake neurological monitoring, and the use of monitors of cerebral perfusion. There is no ideal monitor of cerebral perfusion in the patient receiving general anaesthesia. Both the intraoperative and postoperative periods may be witness to dramatic haemodynamic changes that may compromise the cerebral or myocardial circulations. In particular, postoperative hypotension may compromise both myocardial and cerebral perfusion, and severe hypertension can cause cerebral hyperperfusion. There is as yet limited evidence to guide the management of these problems. In summary, CEA can yield significant benefit, but those with the most to gain from the operation also present the greatest challenge to the anaesthetist.
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Affiliation(s)
- S J Howell
- Academic Unit of Anaesthesia, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK.
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Groeben H. Epidural anesthesia and pulmonary function. J Anesth 2007; 20:290-9. [PMID: 17072694 DOI: 10.1007/s00540-006-0425-6] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2006] [Accepted: 06/26/2006] [Indexed: 11/29/2022]
Abstract
The epidural administration of local anesthetics can provide anesthesia without the need for respiratory support or mechanical ventilation. Nevertheless, because of the additional effects of epidural anesthesia on motor function and sympathetic innervation, epidural anesthesia does affect lung function. These effects, i.e., a reduction in vital capacity (VC) and forced expiratory volume in 1 s (FEV(1.0)), are negligible under lumbar and low thoracic epidural anesthesia. Going higher up the vertebral column, these effects can increase up to 20% or 30% of baseline. However, compared with postoperative lung function following abdominal or thoracic surgery without epidural anesthesia, these effects are so small that the beneficial effects still lead to an improvement in postoperative lung function. These results can be explained by an improvement in pain therapy and diaphragmatic function, and by early extubation. In chronic obstructive pulmonary disease (COPD) patients, the use of thoracic epidural anesthesia has raised concerns about respiratory insufficiency due to motor blockade, and the risk of bronchial constriction due to sympathetic blockade. However, even in patients with severe asthma, thoracic epidural anesthesia leads to a decrease of about 10% in VC and FEV(1.0) and no increase in bronchial reactivity. Overall, epidural administration of local anesthetics not only provides excellent anesthesia and analgesia but also improves postoperative outcome and reduces postoperative pulmonary complications compared with anesthesia and analgesia without epidural anesthesia.
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Affiliation(s)
- Harald Groeben
- Clinic for Anesthesiology, Pain and Critical Care Therapy, Clinics Essen-Mitte, Teaching Hospital University Duisburg-Essen, Henricistrasse 92, D-45136 Essen, Germany
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Singh AP, Tewari M, Singh DK, Shukla HS. Cervical Epidural Anesthesia: A Safe Alternative to General Anesthesia for Patients Undergoing Cancer Breast Surgery. World J Surg 2006; 30:2043-7; discussion 2048-9. [PMID: 16927058 DOI: 10.1007/s00268-006-0117-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND General anesthesia (GA) is the standard anesthesia for patients undergoing modified radical mastectomy (MRM) for breast cancer. Cervical epidural anesthesia (CEA) is practiced less often because of its reported complications. This prospective study aimed to evaluate the safety and efficacy of CEA as an anesthetic technique for MRM. PATIENTS AND METHODS Fifty breast cancer patients with ASA (American Society of Anesthesiologists) grade I or II underwent MRM under CEA from September 2004 to January 2006. Anesthesia was induced with 10 ml of 1% lignocaine; adrenaline was administered through an 18-gauge catheter in C(6)-C(7) or C(7)-T(1) epidural space. Postoperative analgesia was maintained with 0.125% bupivacaine through the epidural catheter. RESULTS In 49 (98%) patients surgery was conducted smoothly under CEA with good analgesia. 44 patients were awake during surgery. Five patients had to be given intravenous sedation with midazolam, and in one case the procedure was terminated after accidental dura puncture. There were no clinically significant variations in perioperative pulse and respiratory rate, and there was no fall in mean arterial blood pressure during the procedure. The mean preoperative anesthesia time and total cost of the procedure was 20.36 + 2.75 minutes and 12.19 + 2.2 pound, respectively. All patients were started on a liquid diet and mobilized 4 hours after surgery. CONCLUSIONS Cervical epidural anesthesia is a safe alternative to GA and was preferred by our patients because of its lower cost and reduced perioperative morbidity.
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Affiliation(s)
- A P Singh
- Department of Anaesthesiology, IMS, BHU, Varanasi, Uttar Pradesh, India
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Roussier M, Mahul P, Pascal J, Baylot D, Prades JM, Auboyer C, Molliex S. Patient-controlled cervical epidural fentanyl compared with patient-controlled i.v. fentanyl for pain after pharyngolaryngeal surgery. Br J Anaesth 2006; 96:492-6. [PMID: 16476697 DOI: 10.1093/bja/ael025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Analgesia after pharyngolaryngeal surgery is commonly provided through the i.v. route. The aim of the study was to compare cervical epidural administration of fentanyl with the i.v. route for postoperative analgesia after pharyngolaryngeal surgery. METHODS In a randomized double-blind study 42 patients received fentanyl via patient-controlled analgesia (PCA) either through the i.v. route (PCA-IV group, n=22) or through the cervical epidural route (PCA-Epid group, n=20). Identical PCA settings were used in the two groups (bolus dose: 1.5 microg kg(-1), bolus: 25 microg, lockout interval: 10 min, maximum cumulative dose: 400 microg per 4 h). Analgesia at rest and during swallowing was evaluated using a visual analogue scale. RESULTS Analgesia at rest was better in the PCA-Epid group than in the PCA-IV group but only 2 and 6 h after surgery (P<0.02). There was no difference in analgesia during swallowing. Cumulative doses of fentanyl were similar {PCA-Epid group: 1412 microg (912), PCA-IV group: 1287 microg (1200) [median (IQR)]}. The Pa(o(2)) showed a significant decrease between the preoperative and postoperative period, but this decrease was identical in the two groups [PCA-IV-group: 11.47 (2.4) kPa vs 8.27 (0.9) kPa; PCA-Epid group: 11.33 (1.9) kPa vs 9.20 (2.4) kPa for preoperative and postoperative period respectively]. CONCLUSIONS The study results show that cervical epidural analgesia provides marginally better pain relief at rest with no decrease in the fentanyl consumption. The use of the cervical epidural administration of fentanyl is questionable because of the possible complications of the technique.
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Affiliation(s)
- M Roussier
- Département d'Anesthésie-Réanimation, Hôpital Bellevue, Centre Hospitalier et Universitaire de Saint Etienne, 42055 Saint Etienne Cédex 2, France.
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Prusinkiewicz C, Lang S, Tsui BCH. Lateral cervical epidural catheter placement using nerve stimulation for continuous unilateral upper extremity analgesia following a failed continuous peripheral nerve block. Acta Anaesthesiol Scand 2005; 49:579-82. [PMID: 15777311 DOI: 10.1111/j.1399-6576.2005.00630.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This case report describes the application of electrical stimulation (Tsui test) to confirm placement of a cervical epidural catheter for postoperative pain management in a patient with a failed brachial plexus block who underwent upper extremity surgery. An epidural catheter was easily advanced under nerve stimulation guidance to the surgical dermatome C4 level without any resistance from the C7-T1 level. Successful analgesia was achieved with a bolus of 2 mg ml(-1) ropivacaine 2 ml and fentanyl 20 microg, followed by a continuous infusion of 2 mg ml(-1) ropivacaine with 2 microg ml(-1) of fentanyl at a rate of 2 ml h(-1). This case reminds the clinician that cervical epidural analgesia may serve as an alternative to a difficult continuous peripheral nerve block. Electrical stimulation may also help to confirm cervical epidural catheter placement at the appropriate dermatome to provide effective analgesia with minimal side-effects.
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Affiliation(s)
- C Prusinkiewicz
- Department of Anesthesia, University of Calgary, and Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
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Michalek P, David I, Adamec M, Janousek L. Cervical epidural anesthesia for combined neck and upper extremity procedure: a pilot study. Anesth Analg 2004; 99:1833-1836. [PMID: 15562082 DOI: 10.1213/01.ane.0000137397.68815.7b] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In a prospective pilot study, we evaluated the possibility of performing a total parathyroidectomy with parathyroid gland implantation into the forearm (a combined neck and upper extremity procedure) under cervical epidural anesthesia (CEA) at C6-7 level using ropivacaine. The indication for CEA was the patient's choice or a previous procedure on the neck with unilateral vocal cord paralysis. Anesthesia was induced by 10 mL of 0.75% ropivacaine plus 10 mug of sufentanil in 2 mL. Block onset time, success rate, analgesia, sensory block extent, changes in respiratory and hemodynamic variables, complications, and length of hospital stay were assessed. All 15 procedures were successfully performed under CEA. Sensory block was registered in the range C2-T10, with a lower median of T3. The upper margin of sensory block was C2 in all patients. Of the respiratory variables, the only significant decrease was observed in forced vital capacity; none of the patients developed clinically significant respiratory insufficiency. We conclude that combined procedures involving the neck and upper limbs can be performed using CEA with ropivacaine. CEA allows verbal communication with patients and early detection of vocal cord paralysis.
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Affiliation(s)
- Pavel Michalek
- *Department of Cardiovascular Anesthesia and Intensive Care, Na Homolce Hospital; and Department of †Anesthesia and Intensive Care and ‡Transplant Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Tsui BCH, Malherbe S. Inadvertent cervical epidural catheter placement via the caudal route using electrical stimulation. Anesth Analg 2004; 99:259-261. [PMID: 15281541 DOI: 10.1213/01.ane.0000120082.85977.f7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Inadvertent placement of an epidural catheter in the cervical region via the caudal route is described in an infant who underwent revision of a fundoplication. We attempted electrical stimulation (the Tsui test) via the epidural catheter to confirm correct placement and positioning of the catheter tip. In this case, the epidural catheter was inadvertently advanced to the cervical region, resulting in stimulation of the phrenic nerve. These diaphragmatic twitches were misinterpreted as chest wall twitches, and it was incorrectly assumed that the catheter was in the thoracic region. To avoid misinterpretation of the stimulation level, the catheter should be continuously stimulated while it is advanced. We also recommend that the catheter length be estimated before insertion (although doing so did not help in this case) and that the catheter position be radiographically confirmed after surgery.
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Affiliation(s)
- Ban C H Tsui
- Department of Anesthesiology and Pain Medicine, University of Alberta Hospitals, Edmonton, Alberta, Canada
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Cervical Epidural Analgesia Via a Thoracic Approach Using Nerve Stimulation Guidance in an Adult Patient Undergoing Elbow Surgery. Reg Anesth Pain Med 2004. [DOI: 10.1097/00115550-200407000-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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McCleary AJ, Maritati G, Gough MJ. Carotid endarterectomy; local or general anaesthesia? Eur J Vasc Endovasc Surg 2001; 22:1-12. [PMID: 11461095 DOI: 10.1053/ejvs.2001.1382] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES to review the evidence for theoretical and clinical benefits of local or general anaesthesia for carotid endarterectomy. METHODS literature review. RESULTS animal studies suggest cerebral protection by a variety of general anaesthetic agents but clinical evidence is lacking. There is some clinical evidence that normal cerebral protective reflexes are preserved with local anaesthesia. Shunt insertion is the most widely used method of providing cerebral protection with awake testing the most reliable monitoring technique for the identification of ischaemia. There are therefore theoretical arguments for a reduced risk of perioperative stroke when local anaesthesia is used and this is supported by a meta-analysis of non-randomised studies. Intraoperative blood pressure is always higher with local anaesthesia but the incidence of postoperative haemodynamic instability seems to be independent of anaesthetic technique. There is little evidence that myocardial ischaemia is more common with either anaesthetic technique but meta-analysis of non-randomised again suggests fewer cardiac complications with local anaesthesia. Cranial nerve injury and haematoma formation may be less common with local anaesthesia but the evidence is weak. There is no evidence that surgery is more difficult with local anaesthesia or that it is poorly tolerated by the patients. CONCLUSIONS there are theoretical arguments and clinical evidence that the outcome from carotid endarterectomy may be better when local anaesthesia is used with no significant disadvantages. An appropriately designed randomised trial is required to confirm this.
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Affiliation(s)
- A J McCleary
- Vascular Surgical Unit, General Infirmary at Leeds, UK
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Amar AP, Wang MY, Larsen DW, Teitelbaum GP. Microcatheterization of the Cervical Epidural Space via Lumbar Puncture: Technical Note. Neurosurgery 2001. [DOI: 10.1227/00006123-200105000-00052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Amar AP, Wang MY, Larsen DW, Teitelbaum GP. Microcatheterization of the cervical epidural space via lumbar puncture: technical note. Neurosurgery 2001; 48:1183-7. [PMID: 11334291 DOI: 10.1097/00006123-200105000-00052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Deposition of opiates, corticosteroids, or local anesthetics into the epidural space is useful for the management of painful maladies of the cervical and thoracic spine. We describe a novel technique for epidural medication delivery via an angiographic microcatheter inserted at or below the conus and advanced cephalad under fluoroscopic guidance. Unlike commercial kits used by anesthesiologists, this method uses a radiopaque catheter that can be precisely targeted to the levels of interest. The hazards of direct puncture, such as "wet tap" or injury to the cervical cord, are minimized. METHODS An 18-gauge Tuohy needle is inserted into the lumbar epidural space. A 2.3-French microcatheter and a 0.018-inch steerable guidewire are then introduced through the lumen of the needle. The catheter is fluoroscopically advanced to the cervical epidural space, where Depo-Medrol (Pharmacia & Upjohn, Kalamazoo, MI) is administered. As the catheter is withdrawn, additional corticosteroid can be delivered to the thoracic epidural space, together with long-acting morphine compounds or local anesthetics. Regional pressures within the epidural space and other physiological parameters can be measured, and the local microenvironment can be sampled. RESULTS To date, we have performed 16 procedures for 13 patients. All patients reported improvement, of varying extent and duration. There have been no complications. CONCLUSION Our system of accessing the epidural space has many advantages, compared with direct puncture and commercially available kits. It provides a safe means of delivering epidural medication to multiple spinal levels and permits measurement of physiological variables that may be useful in the diagnosis and treatment of cervical and thoracic spine disease.
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Affiliation(s)
- A P Amar
- Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles 90033-1029, USA.
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Abstract
We conducted a postal questionnaire survey of the members of the Vascular Anasthesia Society of Great Britain and Ireland, asking questions about the provision of anasthesia for carotid endartectomy. Of 215 respondents, 187 were currently providing anasthesia for carotid endarterectomy. The majority of respondents (69%) always use general anasthesia for this operation but 99/215 (46%) had some experience of regional anasthesia for carotid endartectomy. Amongst those currently using regional anasthesia, combined deep and superficial cervical plexus block was the technique used by 71%. Other regional techniques used included local infiltration and superficial block alone. During regional anasthesia, most (66%) anasthetists used cerebral monitoring techniques such as stump pressure or transcranial Doppler as well as keeping the patient awake. However, in a significant proportion of cases (37%) under general anasthesia no cerebral monitoring was used. Reported surgical shunt insertion rates were lower in awake (mean 42%) patients than those receiving general anasthesia (61%). Respondents using regional anasthesia were more likely to feel that their technique was appropriate than those using general anasthesia.
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Affiliation(s)
- J D Knighton
- Specialist Registrar in Anasthesia, Department of Anasthesia, Salisbury District Hospital NHS Trust, Salisbury, Wilts. SP2 8BJ, UK
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Lateral Cervical Epidural Catheter Placement for Continuous Unilateral Upper Extremity Analgesia and Sympathetic Block. Reg Anesth Pain Med 2000. [DOI: 10.1097/00115550-200005000-00020] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Merle JC, Mazoit JX, Desgranges P, Abhay K, Rezaiguia S, Dhonneur G, Duvaldestin P. A Comparison of Two Techniques for Cervical Plexus Blockade: Evaluation of Efficacy and Systemic Toxicity. Anesth Analg 1999. [DOI: 10.1213/00000539-199912000-00006] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Moss E. Anaesthetic management of intracranial aneurysms, arteriovenous malformationsand carotid endarterectomy. Best Pract Res Clin Anaesthesiol 1999. [DOI: 10.1053/bean.1999.0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Merle JC, Mazoit JX, Desgranges P, Abhay K, Rezaiguia S, Dhonneur G, Duvaldestin P. A comparison of two techniques for cervical plexus blockade: evaluation of efficacy and systemic toxicity. Anesth Analg 1999; 89:1366-70. [PMID: 10589609 DOI: 10.1097/00000539-199912000-00006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
UNLABELLED We compared two techniques of cervical plexus blockade (CPB) for carotid endarterectomy. Cervical plexus nerve block was performed with a combination of bupivacaine and lidocaine, with injections at the C2-C3, C3-C4, and C4-C5 transverse processes in 11 patients (classical CPB) or with a single injection after localization of the cervical plexus with a nerve stimulator in 12 patients (interscalene CPB). Pain scores were obtained during block placement and at predetermined phases of the operation. Arterial blood was sampled before and 3, 5, 8, 10, 15, 25, 40, and 60 min after CPB for measurement of bupivacaine and lidocaine concentrations. Interscalene CPB was less painful than classical CPB. The techniques appeared equally effective. Patients in both groups required equivalent supplementation with IV fentanyl and additional local infiltration with lidocaine during the most painful stages of surgery. The maximal concentration of bupivacaine was lower in interscalene CPB compared with classical CPB (1.0 microg/mL versus 1.5 microg/mL, P < 0.01). The time required to reach the maximal concentration of bupivacaine was 15 (10-40) min in interscalene CPB and 10 (5-17) min in classical CPB (P < 0.05). Lidocaine maximal concentration was similar in both groups, however the time required to reach the maximal concentration was longer (P < 0.05) in interscalene CPB (15 [10-60] min) than in classical CPB (10 [8-20] min). We conclude that the interscalene CPB is as effective as the classical CPB as a regional technique for carotid endarterectomy and may be associated with a lower systemic absorption of bupivacaine. IMPLICATIONS Cervical plexus blockade for carotid endarterectomy can be effectively performed with a single injection after localization of the cervical plexus with a nerve stimulator. This technique is simple and was associated with less systemic absorption of local anesthetic than the multiple-injection technique.
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Affiliation(s)
- J C Merle
- Service d'Anesthésie-Réanimation, Henri Mondor Hospital, Creteil, France
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Abstract
Continuous cervical epidural anesthesia was used for 17 operations in 16 patients undergoing immediate reconstructive surgery after upper-extremity injuries or tumor resection and was continued for postoperative pain management. Routine hemodynamics, arterial blood gases, plasma bupivacaine levels, and skin temperatures were recorded before and after the block. The surgery time ranged from 3 to 18 hours. Postoperative pain management was maintained for up to 6 days. The blocks were adequate for surgery and postoperative pain treatment in all cases. There were no signs or symptoms indicating local anesthetic toxicity. Circulatory and respiratory integrity was well maintained. The patients were all ambulatory the day after surgery and could start physiotherapy immediately. This regional anesthesia technique may have significant advantages over branchial plexus block or general anesthesia for lengthy surgical procedures of the upper extremity.
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Affiliation(s)
- U M Nystrom
- Department of Anesthesia, University of Umeå, Sweden
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Abstract
To provide an overview of current knowledge, this article reviews experimental and clinical data from investigations examining effects of regional anesthesia on perioperative morbidity in specific physiologic systems. The issues of morbidity and mortality following general and regional anesthesia are addressed, as are the development of perioperative thromboembolism and blood loss, which are known to be increased during general anesthesia. Finally, the effects of regional anesthesia on the vascular system, the perioperative stress response, and the pulmonary function are discussed.
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Affiliation(s)
- P G Atanassoff
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06510-8051, USA
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Chaillou P, Bizouarn P, Patra P, Noel SF, Sellier E, Chabbert C. Arterial pressure and neurologic morbidity during carotid surgery under peridural anesthesia. Ann Vasc Surg 1996; 10:228-32. [PMID: 8792990 DOI: 10.1007/bf02001887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In 163 carotid reconstructions under peridural anesthesia performed from 1988 to 1991, we routinely measured residual systemic and carotid artery pressure during clamping. Seventy-nine patients (48.5%) were asymptomatic and 84 (51.5%) had a history of neurologic manifestations in the form of transient ischemic attacks (28%) or stroke (13.5%). None of the patients died perioperatvely. Eight patients (4.9%) had strokes, with complete recovery in five. A shunt was placed in 22 patients (13.5%) because of neurologic evidence that carotid clamping was poorly tolerated. This study showed a distinct association between residual pressure in the internal carotid artery and systemic arterial pressure and intraoperative neurologic morbidity. Using a cutoff value of 35 mm Hg for residual pressure, the sensitivity was 77% and specificity 81%. Using a cutoff of 80 mm Hg, the sensitivity was 60% and specificity 86%. There was no correlation between mean systemic arterial pressure and residual carotid artery pressure. The use of a shunt was the only factor with predictive value for postoperative neurologic complications. These findings suggest that measurement of systemic arterial pressure and residual carotid artery pressure is useful during carotid surgery, but further study is needed before this information can be extrapolated to carotid surgery under general anesthesia.
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Affiliation(s)
- P Chaillou
- Clinique Chirurgicale Thoracique, Cardiaque et Vasculaire, Hôpital G. et R. Laennec, Nantes, France
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Walleck P, Becquemin JP, Desgranges P, Bonnet F. Are neurologic events occurring during carotid artery surgery predictive of postoperative neurologic complications? Acta Anaesthesiol Scand 1996; 40:167-70. [PMID: 8848914 DOI: 10.1111/j.1399-6576.1996.tb04415.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Per- and postoperative neurologic complications occurring during carotid artery surgery may be related to different mechanisms. Nevertheless, recent studies suggest that they are related and that patients who develop reversible neurologic events peroperatively are at risk of postoperative neurologic complications. We, therefore, studied 265 patients operated under regional anaesthesia to assess the incidence and the pathogenesis of per- and postoperative neurologic disorders and their relationship. METHOD Neurologic function was adequately assessed in 261 patients during surgery. The operation was uneventful in 234 patients, while 27 suffered from transient ischaemic neurologic deficit occurring mainly during carotid artery clamping. RESULTS Postoperative neurologic complications occurred in 6 (2.5%) of the patients who were symptom-free during surgery and in 1 (3.7%) of the patients who experienced neurologic deficit during surgery (NS). In this group, two additional patients had peroperative neurologic deficit which lasted a few hours postoperatively so that the total incidence of postoperative neurologic deficit (11.1%) was significantly higher than in the other group (P < 0.05). Emboli (N = 3) and carotid artery thrombosis (N = 3) were the main causes of postoperative neurologic deficit. CONCLUSION We conclude that patients who have suffered from a peroperative neurologic complication were more frequently in an unstable neurologic condition postoperatively. However, the incidence of "new" neurologic deficit, separated by a free interval from the one occurring peroperatively, was not significantly different in this group.
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Affiliation(s)
- P Walleck
- Department d'Anesthésie Réanimation, Hôpital Henri Mondor, Créteil, France
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Lehot JJ, Durand PG, Mure PY, Blanc P, Bouvier H, Pannetier JC, Bompard D. [Anesthesia for carotid endarterectomy]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1994; 13:33-48. [PMID: 7916552 DOI: 10.1016/s0750-7658(94)80185-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- J J Lehot
- Service d'Anesthésie-Réanimation, Hôpital Cardiovasculaire et Pneumologique Louis-Pradel, BP Lyon-Montchat
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Baylot D, Mahul P, Navez ML, Hajjar J, Prades JM, Auboyer C. [Cervical epidural anesthesia]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1993; 12:483-92. [PMID: 8311355 DOI: 10.1016/s0750-7658(05)80996-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Cervical epidural anaesthesia (CEA) results in an effective sensory blockade of the superficial cervical (C1/C4) and brachial plexus (C5/T1-T2). It is used both intraoperatively and in the treatment of postoperative or chronic pain. The approach to the epidural space at the C7-T1 interspace is not technically difficult. Patients are placed in the sitting position, increasing the negative pressure in the epidural space, with the head flexed on the thorax, in order to open the lowest cervical interspace. A 18-gauge Tuohy needle is inserted by a midline approach into the C6-C7 or C7-T1 interspace. A catheter may be inserted and left in place for postoperative analgesia. Local anaesthetics are administered either alone, or in combination with opiates. The CEA blocks the cardiac sympathetic fibers and consequently decreases heart rate, cardiac output and contractility. The mean blood pressure is unchanged or decreased, depending on peripheral systemic vascular resistance changes. The baroreflex activity is also partly impaired. Sympathetic blockade also decreases myocardial ischaemia. The cardiovascular changes induced by CEA are also partly due to the systemic effect of the local anaesthetic. The respiratory effects are minimal and depend on the extent of the blockade and the concentration of the local anaesthetic. A moderate restrictive syndrome occurs. Since the phrenic nerves originate from C3 to C5, ventilation may be impaired by CEA. Extension of the block may also impair intercostal muscle function, with a risk of respiratory failure when a CEA is used in patients with compromised respiratory function. The potential specific complications, mainly cardiovascular and respiratory, are the exacerbation of the effects of CEA. Side effects such as bradycardia, hypotension and acute ventilatory failure in relation to respiratory muscle paralysis, may be observed. Close monitoring of haemodynamics, respiratory rate and level blockade is required. Cervical epidural anaesthesia may be used either alone, or in combination with general anaesthesia depending on the surgical procedure. This technique seems to be effective in carotid artery surgery since sensitive and reliable information on cerebral function may be obtained. It is also for shoulder and upper limb surgery as well as for pharyngolaryngeal surgery, providing efficient operative anaesthesia and postoperative analgesia. CEA is used for relief of chronic pain in the head and neck or cancer pain due to Pancoast-Tobias syndrome. It seems to be effective for treating pain in patients with unstable angina pectoris or acute myocardial infarction.
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Affiliation(s)
- D Baylot
- Département d'Anesthésie-Réanimation, CHU, Hôpital Bellevue, Saint-Etienne
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Campbell RL. The Role of Nerve Blocks in the Diagnosis of Traumatic Trigeminal Neuralgia. Oral Maxillofac Surg Clin North Am 1992. [DOI: 10.1016/s1042-3699(20)30594-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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