Successful transesophageal echocardiography in an unsedated critically ill patient with superior laryngeal nerve blocks

Regional anesthesia and analgesia in critically ill patients: a systematic review

Regional anesthesia has become invaluable for the treatment of pain during and after a wide range of surgical procedures. However, its benefits in the nonsurgical setting have been less well studied. Regional anesthesia is an appealing modality for critically ill patients, providing focused and sustained pain control with beneficial systemic effect profiles. Indications for regional anesthesia in this patient group are not limited to surgical and postsurgical analgesia but expand to the management of trauma-related issues, medical conditions, and painful procedures at the bedside. Patients in the critical care unit present special challenges to the regional anesthesiologist, including coagulopathies, infections, immunocompromised states, sedation- and ventilation-associated problems, and factors potentially increasing the risk for systemic toxicity. This review is intended to evaluate the role of regional anesthesia in critically ill patients, to discuss potential benefits, and to provide a summary of the published evidence on the subject.

Anatomical study applied to anesthetic block technique of the superior laryngeal nerve

BACKGROUND

The topography of the internal branch of the superior laryngeal nerve (ibSLN) was prospectively studied to evaluate the greater horn of the hyoid bone (ghHB) and the incisura of the thyroid cartilage (iTC) as anatomical repairs in laryngeal anesthetic block. Factors such as gender, ethnicity and side of the neck were also analyzed concerning their influence in the ibSLN position.

METHODS

One hundred neck dissections were performed in 50 human cadavers bilaterally identifying the ibSLN, the ghHB and iTC. The distance between the ghHB and ibSLN in the cranio-caudal direction (dHB), and the distance between the iTC and the ipsilateral thyrohyoid membrane ostium (dTC) were measured. Furthermore, the results were statistically analyzed according to ethnicity, gender and side of the neck.

RESULTS

The ibSLN was juxtaposed to the apex ghBH in 31 out of 100 dissections. The mean dHB was 2.4 mm, and mean dTC was 33.4 mm. The statistical analysis did not identify any significant difference regarding those distances between the groups in terms of ethnicity, gender and side of the neck.

CONCLUSION

The ibSLN was often dissected very close to the ghHB, and this result was not influenced by any factor studied. Therefore, the ghHB can be considered a good anatomical repair to localize the ibSLN in the local block of the larynx. Furthermore, the dTC could frequently be reached by routinely used nerve block needle. However, a few anatomical variations may occur, resulting in a low failure rate of this anesthetic procedure.

Sensory blockade for difficult passage of transesophageal echocardiography probes

During transesophageal echocardiography probe passage, airway reflexes are usually obtunded with topical local anesthetics. This technique meets with varying degrees of success. Even partially intact airway reflexes result in coughing, retching, and withdrawal, which may prevent transesophageal echocardiography examination or predispose to life-threatening tachycardia and hypertension. Proper preparation of the patient enhances comfort and helps protect against tachycardia and hypertension as well as reducing the time required for examination. This article outlines specific monitoring issues and offers precautions that are critical to transesophageal echocardiography probe passage. It suggests a premedication regimen and describes methods of sedation. Furthermore, it outlines the afferent innervation of the upper airway and specific techniques of temporary reflex interruption.