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Tomas VG, Hollis N, Ouanes JPP. Regional Anesthesia for Vascular Surgery and Pain Management. Anesthesiol Clin 2022; 40:751-773. [PMID: 36328627 DOI: 10.1016/j.anclin.2022.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Patients undergoing vascular surgery tend to have significant systemic comorbidities. Vascular surgery itself is also associated with greater cardiac morbidity and overall mortality than other types of noncardiac surgery. Regional anesthesia is amenable as the primary anesthetic technique for vascular surgery or as an adjunct to general anesthesia. When used as the primary anesthetic, regional anesthesia techniques avoid complications associated with general anesthesia in this challenging patient population. In this article, the authors describe regional anesthetic techniques for carotid endarterectomy, arteriovenous fistula creation, lower extremity bypass surgery, and amputation.
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Affiliation(s)
- Vicente Garcia Tomas
- Department of Anesthesiology, Regional Anesthesia and Acute Pain Medicine, Northwestern University Feinberg School of Medicine Chicago, 251 E. Huron St F5-704, Chicago, IL 60611, USA.
| | - Nicole Hollis
- Department of Anesthesiology, West Virginia University, 1 Medical Center Drive PO Box 8255, Morgantown, WV 26508, USA
| | - Jean-Pierre P Ouanes
- Cornell Medicine, Hospital for Special Surgery, Florida, 300 Palm Beach Lakes Boulevard, West Palm Beach, FL 33401, USA
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Kim JS, Ko JS, Bang S, Kim H, Lee SY. Cervical plexus block. Korean J Anesthesiol 2018; 71:274-288. [PMID: 29969890 PMCID: PMC6078883 DOI: 10.4097/kja.d.18.00143] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 06/24/2018] [Indexed: 12/14/2022] Open
Abstract
Cervical plexus blocks (CPBs) have been used in various head and neck surgeries to provide adequate anesthesia and/or analgesia; however, the block is performed in a narrow space in the region of the neck that contains many sensitive structures, multiple fascial layers, and complicated innervation. Since the intermediate CPB was introduced in addition to superficial and deep CPBs in 2004, there has been some confusion regarding the nomenclature and definition of CPBs, particularly the intermediate CPB. Additionally, as the role of ultrasound in the head and neck region has expanded, CPBs can be performed more safely and accurately under ultrasound guidance. In this review, the authors will describe the methods, including ultrasound-guided techniques, and clinical applications of conventional deep and superficial CPBs; in addition, the authors will discuss the controversial issues regarding intermediate CPBs, including nomenclature and associated potential adverse effects that may often be neglected, focusing on the anatomy of the cervical fascial layers and cervical plexus. Finally, the authors will attempt to refine the classification of CPB methods based on the target compartments, which can be easily identified under ultrasound guidance, with consideration of the effects of each method of CPB.
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Affiliation(s)
- Jin-Soo Kim
- Department of Anesthesiology and Pain Medicine, Ajou University College of Medicine, Suwon, Korea
| | - Justin Sangwook Ko
- Depatment of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University College of Medicine,, Seoul, Korea
| | - Seunguk Bang
- Depatment of Anesthesiology and Pain Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyungtae Kim
- Department of Anesthesiology and Pain Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Sook Young Lee
- Department of Anesthesiology and Pain Medicine, Ajou University College of Medicine, Suwon, Korea
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Mismar AA, Mahseeri MI, Al-Ghazawi MA, Obeidat FW, Albsoul MN, Al-Qudah MS, Albsoul NM. Wound infiltration with bupivacaine 0.5% with or without adrenaline does not decrease pain after thyroidectomy. A randomized controlled study. Saudi Med J 2018; 38:994-999. [PMID: 28917062 PMCID: PMC5694648 DOI: 10.15537/smj.2017.10.20294] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: To study the effect of local wound infiltration with and without adrenaline on pain perception after thyroidectomy using the visual analog score (VAS). Methods: A prospective randomized controlled double-blinded study was conducted between May 2015 and June 2016 at The University of Jordan Hospital, Amman, Jordan. Eighty-nine patients undergoing planned thyroidectomy were included in the study. Patients were divided randomly into 3 groups: Group A, local wound infiltration with bupivacaine 0.5% was administered; Group B, bupivacaine 0.5% with adrenaline was administered; Group C (control), no infiltration was performed. Standardized thyroidectomies were performed in the 3 groups. Pain perception was measured using VAS at 2, 4, 6, 12, and 24 hours after surgery. A comparison between the 3 groups was carried out. Results: No significant differences among the 3 groups were observed at all time points (p=0.246). Visual analog scores were significantly lower at 12 and 24 hours after operations. Conclusion: Local wound infiltration with bupivacaine 0.5% does not decrease pain perception after thyroidectomy performed under general anesthesia, and adding adrenaline does not enhance its effect.
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Affiliation(s)
- Ayman A Mismar
- Department of Surgery, Faculty of Medicine, The University of Jordan, Amman, Jordan. E-mail.
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Lam SKH, Reeves KD, Cheng AL. Transition from Deep Regional Blocks toward Deep Nerve Hydrodissection in the Upper Body and Torso: Method Description and Results from a Retrospective Chart Review of the Analgesic Effect of 5% Dextrose Water as the Primary Hydrodissection Injectate to Enhance Safety. BIOMED RESEARCH INTERNATIONAL 2017; 2017:7920438. [PMID: 29226148 PMCID: PMC5684526 DOI: 10.1155/2017/7920438] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/19/2017] [Accepted: 07/24/2017] [Indexed: 01/29/2023]
Abstract
Deep nerve hydrodissection uses fluid injection under pressure to purposely separate nerves from areas of suspected fascial compression, which are increasingly viewed as potential perpetuating factors in recalcitrant neuropathic pain/complex regional pain. The usage of 5% dextrose water (D5W) as a primary injectate for hydrodissection, with or without low dose anesthetic, could limit anesthetic-related toxicity. An analgesic effect of 5% dextrose water (D5W) upon perineural injection in patients with chronic neuropathic pain has recently been described. Here we describe ultrasound-guided methods for hydrodissection of deep nerve structures in the upper torso, including the stellate ganglion, brachial plexus, cervical nerve roots, and paravertebral spaces. We retrospectively reviewed the outcomes of 100 hydrodissection treatments in 26 consecutive cases with a neuropathic pain duration of 16 ± 12.2 months and the mean Numeric Pain Rating Scale (NPRS) 0-10 pain level of 8.3 ± 1.3. The mean percentage of analgesia during each treatment session involving D5W injection without anesthetic was 88.1% ± 9.8%. The pretreatment Numeric Pain Rating Scale score of 8.3 ± 1.3 improved to 1.9 ± 0.9 at 2 months after the last treatment. Patients received 3.8 ± 2.6 treatments over 9.7 ± 7.8 months from the first treatment to the 2-month posttreatment follow-up. Pain improvement exceeded 50% in all cases and 75% in half. Our results confirm the analgesic effect of D5W injection and suggest that hydrodissection using D5W provides cumulative pain reduction.
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Affiliation(s)
- Stanley K. H. Lam
- Department of Family Medicine, Faculty of Medicine, The Chinese University of Hong Kong, Sha Tin, Hong Kong
- KH Lam Musculoskeletal Pain Management and Sports Injury Centre, Kowloon, Hong Kong
- The Hong Kong Institute of Musculoskeletal Medicine, Tsuen Wan, Hong Kong
| | | | - An-Lin Cheng
- Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
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Kale S, Aggarwal S, Shastri V, Chintamani. Evaluation of the Analgesic Effect of Bilateral Superficial Cervical Plexus Block for Thyroid Surgery: A Comparison of Presurgical with Postsurgical Block. Indian J Surg 2016; 77:1196-200. [PMID: 27011535 DOI: 10.1007/s12262-015-1244-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 02/02/2015] [Indexed: 10/24/2022] Open
Abstract
Bilateral superficial cervical plexus block may help in reduction of postthyroidectomy pain. The aim of this study was to evaluate the influence of bilateral superficial cervical plexus block (BSCB) given either presurgically or postsurgically on analgesia in postthyroidectomy patients. Sixty adult euthyroid patients were randomly allocated to one of the three groups, to receive BSCB either presurgically (group A) or postsurgically (group B). Both of the above groups were compared with parenteral analgesics (group C). Thyroid surgery was performed according to a standardised procedure. Postoperative pain was assessed by visual analog scale (VAS), with 10 being the worst pain and 0 being no pain, when patient was fully awake and extubated (0) and after 1, 2, 4, 8, 12, 18, 24, 36 and 48 h. VAS was assessed at four phases: at rest, neck movements, vocalisation and swallowing. Total use of intraoperative fentanyl was noted. The time for first rescue analgesic was also noted. There was no significant statistical difference amongst three groups as regards demographic data and duration of surgery. Patients given BSCBs (either presurgically or postsurgically) had significant lower VAS at all four phases of pain assessment as compared to group C. The time for first rescue analgesia was the earliest in group C. We concluded that BSCB whether given presurgically or postsurgically significantly reduce pain intensity and opioids requirement in postoperative period after thyroid surgery.
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Affiliation(s)
- Suniti Kale
- Department of Anesthesiology and Intensive Care, Safdarjung Hospital, New Delhi, 110029 India
| | - Shipra Aggarwal
- Department of Anesthesiology and Intensive Care, Safdarjung Hospital, New Delhi, 110029 India
| | - Vineet Shastri
- Department of Anesthesiology and Intensive Care, Safdarjung Hospital, New Delhi, 110029 India
| | - Chintamani
- Department of Anesthesiology and Intensive Care, Safdarjung Hospital, New Delhi, 110029 India
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Cervical sympathetic block prolongs the latency and reduces the amplitude of trigeminal somatosensory evoked potentials on the contralateral side. J Clin Neurophysiol 2015; 32:39-43. [PMID: 25159735 DOI: 10.1097/wnp.0000000000000122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The purpose of this study was to investigate the latency and amplitude of trigeminal somatosensory evoked potentials to clarify how nerve function on the contralateral side is affected after cervical sympathetic block (CSB). METHODS Subjects comprised 16 volunteers. For CSB, the tip of a needle was contacted with the transverse process of the sixth cervical vertebra on the right side, and lidocaine was injected. Trigeminal somatosensory evoked potentials were recorded bilaterally from C5/C6 scalp positions. Pupil diameters were also measured. Electrical stimulations were applied to the left-side lower lip, and trigeminal somatosensory evoked potentials waveforms derived from both sides of the scalp were recorded. Then, electrical stimulations were applied to the right-side of the lower lip, and recording was again performed. Recordings were performed at 5, 15, and 30 minutes after CSB. RESULTS On the CSB side, pupil diameter decreased at 5 and 15 minutes after CSB. Trigeminal somatosensory evoked potentials at contralateral stimulation showed a prolongation of the latency in both P20 and N25 components on bilateral recording sites 5 and 15 minutes after CSB. Trigeminal somatosensory evoked potentials' amplitude at contralateral stimulation was smaller than at ipsilateral stimulation 5 minutes after CSB. CONCLUSIONS Cervical sympathetic block prolongs the latency and reduces the amplitude of trigeminal somatosensory evoked potentials on the contralateral side.
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Abstract
Summary Regional anaesthesia is a popular choice for patients undergoing carotid endarterectomy (CEA). Neurological function is easily assessed during carotid cross-clamping; haemodynamic control is predictable; and hospital stay is consistently shorter compared with general anaesthesia (GA). Despite these purported benefits, mortality and stroke rates associated with CEA remain around 5% for both regional anaesthesia and GA. Regional anaesthetic techniques for CEA have improved with improved methods of location of peripheral nerves including nerve stimulators and ultrasound together with a modification in the classification of cervical plexus blocks. There have also been improvements in local anaesthetic, sedative, and arterial pressure-controlling drugs in patients undergoing CEA, together with advances in the management of patients who develop neurological deficit after carotid cross-clamping. In the UK, published national guidelines now require the time between the patient's presenting neurological event and definitive treatment to 1 week or less. This has implications for the ability of vascular centres to provide specialized vascular anaesthetists familiar with regional anaesthetic techniques for CEA. Providing effective regional anaesthesia for CEA is an important component in the armamentarium of techniques for the vascular anaesthetist in 2014.
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Affiliation(s)
- M D Stoneham
- Nuffield Division of Anaesthetics, Level 2, Oxford University Hospitals NHS Trust, Headley Way, Oxford OX3 9DU, UK
| | - D Stamou
- Nuffield Division of Anaesthetics, Level 2, Oxford University Hospitals NHS Trust, Headley Way, Oxford OX3 9DU, UK
| | - J Mason
- Nuffield Division of Anaesthetics, Level 2, Oxford University Hospitals NHS Trust, Headley Way, Oxford OX3 9DU, UK
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Kwak IS, Lim T, Oh Y, Kim YR, Lee YK. Bilateral recurrent laryngeal nerve palsy in a patient undergoing consecutive thyroid operations. Korean J Anesthesiol 2013; 65:S36-7. [PMID: 24478864 PMCID: PMC3903852 DOI: 10.4097/kjae.2013.65.6s.s36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- In-Suk Kwak
- Department of Anesthesiology and Pain Medicine, Hangang Sacread-Heart Hospital, Seoul, Korea
| | - Taewan Lim
- Department of Anesthesiology and Pain Medicine, Dongtan Sacread-Heart Hospital, Hwasung, Korea
| | - Yul Oh
- Department of Anesthesiology and Pain Medicine, Dongtan Sacread-Heart Hospital, Hwasung, Korea
| | - Young Ri Kim
- Department of Anesthesiology and Pain Medicine, Dongtan Sacread-Heart Hospital, Hwasung, Korea
| | - Yoon Kyung Lee
- Department of Anesthesiology and Pain Medicine, Hangang Sacread-Heart Hospital, Seoul, Korea
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Mukhopadhyay S, Niyogi M, Dutta M, Ray R, Gayen GC, Mukherjee M, Mukhopadhyay BS. Bilateral superficial cervical plexus block with or without low-dose intravenous ketamine analgesia: effective, simple, safe, and cheap alternative to conventional general anesthesia for selected neck surgeries. Local Reg Anesth 2012; 5:1-7. [PMID: 22915895 PMCID: PMC3417975 DOI: 10.2147/lra.s28360] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background General anesthesia is commonly used for surgery in the neck region. Superficial cervical plexus block is adequate to produce anesthesia in the anterior and anterolateral aspects of the neck. Our aim was to observe the effectiveness of bilateral cervical plexus block for surgery in this region of the neck. Methods A total of 136 neck surgery cases were enrolled in this prospective uncontrolled study. All patients were administered ropivacaine 0.5% as a bilateral cervical plexus block. The incision line was infiltrated with lignocaine 1% and adrenaline 1:100,000. For thyroglossal cyst and thyroglossal fistula, an additional 1.5 mL of LA solution was deposited over the hyoid bone on both sides of the midline. Any anesthetic inadequacy was corrected using ketamine 25 mg intravenously and repeated if necessary. Results Of 37 patients with thyroglossal cyst, the block was sufficient in 36 patients, and one patient required ketamine. Block was adequate in 23 of 24 patients with thyroglossal fistula, and one patient required ketamine. Among the branchial cyst and branchial fistula cases, six of 16 patients required ketamine supplementation. Of three thyroidectomy patients, one required ketamine supplementation, and one was converted to conventional general anesthesia. For lymph node excision and lymph node biopsy patients, LA block was sufficient in all 31 cases. In the last group, one of 25 patients required ketamine supplementation. Conclusion The overall success of bilateral cervical plexus block as a sole method of anesthesia in these selected neck surgeries was 91.9% and with low-dose ketamine supplementation it approached more than 99%. However, cervical plexus block was not a good method of anesthesia for thyroid surgery in this study. For the remainder of cases, bilateral cervical plexus block alone or in conjunction with ketamine appeared to be a cheap, safe, and effective alternative to conventional general anesthesia.
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Shih ML, Duh QY, Hsieh CB, Liu YC, Lu CH, Wong CS, Yu JC, Yeh CC. Bilateral superficial cervical plexus block combined with general anesthesia administered in thyroid operations. World J Surg 2011; 34:2338-43. [PMID: 20623224 PMCID: PMC2939771 DOI: 10.1007/s00268-010-0698-7] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background We investigated the analgesic efficacy of bilateral superficial cervical plexus block in patients undergoing thyroidectomy and to determine whether it reduces the adverse effects of general anesthesia. Methods We prospectively recruited 162 patients who underwent elective thyroid operations from March 2006 to October 2007. They were randomly assigned to receive a bilateral superficial cervical block (12 ml per side) with isotonic saline (group A; n = 56), bupivacaine 0.5% (group B; n = 52), or levobupivacaine 0.5% (group C; n = 54) after induction of general anesthesia. The analgesic efficacy of the block was assessed with: intraoperative anesthetics (desflurane), numbers of patients needing postoperative analgesics, the time to the first analgesics required, and pain intensity by visual analog scale (VAS). Postoperative nausea and vomiting (PONV) for 24 h were also assessed by the “PONV grade.” We also compared hospital stay, operative time, and discomfort in swallowing. Results There were no significant differences in patient characteristics. Each average end-tidal desflurane concentration was 5.8, 3.9, and 3.8% in groups A, B, and C, respectively (p < 0.001). Fewer patients in groups B and C required analgesics (A: B: C = 33:8:7; p < 0.001), and it took longer before the first analgesic dose was needed postoperatively (group A: B: C = 82.1:360.8:410.1 min; p < 0.001). Postoperative pain VAS were lower in groups B and C for the first 24 h postoperatively (p < 0.001). Incidences of overall and severe PONV were lower, however, there were not sufficient numbers of patients to detect differences in PONV among the three groups. Hospital stay was shorter in group B and group C (p = 0.011). There was no significant difference in operative time and postoperative swallowing pain among the three groups. Conclusions Bilateral superficial cervical plexus block reduces general anesthetics required during thyroidectomy. It also significantly lowers the severity of postoperative pain during the first 24 h and shortens the hospital stay.
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Affiliation(s)
- Ming-Lang Shih
- Division of General Surgery, Department of Surgery, Tri-service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC.
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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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Steffen T, Warschkow R, Brändle M, Tarantino I, Clerici T. Randomized controlled trial of bilateral superficial cervical plexus block versus placebo in thyroid surgery. Br J Surg 2010; 97:1000-6. [DOI: 10.1002/bjs.7077] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Bilateral superficial cervical block during thyroid surgery can reduce postoperative pain but its value is unclear. This randomized clinical trial assessed the efficacy of such regional anaesthesia on postoperative pain after thyroid surgery performed under general anaesthesia.
Methods
Patients undergoing thyroid surgery were randomized to one of four groups in a double-blind fashion. Patients received a cervical block with placebo or bupivacaine at the start or end of surgery. Postoperative pain, analgesic use and length of hospital stay were assessed.
Results
There were 159 patients eligible for analysis. The bupivacaine group had significantly less pain than the placebo group (P = 0·016). The timing of bupivacaine administration did not significantly influence pain (preoperative versus postoperative, P = 0·723). There was no difference between groups in the amount of analgesic used. Length of hospital stay was the same in the bupivacaine and placebo groups (P = 0·925) and when bupivacaine was administered at the beginning or end of surgery (P = 0·087).
Conclusion
Bilateral superficial cervical block with bupivacaine combined with general anaesthesia significantly reduced postoperative pain after thyroid surgery. Registration number: NCT00472446 (http://www.clinicaltrials.gov).
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Affiliation(s)
- T Steffen
- Department of Surgery, Kantonsspital St Gallen, St Gallen, Switzerland
| | - R Warschkow
- Department of Surgery, Kantonsspital St Gallen, St Gallen, Switzerland
| | - M Brändle
- Division of Endocrinology and Diabetes, Kantonsspital St Gallen, St Gallen, Switzerland
| | - I Tarantino
- Department of Surgery, Kantonsspital St Gallen, St Gallen, Switzerland
| | - T Clerici
- Department of Surgery, Kantonsspital St Gallen, St Gallen, Switzerland
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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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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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15
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Vercauteren M, Heytens L. Anaesthetic considerations for patients with a pre-existing neurological deficit: are neuraxial techniques safe? Acta Anaesthesiol Scand 2007; 51:831-8. [PMID: 17488315 DOI: 10.1111/j.1399-6576.2007.01325.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pre-existing neurological and muscular disease may be a specific concern for anaesthetists as they need to consider the effect of anaesthesia upon the disease, vice versa, and the interaction of anaesthesia with the medication taken by the patient. Despite a lack of controlled studies, many anaesthetists, being afraid of a claim, will prefer general rather than regional anaesthesia in these patients. Nevertheless regional anaesthesia certainly merits its place because it offers undeniable advantages. A good pre-operative examination is very important while patients should also be informed about peri-operative implications of anaesthesia, surgery and stress. Paraesthesias, epinephrine and high concentrations of local anaesthetics should be avoided in the majority of the diseases. Some diseases may benefit from epidural anaesthesia while for others a spinal technique may be the technique of preference. Special attention should be paid to patients with spinal stenosis despite recent reassuring reports with respect to safety of regional anaesthetic techniques. Anaesthetists should not automatically take all responsibility in case of progressive or new deficit after the procedure.
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Affiliation(s)
- M Vercauteren
- Department of Anaesthesia, University Hospital Antwerp, Edegem, Belgium.
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Thermann F, Ukkat J, John E, Dralle H, Brauckhoff M. Frequency of transient ipsilateral vocal cord paralysis in patients undergoing carotid endarterectomy under local anesthesia. J Vasc Surg 2007; 46:37-40. [PMID: 17543491 DOI: 10.1016/j.jvs.2007.02.071] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Accepted: 02/28/2007] [Indexed: 11/21/2022]
Abstract
BACKGROUND Especially because of improvements in clinical neurologic monitoring, carotid endarterectomy done under local anesthesia has become the technique of choice in several centers. Temporary ipsilateral vocal nerve palsies due to local anesthetics have been described, however. Such complications are most important in situations where there is a pre-existing contralateral paralysis. We therefore examined the effect of local anesthesia on vocal cord function to better understand its possible consequences. METHODS This prospective study included 28 patients undergoing carotid endarterectomy under local anesthesia. Vocal cord function was evaluated before, during, and after surgery (postoperative day 1) using flexible laryngoscopy. Anesthesia was performed by injecting 20 to 40 mL of a mixture of long-acting (ropivacaine) and short-acting (prilocaine) anesthetic. RESULTS All patients had normal vocal cord function preoperatively. Twelve patients (43%) were found to have intraoperative ipsilateral vocal cord paralysis. It resolved in all cases < or =24 hours. There were no significant differences in operating time or volume or frequency of anesthetic administration in patients with temporary vocal cord paralysis compared with those without. CONCLUSION Local anesthesia led to temporary ipsilateral vocal cord paralysis in almost half of these patients. Because pre-existing paralysis is of a relevant frequency (up to 3%), a preoperative evaluation of vocal cord function before carotid endarterectomy under local anesthesia is recommended to avoid intraoperative bilateral paralysis. In patients with preoperative contralateral vocal cord paralysis, surgery under general anesthesia should be considered.
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Affiliation(s)
- Florian Thermann
- Department for General, Visceral and Vascular Surgery, University Hospital Halle, Ernst-Grube-Strasse 40, 06097 Halle, Germany.
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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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Narins CR, Illig KA. Patient selection for carotid stenting versus endarterectomy: A systematic review. J Vasc Surg 2006; 44:661-72. [PMID: 16950453 DOI: 10.1016/j.jvs.2006.05.042] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2006] [Accepted: 05/20/2006] [Indexed: 11/18/2022]
Abstract
Carotid artery stenting has emerged as an alternative to carotid endarterectomy for the treatment of severe extracranial carotid stenosis in patients with anatomic or clinical factors that increase their risk of complications with surgery, yet there remains a substantial amount of variability and uncertainty in clinical practice in the referral of patients for stenting vs endarterectomy. By undertaking a thorough review of the literature, we sought to better define which subsets of patients with "high-risk" features would be likely to preferentially benefit from carotid stenting or carotid endarterectomy. Although only a single randomized trial comparing the outcomes of carotid stenting with distal protection and endarterectomy has been completed, a wealth of observational data was reviewed. Relative to endarterectomy, the results of carotid stenting seem favorable in the setting of several anatomic conditions that render surgery technically difficult, such as restenosis after prior endarterectomy, prior radical neck surgery, and previous radiation therapy involving the neck. The results of stenting are also favorable among patients with severe concomitant cardiac disease. Carotid endarterectomy, alternatively, seems to represent the procedure of choice among patients 80 years of age or older in the absence of other high-risk features. Overall, existing data support the concept that carotid stenting and endarterectomy represent complementary rather than competing modes of therapy. Pending the availability of randomized trial data to help guide procedural selection, which is likely many years away, an objective understanding of existing data is valuable to help select the optimal mode of revascularization therapy for patients with severe carotid artery disease who are at heightened surgical risk.
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Affiliation(s)
- Craig R Narins
- Division of Cardiology, University of Rochester Medical Center, NY 14642, USA.
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Nouraei SAR, Davies MR, Obholzer R, Sandhu GS, Porter F. Haemodynamic instability during thyroid surgery: a baroreflex-mediated neurogenic phenomenon? Anaesthesia 2006; 61:282-4. [PMID: 16480355 DOI: 10.1111/j.1365-2044.2005.04436.x] [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: 11/28/2022]
Abstract
We present a case of marked intra-operative blood pressure instability in a euthyroid, fit 33-year-old female undergoing elective hemithyroidectomy. This led to significant haemodynamic compromise, cardiac failure and end-organ damage. There was no evidence of a vasoactive endocrine cause, and the nature and timing of the event strongly pointed towards baroreflex-mediated neurogenic sympathetic dysfunction. This can occur during carotid surgery and neck dissection. Although haemodynamic fluctuations may happen during thyroid surgery, their severity in this case was unusual. We believe this could have been a rebound phenomenon in response to acute decompression of the carotid artery which had been compressed by an enlarging cyst. We suggest that in similar cases blockade of the carotid sinus could attenuate such responses.
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Affiliation(s)
- S A R Nouraei
- Department of Otolaryngology, Charing Cross Hospital, London W6 8RF, UK
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