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Vuurberg NE, Post ICJH, Keller BPJA, Schaafsma A, Vos CG. A systematic review & meta-analysis on perioperative cerebral and hemodynamic monitoring methods during carotid endarterectomy. Ann Vasc Surg 2022; 88:385-409. [PMID: 36100123 DOI: 10.1016/j.avsg.2022.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 08/23/2022] [Accepted: 08/31/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To compare outcomes between different strategies of perioperative cerebral and hemodynamic monitoring during carotid endarterectomy. DATA SOURCES MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL databases were searched. METHODS This review was performed according to the PRISMA guidelines and prospectively registered in the international prospective register of systematic reviews (CRD42021241891). The GRADE approach was used to describe the methodological quality of the studies and certainty of the evidence. The primary outcome was 30-day stroke rate. Secondary outcomes measures are 30-day ipsilateral stroke, 30-day mortality, shunt rate and complication rates. RESULTS The search identified 3 460 articles. Seventeen RCTs, three prospective observational studies and seven registries were included, reporting on 236 983 patients. The overall pooled 30-day stroke rate is 1.8% (95% CI 1.4 - 2.2%), ranging from 0 - 12.6%. In RCT's the pooled 30-day stroke rate is 2.7% (95% CI 1.6 - 3.7%) compared to 1.3% (95%CI 0.8 - 1.8%) in the registries. The overall stroke risk decreased from 3.7% before the year 2000 to 1.6% after 2000. No significant differences could be identified between different monitoring and shunting strategies, although a trend to higher stroke rates in routine no shunting arms of RCTs was observed. Overall 30-day mortality, myocardial infarction and nerve injury rates are 0.6% (95%CI 0.4 - 0.8), 0.8% (95%CI 0.6-1.0) and 1.3% (95%CI 0.4-2.2), respectively. CONCLUSIONS No significant differences between the compared shunting and monitoring strategies are found. However, routine no shunting is not recommended. The available data is too limited to prefer one method of neuromonitoring over another method when selective shunting is applied.
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Affiliation(s)
| | - Ivo C J H Post
- Department of Surgery, Martini Hospital, Groningen, The Netherlands
| | | | - Arjen Schaafsma
- Department of Clinical Neurophysiology & Neurology, Martini Hospital, Groningen, The Netherlands
| | - Cornelis G Vos
- Department of Surgery, Martini Hospital, Groningen, The Netherlands.
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Bevilacqua S, Ticozzelli G, Orso M, Alba G, Capoccia L, Cappelli A, Cernetti C, Diomedi M, Dorigo W, Faggioli G, Giannace G, Giannandrea D, Giannetta M, Lessiani G, Marone EM, Mazzaccaro D, Migliacci R, Nano G, Pagliariccio G, Petruzzellis M, Plutino A, Pomatto S, Pulli R, Sirignano P, Vacirca A, Visco E, Moghadam SP, Lanza G, Lanza J. Anesthetic management of carotid endarterectomy: an update from Italian guidelines. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:24. [PMID: 37386522 PMCID: PMC10245611 DOI: 10.1186/s44158-022-00052-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/12/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND AND AIMS In order to systematically review the latest evidence on anesthesia, intraoperative neurologic monitoring, postoperative heparin reversal, and postoperative blood pressure management for carotid endarterectomy. The present review is based on a single chapter of the Italian Health Institute Guidelines for diagnosis and treatment of extracranial carotid stenosis and stroke prevention. METHODS AND RESULTS A systematic article review focused on the previously cited topics published between January 2016 and October 2020 has been performed; we looked for both primary and secondary studies in the extensive archive of Medline/PubMed and Cochrane library databases. We selected 14 systematic reviews and meta-analyses, 13 randomized controlled trials, 8 observational studies, and 1 narrative review. Based on this analysis, syntheses of the available evidence were shared and recommendations were indicated complying with the GRADE-SIGN version methodology. CONCLUSIONS From this up-to-date analysis, it has emerged that any type of anesthesia and neurological monitoring method is related to a better outcome after carotid endarterectomy. In addition, insufficient evidence was found to justify reversal or no-reversal of heparin at the end of surgery. Furthermore, despite a low evidence level, a suggestion for blood pressure monitoring in the postoperative period was formulated.
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Affiliation(s)
- Sergio Bevilacqua
- Department of Anesthesia, Azienda Ospedaliera Universitaria Careggi, Firenze, Italy
| | - Giulia Ticozzelli
- Anesthesiology and Intensive Care Unit, Fondazione I.R.C.C.S. Policlinico San Matteo, Pavia, Italy.
| | - Massimiliano Orso
- Società Italiana di Chirurgia Vascolare ed Endovascolare (SICVE), Roma, Italy
| | - Giuseppe Alba
- Department of Vascular Surgery, University of Siena, Siena, Italy
| | - Laura Capoccia
- Vascular and Endovascular Surgery Division, Policlinico Umberto I La Sapienza University of Rome, Rome, Italy
| | - Alessandro Cappelli
- Vascular Surgery Unit, Policlinico Le Scotte Hospital University of Siena, Siena, Italy
| | - Carlo Cernetti
- Division of Cardiology and and Interventional Hemodynamics, Ca' Foncello Hospital, Azienda USLL2 Marca Trevigiana, Treviso, Italy
| | - Marina Diomedi
- Stroke Unit, Department of Systems Medicine, Tor Vergata University Hospital, Rome, Italy
| | - Walter Dorigo
- Vascular Surgery Unit, University of Florence, Florence, Italy
| | - Gianluca Faggioli
- Vascular Surgery Unit, Policlinico Sant'Orsola, Alma Mater Studiorum University, Bologna, Italy
| | - Giovanni Giannace
- Vascular Surgery Unit, Arcispedale Snata Maria Nuova, Reggio Emilia, Italy
| | - David Giannandrea
- Stroke Unit, Neurology Department, USL Umbria 1, Cittá di Castello, Perugia, Italy
| | - Matteo Giannetta
- Vascular Surgery Unit, IRCCS Policlinico San Donato Hospital University, San Donato Milanese, Italy
| | | | - Enrico Maria Marone
- Vascular Surgery Unit, Department of Policlinico Monaza, Monza, Italy
- Pavia University, Pavia, Italy
| | - Daniela Mazzaccaro
- Vascular Surgery Unit, IRCCS Policlinico San Donato Hospital University, San Donato Milanese, Italy
| | - Rino Migliacci
- Angiology and Internal Medicine, Valdichiana S.Margherita Hospital, Cortona, Italy
| | - Giovanni Nano
- Vascular Surgery Unit, IRCCS Policlinico San Donato Hospital University, San Donato Milanese, Italy
| | | | | | | | - Sara Pomatto
- Vascular Surgery Unit, Policlinico Sant'Orsola, Alma Mater Studiorum University, Bologna, Italy
| | - Raffaele Pulli
- Vascular Surgery Unit, Policlinico Careggi Hospital University, Florence, Italy
| | - Pasqualino Sirignano
- Vascular and Endovascular Surgery Division, Sant'andrea Hospital , "La sapienza" University of Rome, Rome, Italy
| | - Andrea Vacirca
- Vascular Surgery Unit, Policlinico San'Orsola-Alma Mater Studiorum University, Bologna, Italy
| | - Emanuele Visco
- Division of Cardiology and Interventional Hemodynamic, San Giacomo Apostolo Hospital, Azienda ULSS2 Marca Trevigiana, Castelfranco Veneto, Italy
| | | | - Gaetano Lanza
- Vascular Surgery Department, Multimedica Hospital-IRCCS, Castellanza, Italy
| | - Jessica Lanza
- Vascular Surgery Department, IRCSS Ospedale Policlinico, San Martino Genova, Italy
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Rerkasem A, Orrapin S, Howard DP, Nantakool S, Rerkasem K. Local versus general anaesthesia for carotid endarterectomy. Cochrane Database Syst Rev 2021; 10:CD000126. [PMID: 34642940 PMCID: PMC8511439 DOI: 10.1002/14651858.cd000126.pub5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Carotid endarterectomy may significantly reduce the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks that may be minimised by performing the operation under local rather than general anaesthetics. This is an update of a Cochrane Review first published in 1996, and previously updated in 2004, 2008, and 2013. OBJECTIVES To determine whether carotid endarterectomy under local anaesthetic: 1) reduces the risk of perioperative stroke and death compared with general anaesthetic; 2) reduces the complication rate (other than stroke) following carotid endarterectomy; and 3) is acceptable to individuals and surgeons. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and two trials registers (to February 2021). We also reviewed reference lists of articles identified. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing the use of local anaesthetics to general anaesthetics for people having carotid endarterectomy were eligible. DATA COLLECTION AND ANALYSIS Three review authors independently extracted data, assessed risk of bias, and evaluated quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool. We calculated a pooled Peto odds ratio (OR) and corresponding 95% confidence interval (CI) for the following outcomes that occurred within 30 days of surgery: stroke, death, ipsilateral stroke, stroke or death, myocardial infarction, local haemorrhage, and arteries shunted. MAIN RESULTS We included 16 RCTs involving 4839 participants, of which 3526 were obtained from the single largest trial (GALA). The main findings from our meta-analysis showed that, within 30 days of operation, neither incidence of stroke nor death were significantly different between local and general anaesthesia. Of these, the incidence of stroke in the local and general anaesthesia groups was 3.2% and 3.5%, respectively (Peto odds ratio (OR) 0.91, 95% confidence interval (CI) 0.66 to 1.26; P = 0.58; 13 studies, 4663 participants; low-quality evidence). The rate of ipsilateral stroke under both types of anaesthesia was 3.1% (Peto OR 1.03, 95% CI 0.71 to 1.48; P = 0.89; 2 studies, 3733 participants; low-quality evidence). The incidence of stroke or death in the local anaesthesia group was 3.5%, while stroke or death incidence was 4.1% in the general anaesthesia group (Peto OR 0.85, 95% CI 0.62 to 1.16; P = 0.31; 11 studies, 4391 participants; low-quality evidence). A lower rate of death was observed in the local anaesthetic group but evidence was of low quality (Peto OR 0.61, 95% CI 0.35 to 1.06; P = 0.08; 12 studies, 4421 participants). AUTHORS' CONCLUSIONS The incidence of stroke and death were not convincingly different between local and general anaesthesia for people undergoing carotid endarterectomy. The current evidence supports the choice of either approach. Further high-quality studies are still needed as the evidence is of limited reliability.
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Affiliation(s)
- Amaraporn Rerkasem
- Environmental - Occupational Health Sciences and Non Communicable Diseases Center of Excellence, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Saritphat Orrapin
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Thammasat University (Rangsit Campus), Pathum Thani, Thailand
| | - Dominic Pj Howard
- Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Sothida Nantakool
- Environmental - Occupational Health Sciences and Non Communicable Diseases Center of Excellence, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Kittipan Rerkasem
- Environmental - Occupational Health Sciences and Non Communicable Diseases Center of Excellence, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Tauber H, Streif W, Gebetsberger J, Gasteiger L, Pierer E, Knoflach M, Fraedrich G, Gummerer M, Fritz J, Velik-Salchner C. Cardiac output and cerebral blood flow during carotid surgery in regional versus general anesthesia: A prospective randomized controlled study. J Vasc Surg 2021; 74:930-937.e2. [PMID: 33887429 DOI: 10.1016/j.jvs.2021.03.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 03/19/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) is a preventive procedure aimed at decreasing the subsequent risk of fatal or disabling stroke in patients with significant carotid stenosis. It is well-known that carotid surgery under ultrasound-guided regional anesthesia (US-RA) causes a significant increase in blood pressure, heart rate and stress hormone levels owing to increased sympathetic activity. However, little is known about the effects on cardiac output (CO), cardiac index (CI), and cerebral blood flow (CBF) under US-RA as compared with general anesthesia (GA). METHODS Patients scheduled for CEA were randomized prospectively to receive US-RA (n = 37) or GA (n = 41). The primary end point was the change in CI after induction of anesthesia and the change from baseline over time at four different times during the entire procedure in the respective randomized US-RA and GA groups. In addition to systolic blood pressure and heart rate, we also recorded peak systolic velocity, end-diastolic velocity, and minimum diastolic velocity as seen from transcranial Doppler ultrasound examination, as well as regional cerebral oxygenation (rSO2) as seen from near-infrared refracted spectroscopy to evaluate cerebral blood flow. RESULTS In the US-RA group, the CI increased after induction of anesthesia (3.7 ± 0.8 L/min/m2) and remained constant until the end of the procedure. In the GA group CI was significantly lower (2.4 ± 0.6 L/min/m2; P < .001). After induction of anesthesia, the rSO2 remained constant in the GA group on both the ipsilateral (63 ± 9 rSO2) and the contralateral (65 ± 7 rSO2) sides; in contrast, it significantly increased in the US-RA group (ipsilateral 72 ± 8 rSO2; P < .001; contralateral 72 ± 6 rSO2; P < .001). The transcranial Doppler ultrasound parameters (peak systolic velocity, end-diastolic velocity, and minimum diastolic velocity) did not differ between the US-RA and the GA group. The clinical outcome was similarly favorable for both groups. CONCLUSIONS CI was maintained near baseline values throughout the procedure during US-RA, whereas a significant decrease in CI values was observed during CEA under GA. Near-infrared refracted spectroscopy values, reflecting blood flow in small vessels, were higher in US-RA patients than in those with GA. These differences did not influence clinical outcome.
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Affiliation(s)
- Helmuth Tauber
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Werner Streif
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Lukas Gasteiger
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Eve Pierer
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gustav Fraedrich
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Maria Gummerer
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Josef Fritz
- Department of Medical Statistics, Informatics and Health Economics, Medical University of Innsbruck, Innsbruck, Austria
| | - Corinna Velik-Salchner
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria.
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Harky A, Chan JSK, Kot TKM, Sanli D, Rahimli R, Belamaric Z, Ng M, Kwan IYY, Bithas C, Makar R, Chandrasekar R, Dimitri S. General Anesthesia Versus Local Anesthesia in Carotid Endarterectomy: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2019; 34:219-234. [PMID: 31072705 DOI: 10.1053/j.jvca.2019.03.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 03/13/2019] [Accepted: 03/14/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The choice of anesthetic technique in carotid endarterectomy (CEA) has been controversial. This study compared the outcomes of general anesthesia (GA) and local anesthesia (LA) in CEA. DESIGN Systematic review and meta-analysis of comparative studies. SETTING Hospitals. PARTICIPANTS Adult patients undergoing CEA with either LA or GA. INTERVENTIONS The effects of GA and LA on CEA outcomes were compared. MEASUREMENTS AND MAIN RESULTS PubMed, OVID, Scopus, and Embase were searched to June 2018. Thirty-one studies with 152,376 patients were analyzed. A random effect model was used, and heterogeneity was assessed with the I2 and chi-square tests. LA was associated with shorter surgical time (weighted mean difference -9.15 min [-15.55 to -2.75]; p = 0.005) and less stroke (odds ratio [OR] 0.76 [0.62-0.92]; p = 0.006), cardiac complications (OR 0.59 [0.47-0.73]; p < 0.00001), and in-hospital mortality (OR 0.72 [0.59-0.90]; p = 0.003). Transient neurologic deficit rates were similar (OR 0.69 [0.46-1.04]; p = 0.07). Heterogeneity was significant for surgical time (I2 = 0.99, chi-square = 1,336.04; p < 0.00001), transient neurologic deficit (I2 = 0.41, chi-square = 28.81; p = 0.04), and cardiac complications (I2 = 0.42, chi-square = 43.32; p = 0.01) but not for stroke (I2 = 0.22, chi-square = 30.72; p = 0.16) and mortality (I2 = 0.00, chi-square = 21.69; p = 0.65). Randomized controlled trial subgroup analysis was performed, and all the aforementioned variables were not significantly different or heterogenous. CONCLUSION The results from this study showed no inferiority of using LA to GA in patients undergoing CEA. Future investigations should be reported more systematically, preferably with randomization or propensity-matched analysis, and thus registries will facilitate investigation of this subject. Anesthetic choice in CEA should be individualized and encouraged where applicable.
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Affiliation(s)
- Amer Harky
- Department of Vascular Surgery, Countess of Chester, Chester, United Kingdom.
| | - Jeffrey Shi Kai Chan
- Faculty of Medicine, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Thompson Ka Ming Kot
- Faculty of Medicine, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | | | - Rashad Rahimli
- Faculty of Medicine, Bulent Ecevit University, Zonguldak, Turkey
| | - Zlatka Belamaric
- Department of Perioperative Medicine, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Marcus Ng
- Faculty of Medicine, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Ian Yu Young Kwan
- Faculty of Medicine, Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Christiana Bithas
- School of Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Ragai Makar
- Department of Vascular Surgery, Countess of Chester, Chester, United Kingdom
| | | | - Sameh Dimitri
- Department of Vascular Surgery, Countess of Chester, Chester, United Kingdom
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Local anaesthesia for carotid endarterectomy: Con: decrease the stress for all. Eur J Anaesthesiol 2016; 33:238-40. [PMID: 26928168 DOI: 10.1097/eja.0000000000000377] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Schmidli J, Savolainen H, Eckstein F, Irwin E, Peters TK, Martin R, Kieval R, Cody R, Carrel T. Acute Device-Based Blood Pressure Reduction: Electrical Activation of the Carotid Baroreflex in Patients Undergoing Elective Carotid Surgery. Vascular 2016; 15:63-9. [PMID: 17481366 DOI: 10.2310/6670.2007.00024] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Carotid sinus baroreceptors are involved in controlling blood pressure (BP) by providing input to the cardiovascular regulatory centers of the medulla. The acute effect of temporarily placing an electrode on the carotid sinus wall to electrically activate the baroreflex was investigated. We studied 11 patients undergoing elective carotid surgery. Baseline BP was 146+30/66±17 mm Hg and heart rate (HR) 72±7 bpm (mean ± standard deviation). An electrode was placed upon the carotid sinus and after obtaining a steady state baseline of BP and HR, an electric current was applied and increased in 1-volt increments. A voltage dependent and highly significant reduction in BP was observed which averaged 18±26* and 8.0±12 mm Hg for systolic BP and diastolic BP, respectively. Maximal reductions occurred at 4.4±1.2 V: 23±24 mm Hg*, 16±10 mm Hg* and 7±12 bpm* for systolic BP, diastolic BP and HR, respectively (= p <.05). Thus, electrical stimulation of the carotid sinus activates the carotid baroreflex resulting in a reduction in BP and HR. This presents a proof of concept for device based baroreflex modulation in acute BP regulation and adds to the available data which provide a rationale for evaluating this system in the context of chronic BP reduction in hypertensive patients.
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Affiliation(s)
- Jürg Schmidli
- Department of Cardiovascular Surgery, University Hospital, Berne, Switzerland.
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Demirel S, Celi de la Torre JA, Bruijnen H, Martin E, Popp E, Böckler D, Attigah N. Effect of Superficial Cervical Plexus Block on Baroreceptor Sensitivity in Patients Undergoing Carotid Endarterectomy. J Cardiothorac Vasc Anesth 2016; 30:309-16. [PMID: 26718664 DOI: 10.1053/j.jvca.2015.08.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Regional anesthesia for patients undergoing carotid endarterectomy is associated with improved intraoperative hemodynamic stability compared with general anesthesia. The authors hypothesized that the reported advantages might be related to attenuated ipsilateral baroreflex control of blood pressure, caused by chemical denervation of the carotid bulb baroreceptor nerve fibers. DESIGN A prospective cohort study. SETTING Single-center university hospital. PARTICIPANTS The study included 46 patients undergoing carotid endarterectomy using superficial cervical block. INTERVENTIONS A noninvasive computational periprocedural measurement of baroreceptor sensitivity was performed in all patients. Two groups were formed, depending on the patients' subjective response to surgical stimulation regarding the necessity of additional intraoperative local anesthesia (LA) administration on the carotid bulb. Group A (block alone) included 23 patients who required no additional anesthesia, and group B (block + LA) consisted of 23 patients who required additional anesthesia. MEASUREMENTS AND MAIN RESULTS Baroreceptor sensitivity showed no significant change after application of the block in both groups (group A: median [IQR], 5.19 [3.07-8.54] v 4.96 [3.1-9.07]; p = 0.20) (group B: median [IQR], 4.47 [3.36-8.09] v 4.53 [3.29-8.01]; p = 0.55). There was a significant decrease in baroreceptor sensitivity in group B after intraoperative LA administration (median [IQR], 4.53 [3.29-8.01] v 3.31 [2.26-7.31]; p = 0.04). CONCLUSIONS Standard superficial cervical plexus block did not impair local baroreceptor function, and, therefore, it was not related to improved cerebral perfusion in awake patients undergoing carotid endarterectomy. However, direct infiltration of the carotid bulb was associated with the expected attenuation of baroreflex sensitivity.
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Affiliation(s)
- Serdar Demirel
- Department of Vascular and Endovascular Surgery, University Hospital of Heidelberg, Heidelberg, Germany;.
| | | | - Hans Bruijnen
- Department of Vascular and Thoracic Surgery, Augsburg City Hospital, University of Ludwig-Maximillians, Munich, Germany
| | - Eike Martin
- Department of Anesthesiology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Erik Popp
- Department of Anesthesiology, University Hospital of Heidelberg, Heidelberg, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, University Hospital of Heidelberg, Heidelberg, Germany
| | - Nicolas Attigah
- Department of Vascular Surgery, City Hospital Triemli, Zurich, Switzerland
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Hoefer J, Pierer E, Rantner B, Stadlbauer KH, Fraedrich G, Fritz J, Kleinsasser A, Velik-Salchner C. Ultrasound-guided regional anesthesia for carotid endarterectomy induces early hemodynamic and stress hormone changes. J Vasc Surg 2015; 62:57-67. [DOI: 10.1016/j.jvs.2015.02.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 02/21/2015] [Indexed: 11/26/2022]
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Abstract
BACKGROUND Carotid endarterectomy may significantly reduce the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks that may be reduced by performing the operation under local rather than general anaesthetic. This is an update of a Cochrane Review first published in 1996, and previously updated in 2004 and 2008. OBJECTIVES To determine whether carotid endarterectomy under local anaesthetic: (1) reduces the risk of perioperative stroke and death compared with general anaesthetic; (2) reduces the complication rate (other than stroke) following carotid endarterectomy; and (3) is acceptable to patients and surgeons. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (September 2013), MEDLINE (1966 to September 2013), EMBASE (1980 to September 2013) and Index to Scientific and Technical Proceedings (ISTP) (1980 to September 2013). We also handsearched relevant journals, and searched the reference lists of articles identified. SELECTION CRITERIA Randomised trials comparing the use of local anaesthetic to general anaesthetic for carotid endarterectomy were considered for inclusion. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trial quality and extracted data. We calculated a pooled Peto odds ratio (OR) and corresponding 95% confidence interval (CI) for the following outcomes that occurred within 30 days of surgery: stroke, death, stroke or death, myocardial infarction, local haemorrhage, cranial nerve injuries, and shunted arteries. MAIN RESULTS We included 14 randomised trials involving 4596 operations, of which 3526 were from the single largest trial (GALA). In general, reporting of methodology in the included studies was poor. All studies were unable to blind patients and surgical teams to randomised treatment allocation and for most studies the blinding of outcome assessors was unclear. There was no statistically significant difference in the incidence of stroke within 30 days of surgery between the local anaesthesia group and the general anaesthesia group. The incidence of strokes in the local anaesthesia group was 3.2% compared to 3.5% in the general anaesthesia group (Peto OR 0.92, 95% CI 0.67 to 1.28). There was no statistically significant difference in the proportion of patients who had a stroke or died within 30 days of surgery. In the local anaesthesia group 3.6% of patients had a stroke or died compared to 4.2% of patients in the general anaesthesia group (Peto OR 0.85, 95% CI 0.63 to 1.16). There was a non-significant trend towards lower operative mortality with local anaesthetic. In the local anaesthesia group 0.9% of patients died within 30 days of surgery compared to 1.5% of patients in the general anaesthesia group (Peto OR 0.62, 95% CI 0.36 to 1.07). However, neither the GALA trial or the pooled analysis were adequately powered to reliably detect an effect on mortality. AUTHORS' CONCLUSIONS The proportion of patients who had a stroke or died within 30 days of surgery did not differ significantly between the two types of anaesthetic techniques used during carotid endarterectomy. This systematic review provides evidence to suggest that patients and surgeons can choose either anaesthetic technique, depending on the clinical situation and their own preferences.
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Affiliation(s)
- Tanat Vaniyapong
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand, 50200
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Attigah N, Kutter J, Demirel S, Hakimi M, Hinz U, Motsch J, Böckler D. Assessment of Patients’ Satisfaction in Carotid Surgery under Local Anaesthesia by Psychometrical Testing – A Prospective Cohort Study. Eur J Vasc Endovasc Surg 2011; 41:76-82. [DOI: 10.1016/j.ejvs.2010.08.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 08/20/2010] [Indexed: 10/19/2022]
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12
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Cervical Plexus Block. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00150-1] [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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Erickson K, Cole D. Carotid artery disease: stenting vs endarterectomy. Br J Anaesth 2010; 105 Suppl 1:i34-49. [DOI: 10.1093/bja/aeq319] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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14
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Tacconi F, Pompeo E, Sellitri F, Mineo TC. Surgical stress hormones response is reduced after awake videothoracoscopy☆. Interact Cardiovasc Thorac Surg 2010; 10:666-71. [DOI: 10.1510/icvts.2009.224139] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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15
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Affiliation(s)
- Joanne Guay
- University of Montreal, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada H1T 2M4.
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16
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Abstract
BACKGROUND Carotid endarterectomy reduces the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks which may be lessened by performing the operation under local rather than general anaesthetic. This is an update of a Cochrane review first published in 1996, and previously updated in 2004. OBJECTIVES To assess the risks of endarterectomy under local compared with general anaesthetic. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (last searched December 2007), MEDLINE (1966 to April 2007) EMBASE (1980 to April 2007) and Index to Scientific and Technical Proceedings (ISTP, 1980 to April 2007). We also handsearched six relevant journals to April 2007, and searched the reference lists of articles identified. For the previous version of this review we handsearched a further seven journals to 2002 and in August 2001 advertised the review in Vascular News, a newspaper for European vascular specialists. SELECTION CRITERIA Randomised trials and non-randomised studies comparing carotid endarterectomy under local versus general anaesthetic. DATA COLLECTION AND ANALYSIS Two review authors assessed trial quality and extracted the data independently. MAIN RESULTS Nine randomised trials involving 812 operations, and 47 non-randomised studies involving 24,181 operations were included. Meta-analysis of the randomised studies showed that there was no evidence of a reduction in the odds of operative stroke, but the use of local anaesthetic was associated with a significant reduction in local haemorrhage (odds ratio 0.30, 95% confidence interval 0.12 to 0.77) within 30 days of the operation. However, the randomised trials were too small to allow reliable conclusions to be drawn, and in some studies intention-to-treat analyses were not possible because of exclusions. Meta-analsis of the non-randomised studies showed that the use of local anaesthetic was associated with significant reductions in the odds of stroke (38 studies), death (42 studies), stroke or death (27 studies), myocardial infarction (27 studies), and pulmonary complications (seven studies), within 30 days of the operation. The methodological quality of the non-randomised trials was questionable. Thirteen of the non-randomised studies were prospective and 36 reported on a consecutive series of patients. In eleven non-randomised studies the number of arteries, as opposed to the number of patients, was unclear. AUTHORS' CONCLUSIONS There is insufficient evidence from randomised trials comparing carotid endarterectomy performed under local and general anaesthetic. Non-randomised studies suggest potential benefits with the use of local anaesthetic, but these studies may be biased.
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Affiliation(s)
- Kittipan Rerkasem
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand, 50200
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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: 130] [Impact Index Per Article: 7.6] [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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18
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Cervical Plexus Block. Pain Manag 2007. [DOI: 10.1016/b978-0-7216-0334-6.50145-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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19
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Guay J. Regional or general anesthesia for carotid endarterectomy? Evidence from published prospective and retrospective studies. J Cardiothorac Vasc Anesth 2006; 21:127-32. [PMID: 17289496 DOI: 10.1053/j.jvca.2006.07.022] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2006] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The aim of this study was to compare outcomes of patients undergoing carotid endarterectomy under regional or general anesthesia for any new neurologic impairment, stroke, stroke and/or death, death, and myocardial infarction. DESIGN Meta-analysis. SETTING A search of the National Library of Medicine of the United States PUBMED from 1966 up to June 11, 2005, with the following key words: "carotid surgery or endarterectomy and regional anesthesia." MEASUREMENTS AND MAIN RESULTS Forty-eight studies (14 prospective and 34 retrospective) were analyzed. The optimal information size was achieved only when all studies were analyzed together (prospective and retrospective). Regional anesthesia reduced the rate of any new neurologic impairment (odds ratio = 0.60; 95% confidence interval, 0.48-0.75; p < 0.00001), stroke (0.54 [0.43-0.68], p < 0.00001), stroke and/or death (0.62 [0.49-0.78], p < 0.0001), death (0.65 [0.48-0.87], p = 0.004), and myocardial infarction (0.50 [0.36-0.70], p < 0.0001). CONCLUSION The number of patients included in randomized controlled trials or even in prospective studies is too low to allow any conclusions on the differences in outcome between the 2 anesthetic techniques. Better outcomes are suggested when results from retrospective studies are added.
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Affiliation(s)
- Joanne Guay
- Department of Anesthesia, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada.
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20
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Kim YK, Hwang GS, Huh IY, Hwang JH, Park JY, Chung SL, Kwon TW, Han SM. Altered Autonomic Cardiovascular Regulation After Combined Deep and Superficial Cervical Plexus Blockade for Carotid Endarterectomy. Anesth Analg 2006; 103:533-9. [PMID: 16931657 DOI: 10.1213/01.ane.0000226096.96451.59] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Compromised cardiac autonomic modulation can produce cardiovascular disturbances. We investigated whether combined deep and superficial cervical plexus (CP) blockade for carotid endarterectomy (CEA) produces changes in autonomic cardiovascular regulation. To estimate alterations in cardiovascular autonomic control before and after combined CP blockade in 22 patients undergoing CEA, the heart rate (HR) variability, systolic blood pressure (SBP) variability, and baroreflex sensitivity were analyzed. We found that SBP (157 +/- 28 mm Hg versus 191 +/- 38 mm Hg before and after combined CP blockade, respectively) and HR (68 +/- 10 bpm versus 84 +/- 9 bpm) increased after combined CP blockade. The high frequency power of HR variability (3.7 +/- 0.9 versus 2.2 +/- 1.2 ln/ms2) decreased (decrease in parasympathetic drive), whereas the low frequency power of SBP variability (5.5 +/- 4.7 versus 8.6 +/- 9.4 mm Hg2) increased (increase in vascular sympathetic outflow). Baroreflex sensitivity decreased, and this decrease was negatively correlated with a SBP increase (r = -0.455). The present results suggest that combined CP blockade impairs autonomic cardiovascular homeostasis and suggests an association between combined CP blockade and intraoperative or postoperative adverse cardiovascular events in high-risk cardiac patients undergoing CEA that merits further studies.
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Affiliation(s)
- Young-Kug Kim
- Department of Anesthesiology and Pain Medicine, University of Ulsan College of Medicine, Asan Medical Center, Songpa-gu, Seoul, Korea
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21
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Schneemilch CE, Bachmann H, Ulrich A, Elwert R, Halloul Z, Hachenberg T. Clonidine Decreases Stress Response in Patients Undergoing Carotid Endarterectomy Under Regional Anesthesia: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Study. Anesth Analg 2006; 103:297-302, table of contents. [PMID: 16861405 DOI: 10.1213/01.ane.0000223673.68072.42] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Inadequate analgesia or anxiety may induce an increased stress response in patients undergoing carotid endarterectomy (CEA) under regional anesthesia (RA). Central alpha2 adrenoceptor agonists have significant sedative and analgesic properties, which may attenuate sympathoadrenal activation during CEA and improve the quality of RA. We randomly assigned 80 patients to 2 groups receiving either RA plus placebo (n = 40) or RA plus clonidine 1 microg/kg as the initial loading dose followed by 1 microg.kg(-1).h(-1) (n = 40). RA was performed as combined deep and superficial cervical plexus blockade. Hemodynamic and neurological variables were assessed before, during, and after CEA. Arterial blood samples were collected at defined time points for the determination of plasma concentrations of epinephrine, norepinephrine, cortisol, and creatinine kinase and creatinine kinase-MB. Throughout the study, all patients responded easily to neurological evaluations. Before and during clamping mean arterial blood pressure and heart rate were not different between the groups, but mean arterial blood pressure was lower in the clonidine group (P < 0.01) at skin closure and postoperatively in the intensive care unit. In the placebo group, cortisol, epinephrine, and norepinephrine plasma concentrations were increased significantly (P < 0.05) and more patients required antihypertensive treatment (P < 0.01). Postoperatively the incidence of hypertension (P < 0.001) and development of neurological deficits (P < 0.05) was significantly decreased in the clonidine group. We conclude that 1 microg.kg(-1).h(-1) clonidine suppresses the hyperadrenergic response to CEA without adverse effects on hemodynamics or clinical neurological monitoring.
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Affiliation(s)
- Christine E Schneemilch
- Department of Anesthesiology and Intensive Care Medicine, Otto-von-Guericke-University Magdeburg, Leipziger Str. 44, D-39120 Magdeburg, Germany.
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22
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Barry MC, Hendriks JM, Alberts G, Boomsma F, Van Dijk LC, Pattynama PMT, Poldermans D, Bouchier-Hayes DJ, Van Urk H, Van Sambeek MRHM. Comparison of Catecholamine Hormone Release in Patients Undergoing Carotid Artery Stenting or Carotid Endarterectomy. J Endovasc Ther 2004; 11:240-50. [PMID: 15174909 DOI: 10.1583/03-1093.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To investigate the pattern of catecholamine response in patients undergoing carotid endarterectomy (CEA) or carotid artery stenting (CAS). METHODS Adrenaline, noradrenaline, and renin levels were measured at 5 time points in 12 patients undergoing 13 CEAs (1 bilateral) and 13 patients undergoing unilateral CAS. Arterial blood samples were taken at the following time points: (1) after induction in CEA patients or 5 minutes following first contrast injection in CAS patients, (2) 5 minutes following ICA clamp release in surgical patients or deflation of the balloon in the CAS cohort, (3) 60 minutes following ICA clamp release in surgical patients or deflation of the balloon in the CAS cohort, and (4) 24 hours following the procedure. Intraoperative blood pressure and heart rate were recorded using radial arterial monitoring. Changes in adrenaline, noradrenaline, and renin levels are expressed as ratios versus baseline. RESULTS Patterns of adrenaline and noradrenaline release were significantly different in patients undergoing CAS and CEA, with much higher and more variable surges of adrenaline and noradrenaline occurring in CEA patients. Adrenaline and noradrenaline levels increased significantly over baseline following carotid artery clamping in patients undergoing CEA (noradrenaline ratio before clamping: 1.54+/-1.25, 24 hours after unclamping: 8.38+/-16.35 [p<0.001]; adrenaline ratio before clamping: 1.12+/-0.49, 60 minutes after unclamping: 17.59+/-19.14 [p<0.001]). Conversely, in patients undergoing CAS, catecholamine levels remained unchanged (noradrenaline ratio before dilation: 0.96+/-0.23, 24 hours after the procedure: 0.92+/-0.32 [p=NS]; adrenaline ratio before dilation: 0.83+/-0.33, 60 minutes after balloon deflation: 0.56+/-0.32 [p=NS]). CONCLUSIONS CAS is associated with a significantly less marked catecholamine response than CEA, which may reflect down-regulation of the sympathetic nervous system in response to carotid sinus stimulation during carotid angioplasty.
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Affiliation(s)
- Mary Claire Barry
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands.
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23
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Sindelić R, Vlajković G, Davidović L, Vujanac B, Vjestica M. Comparation of influence general and regional anesthesia on basic haemodynamic parameters during carotid endarterectomy. ACTA ACUST UNITED AC 2004; 51:37-43. [PMID: 16018364 DOI: 10.2298/aci0403037s] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Carotid endarterectomy (CEA) is a preventive operation to reduce the incidence of embolic and thrombotic cerebral stroke. CEA carries a significant perioeperartive mortality rate from stroke and myocardial infarction, which may even approach 5%. Thus, anesthetic and surgical techniques are constantly under scrutiny to try to reduce this relatively high incidence of morbidity and mortality. Anesthetic technique for CEA is divided to general (GA) and regional (RA) anesthesia, performed by cervical plexus block. The aim this study was to examine changes of basic haemodynamic parameters, which routinely fallows during CEA in condition of GA and RA. After obtaining institutional approval and informed consent, we randomized 50 patients scheduled for CEA (Tab.1) in two groups (GA and RA). We fallow blood pressure: systolic (BPs), mean (BPm), diastolic (BPd), heart rate (HR), and RPP index at the examined patients. The examination performed in six control times: before induction of anesthesia (T1), 10 minutes after beginning of operation (T2), 5 minutes after cross clamping of arteria carotis (T3), 5 minutes after declamping arteria carotis (T4), 10 minutes (T5) and 2 hours after operation (T6). The results of study shows significant changes of blood pressure (BPs and BPm) and RPP index in T2 time in patinets undergoing GA. The changes occurred under influence of induction agent thio- pental. These changes were in homeostatic range. In RA patinets, no haemodynamic changes registrated in control times. Therefore, from haemodynamic aspect RA was superior to GA.
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Affiliation(s)
- R Sindelić
- Institut za anesteziju i reanimaciju KCentra Srbije, Beograd
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24
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Abstract
BACKGROUND Carotid endarterectomy reduces the risk of stroke in people with recently symptomatic, severe carotid artery stenosis. However, there are significant perioperative risks which may be lessened by performing the operation under local rather than general anaesthetic. OBJECTIVES The aim of this review was to assess the risks of endarterectomy under local compared with general anaesthetic. SEARCH STRATEGY We searched the Stroke Group trials register (April 2003), MEDLINE (1966 to April 2003), EMBASE (1980 to 2002), and Index to Scientific and Technical Proceedings (1980 to 1994). We handsearched 13 relevant journals up to 2002, and searched the reference lists of articles identified. We also advertised the review in Vascular News (a newspaper for European vascular specialists) in August 2001. SELECTION CRITERIA Randomised trials and non-randomised studies comparing carotid endarterectomy under local versus general anaesthetic. DATA COLLECTION AND ANALYSIS One reviewer selected studies for inclusion and another independently checked the decisions. Two reviewers assessed trial quality and independently extracted the data. MAIN RESULTS Seven randomised trials involving 554 operations, and 41 non-randomised studies involving 25622 operations were included. The methodological quality of the non-randomised trials was questionable. Eleven of the non-randomised studies were prospective and 29 reported on a consecutive series of patients. In nine non-randomised studies the number of arteries, as opposed to the number of patients, was unclear. Meta-analysis of the non-randomised studies showed that the use of local anaesthetic was associated with significant reductions in the odds of death (35 studies), stroke (31 studies), stroke or death (26 studies), myocardial infarction (22 studies), and pulmonary complications (7 studies), within 30 days of the operation. Meta-analysis of the randomised studies showed that the use of local anaesthetic was associated with a significant reduction in local haemorrhage (OR = 0.31, 95% CI = 0.12 to 0.79) within 30 days of the operation, but there was no evidence of a reduction in the odds of operative stroke. However, the trials were too small to allow reliable conclusions to be drawn, and in some studies intention-to-treat analyses were not possible because of exclusions. REVIEWERS' CONCLUSIONS There is insufficient evidence from randomised trials comparing carotid endarterectomy performed under local and general anaesthetic. Non-randomised studies suggest potential benefits with the use of local anaesthetic, but these studies may be biased. More randomised studies are needed.
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25
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Plasma Concentrations of Lidocaine and Bupivacaine After Cervical Plexus Block for Carotid Surgery. Anesth Analg 1997. [DOI: 10.1213/00000539-199706000-00037] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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26
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Tissot S, Frering B, Gagnieu MC, Vallon JJ, Motin J. Plasma concentrations of lidocaine and bupivacaine after cervical plexus block for carotid surgery. Anesth Analg 1997; 84:1377-9. [PMID: 9174324 DOI: 10.1097/00000539-199706000-00037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- S Tissot
- Service d'Anesthésie-Réanimation, Hôpital Edouard Herriot, Lyon, France
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27
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McGlade DP, Murphy PM, Davies MJ, Scott DA, Silbert BS. Comparative effects of plain and epinephrine-containing bupivacaine on the hemodynamic response to cervical plexus anesthesia in patients undergoing carotid endarterectomy. J Cardiothorac Vasc Anesth 1996; 10:593-7. [PMID: 8841865 DOI: 10.1016/s1053-0770(96)80135-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES This study was designed to investigate whether the addition of epinephrine as a vasoconstrictor additive to local anesthetic affects the hemodynamic profile after cervical plexus block in patients presenting for carotid endarterectomy. DESIGN A prospective, double-blind, randomized trial. SETTING A university hospital. PARTICIPANTS Forty patients scheduled for carotid endarterectomy under regional anesthesia (cervical plexus block). INTERVENTIONS Patients were randomized to one of two groups. Group P (20 patients) received plain bupivacaine; group E (20 patients) received bupivacaine with epinephrine, 5 micrograms/mL. All patients received 2 mg/kg of bupivacaine, and group E received 2 micrograms/kg of epinephrine. The electrocardiogram and intra-arterial blood pressure were monitored continuously, and recordings of heart rate and blood pressure were recorded at predetermined intervals from before the block until the skin incision. RESULTS After the block, group E developed a sustained increase in heart rate of approximately 15% (p < 0.01), whereas group P showed no change. Systolic blood pressure increased significantly with time over the study period in both groups (p < 0.01). Diastolic blood pressure increased significantly in group P (p < 0.01) but not in group E. CONCLUSIONS Concerning cervical plexus block with bupivacaine, the use of epinephrine is associated with an increase in heart rate consistent with a beta-adrenergic effect from systemic absorption of the epinephrine. An increase in systolic blood pressure independent of the use of epinephrine also occurs, but epinephrine appears to mitigate against an increase in diastolic blood pressure.
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Affiliation(s)
- D P McGlade
- Department of Anesthesia, St. Vincent's Hospital, Melbourne, Victoria, Australia
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28
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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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29
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Naylor AR, Bell PR, Ruckley CV. Monitoring and cerebral protection during carotid endarterectomy. Br J Surg 1992; 79:735-41. [PMID: 1393457 DOI: 10.1002/bjs.1800790805] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Two recently published multicentre trials have confirmed the overall benefit of carotid endarterectomy in symptomatic patients with severe carotid artery disease. The key to improving further the long-term advantages of carotid endarterectomy, however, remains the continued reduction of the initial operative risk. While the principal responsibility for this continues to be borne by the surgeon, specifically in reducing technical error, the time is perhaps approaching when he or she might also be able to apply some of the recent advances in cerebrovascular research to reduce operative morbidity still further in the future. This article summarizes the aetiology and pathophysiology of operation-related neurological deficits and reviews current approaches towards intraoperative monitoring, cerebral protection and assessment of quality control.
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Affiliation(s)
- A R Naylor
- Department of Surgery, Leicester Royal Infirmary, UK
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30
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Die Bedeutung des Narkoseverfahrens für den intraund postoperativen Verlauf bei Karotisoperationen. Eur Surg 1991. [DOI: 10.1007/bf02658888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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