A prospective, randomized comparison between combined (deep and superficial) and superficial cervical plexus block with levobupivacaine for minimally invasive parathyroidectomy

Use of intermediate cervical plexus block in carotid endarterectomy -an alternative to deep cervical plexus block: a case series

INTRODUCTION

Carotid endarterectomy is performed for patients with symptomatic carotid artery occlusions. Surgery can be performed under general and regional anesthesia. Traditionally, surgery is performed under deep cervical plexus block which is technically difficult to perform and can cause serious complications. This case series describes 5 cases in which an intermediate cervical plexus block was used in combination with a superficial cervical plexus block for Carotid endarterectomy surgery.

METHODS

Five patients who were classified as American Society of Anesthesiologists 2-3 were scheduled for Carotid endarterectomy due to symptoms and more than 70% occlusion of the carotid arteries. The procedures were carried out in the University Teaching Hospital- Peradeniya, Sri Lanka. All patients were given superficial cervical plexus block followed by intermediate cervical plexus block using 2% lignocaine and 0.5% plain bupivacaine.

RESULTS

Adequate anesthesia was achieved in 4 patients, and local infiltration was necessary in 1 patient. Two patients developed hoarseness of the voice, which settled 2 h after surgery. Hemodynamic fluctuations were observed in all 5 patients. No serious complications were observed. All 5 patients had uneventful recoveries.

DISCUSSIONS

Regional anesthesia for CEA is preferable in patients who are medically complicated to undergo anesthesia or in patients for whom cerebral monitoring is not available. Intermediate cervical plexus block is described for thyroid surgeries in literature, but not much details on its use for carotid surgeries. Deep cervical plexus blocks has few serious complications which is not there with the use of ICPB making it a good alternative for CEA surgeries .

CONCLUSIONS

Superficial cervical plexus block and intermediate cervical plexus block can be used effectively for providing anesthesia for patients undergoing Carotid endarterectomy. It is safe and easier to conduct than deep cervical plexus block and enables monitoring of cerebral function.

Regional Anesthesia for Vascular Surgery and Pain Management

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.

Ultrasound-guided bilateral superficial cervical plexus block enhances the quality of recovery of uremia patients with secondary hyperparathyroidism following parathyroidectomy: a randomized controlled trial

Background

Parathyroidectomy has been proposed as a method for reducing parathyroid hormone levels. We evaluated the effects of ultrasound-guided bilateral superficial cervical plexus block (BSCPB) on the quality of recovery of uremia patients with secondary hyperparathyroidism (SHPT) following parathyroidectomy.

Methods

Eighty-two uremia patients who underwent parathyroidectomy and exhibited SHPT were randomly allocated to the BSCPB group or the control group (CON group). The patients received ultrasound-guided BSCPB with 7.5 ml of ropivacaine 0.5% on each side (BSCPB group) or equal amount of 0.9% normal saline (CON group). The primary outcome of the Quality of Recovery-40(QoR-40) score was recorded on the day before surgery and postoperative day 1(POD1). Secondary outcomes including total consumption of remifentanil, time to first required rescue analgesia, number of patients requiring rescue analgesia, and total consumption of tramadol during the first 24 h after surgery were recorded. The occurrence of postoperative nausea or vomiting (PONV) and the visual analogue scale (VAS) scores were assessed and recorded.

Results

The scores on the pain and emotional state dimensions of the QoR-40 and the total QoR-40 score were higher in the BSCPB group than in the CON group on POD1 (P = 0.000). Compared with the CON group, the total consumption of remifentanil was significantly decreased in the BSCPB group (P = 0.000). The BSCPB group exhibited longer time to first required rescue analgesia (P = 0.018), fewer patients requiring rescue analgesia (P = 0.000), and lower postoperative total consumption of tramadol during the first 24 h after surgery (P = 0.000) than the CON group. The incidence of PONV was significantly lower in the BSCPB group than in the CON group (P = 0.013). The VAS scores in the BSCPB group were lower than those in the CON group at all time-points after surgery (P = 0.000).

Conclusion

Ultrasound-guided BSCPB with ropivacaine 0.5% can enhance the quality of recovery, postoperative analgesia, and reduce the incidence of PONV in uremia patients with SHPT following parathyroidectomy.

Trial registration

ChiCTR1900027185 . (Prospective registered). Initial registration date was 04/11/2019.

Effects of Ultrasound-Guided Bilateral Cervical Plexus Block Combined with General Anesthesia in Patients Undergoing Total Parathyroidectomy and Partial Gland Autotransplantation Surgery

Background

The aim of this study is to evaluate the effect of ultrasound-guided bilateral cervical plexus block on general anesthesia, postoperative analgesia, and surgical outcomes in patients undergoing total parathyroidectomy with autotransplantation.

Patients and Methods

Forty-eight ASA III–IV patients with hyperparathyroidism secondary to renal failure were included: 24 patients received ultrasound-guided bilateral superficial and deep cervical plexus block combined with general anesthesia (group A), and 24 patients received general anesthesia alone (group B). Postoperative patient-controlled intravenous analgesia was provided with sufentanil 2 μg/kg. The primary outcome is the postoperative pain scores. Secondary outcomes include intraoperative remifentanil dosage, changes in hemodynamics, extubation time, and sufentanil consumption. Surgical outcomes regarding calcium, phosphorus and parathormone values were also noted.

Results

The patients in group A required less remifentanil than group B (2.56±0.92mg vs 3.38±0.84mg, P=0.002) and lower VAS scores at 1, 3, 10, 24, and 48h postoperatively (P < 0.001). While the systolic blood pressure in group A patients was significantly greater than that in group B at T3 (immediately after extubation, [138.33±11.36 vs 129.08±17.06 mmHg; P=0.032]), heart rates in group A were lower than in group B at 1 min before induction (T1 [89.46 ± 9.14 vs 96.71±14.19, P=0.042]) and 1 min after intubation (T2 [70.08 ± 5.35 vs 79.25 ± 11.81, P=0.002]). The extubation time in group A was shorter than that in group B (P < 0.001). There was no difference in calcium, phosphorus and parathormone values, nor in sufentanil consumption between the groups.

Conclusion

Ultrasound-guided bilateral superficial and deep cervical plexus block combined with general anesthesia for TPTA is an effective strategy to improve anesthesia management and achieve better postoperative analgesia, and has no impact on surgical outcomes.

Peripheral nerve blocks in the cervical region: from anatomy to ultrasound-guided techniques

Cervical plexus nerve blocks have been employed in various head and neck operations. Both adequate anaesthesia and analgesia are attained in clinical practice. Nowadays, ultrasound imaging in regional anaesthesia is driven towards a certain objective that dictates high accuracy and safety during the implementation of peripheral nerve blocks. In the cervical region, ultrasound-guided nerve blocks have routinely been conducted only for the past few years and thus only a small number of publications pervade the current literature. Moreover, the sonoanatomy of the neck, the foundation stone of interventional techniques, is very challenging; multiple muscles and fascial layers compose a complex of compartments in a narrow anatomic region, in which local anaesthetics are injected. Therefore, this review intends to deliver new insights into ultrasound-guided peripheral nerve block techniques in the neck. The sonoanatomy of the cervical region, in addition to the cervical plexus, cervical ganglia, superior and recurrent laryngeal nerve blocks are comprehensively discussed.

Surgical options in treating patients with primary hyperparathyroidism

Background

Primary hyperparathyroidism is the third most common endocrine disorder for which surgical procedure called parathyroidectomy is the most effective treatment. Since the early 20^th century, parathyroid surgery has improved extensively. With the advances in preoperative imaging and with understanding the causes of disease, new and minimally invasive surgical approaches overrode the standard bilateral exploratory operations. Directed parathyroidectomy is currently the standard technique for treatment of primary hyperparathyroidism worldwide.

Conclusions

Surgery is the only definitive treatment of primary hyperparathyroidism. The most appropriate type of surgical procedure depends on the number and localization of the hyperactive parathyroid glands, availability of modern imaging techniques, limitation of each type of procedure and expertise.

A fluoroscopic assessment of brachial plexus block by the supraclavicular approach: Have we been overmedicating?

Background

Ultrasonography-guided supraclavicular brachial plexus block has demonstrated safety as compared with landmark or nerve stimulation techniques. However, the minimum effective analgesic volume (MEAV) necessary for adequate blockade has not been determined. This study was undertaken to assess under fluoroscopy the postinjection spread of different drug volumes with clinical correlation. Secondary outcome measures included correlation of onset of block, block quality, and incidence of side effects.

Methods

This randomized, multiarm, cross-sectional, observational study was conducted at a single tertiary care center. A total of 549 patients were randomly allocated to 3 groups (20 ml, 30 ml, and 40 ml of drug mixture). A local anesthetic drug mixture with a radiopaque dye was administered under ultrasonographic guidance, and postinjection fluoroscopic drug spread was studied.

Results

Surgical anesthesia was achieved in 494 (89.98%) patients with 85.25%, 92.97%, and 91.71% in 20-, 30-, and 40-ml groups, respectively, being significantly low (p = 0.0317) in the 20-mL group. Cephalad and infraclavicular spread was higher in the 40-mL group than in other two groups (p = 0.103). Horner syndrome (HS) was seen in 51.18% of patients. First, ipsilateral superficial cervical plexus block was also observed in 40.22% of patients. Among patients who developed both, ∼60% of patients (99/167) belonged to the 40-mL group.

Conclusions

Optimal MEAV appears between 20 and 30 mL. Higher drug volumes are associated with more cephalad spread and side effects. Drug spread can predict block efficacy as well. It is postulated that loss of sensation in the ipsilateral neck can be used to predict development of hemidiaphragmatic paresis similar to HS.

Cervical plexus block

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.

Use of Ultrasound-Guided Superficial Cervical Plexus Block for Pain Management in the Emergency Department

BACKGROUND

Although use of the superficial cervical plexus block (SCPB) by anesthesia for perioperative indications is well described, there is a paucity of research on use of SCPB in the emergency department (ED).

OBJECTIVE

This prospective observational study aims to prospectively characterize the feasibility, potential for efficacy, and safety of ultrasound-guided SCPB in a convenience sample of ED patients presenting with painful conditions of the "cape" distribution of the neck and shoulder.

METHODS

Data were gathered prospectively on a convenience sample of 27 patients presenting to a community ED with painful conditions involving the distribution of the SCPB: para-cervical muscle spasm/pain (n = 8), clavicle fractures (n = 7), acromioclavicular joint injuries (n = 3), radicular pain (n = 3), and rotator cuff disorders (n = 6). Pre- and post-block 11-point verbal numeric pain scores (VNPS) were recorded, as was the incidence of any immediate complications. A retrospective chart review looked for delayed complications in the 14-day post-block period.

RESULTS

The mean 11-point VNPS reduction was 5.4 points (62%). There were no early serious complications and one case each of self-limiting vocal hoarseness and asymptomatic hemi-diaphragmatic paresis. No delayed block-related complications were found.

CONCLUSIONS

While limited by the fact that this was a nonrandomized observational experience with no control group, our findings suggest that SCBP may be safe and have potential for efficacy, and warrants further evaluation in a randomized controlled trial.

Ultrasound-guided bilateral superficial cervical plexus block is more effective than landmark technique for reducing pain from thyroidectomy

Purpose

Thyroidectomy causes postoperative pain and patient discomfort. Bilateral superficial cervical plexus block is a regional anesthesia technique that can provide analgesia during and after surgery. This study aims to compare the effectiveness of ultrasound (US)-guided versus landmark (LM) technique for bilateral superficial cervical plexus block in thyroidectomy.

Patients and methods

Thirty-six patients undergoing thyroidectomy were divided into two groups randomly (n=18); either US-guided (US group) or LM technique (LM group) for bilateral superficial cervical plexus block. Patient-controlled analgesia was used to control postoperative pain. Intraoperative opioid rescue, postoperative visual analog scale (VAS) score and opioid consumption were measured.

Results

The number of patients who required intraoperative opioid rescue was significantly lower in the US group (p≤0.05). There was no significant difference in postoperative VAS score at 3 hours (p>0.05), but postoperative VAS score at 6 and 24 hours was significantly lower in the US group (p≤0.05). Twenty-four hour postoperative opioid consumption was significantly lower in the US group (p≤0.05).

Conclusion

Ultrasound-guided bilateral superficial cervical plexus block is more effective in reducing pain both intra- and postoperatively compared with landmark technique in patients undergoing thyroidectomy.

Cervical plexus anesthesia versus general anesthesia for anterior cervical discectomy and fusion surgery: A randomized clinical trial

Both general anesthesia (GA) and cervical plexus anesthesia (CPA) can be used for anterior cervical discectomy and fusion (ACDF) surgery. The aim of this study was to evaluate the influence of anesthetic techniques on perioperative mortality and morbidity in patients undergoing cervical surgery.From January 2008 to December 2015, 356 patients who underwent 1-level ACDF for cervical spinal myelopathy were prospectively reviewed. They were assigned to receive GA (group A) and CPA (group B). The analgesic efficacy of the block was assessed by anesthesia preparation time, the maximum heart rate, and mean arterial blood pressure changes compared with the baseline, time of postoperative revival, and duration of recovery stay. Duration of surgery, blood loss, and anesthesia medical cost were also recorded. Numerical rating scale (NRS) was used to evaluate pain at different time points. Postoperative nausea and vomiting (PONV) was assessed, and postoperative average administered dosages of meperidine and metoclopramide were also recorded. The spinal surgeon satisfaction, anesthetist satisfaction, and patient satisfaction were assessed.Both the anesthesia induction time and postoperative revival time were longer in group A than that in group B; both the duration of surgery and recovery stay were also longer in group A than that in group B, whereas there was no difference in blood loss between the 2 groups. The average dosage of both meperidine and metoclopramide was more in group A than that in group B, and the anesthesia medical cost was greater in group A than that in group B. There were no significant differences in baseline data of systolic blood pressure, diastolic blood pressure, and heart rate between the 2 groups. But the intraoperative data of systolic blood pressure, diastolic blood pressure, and heart rate were higher/larger in group B than that in group A. In group A, there was no complaint of pain in the surgery procedure, but the pain increased after GA, with highest degree at 8 hours postoperation; then the pain degree decreased, and the NRS was 1 at 24 hours postoperation. In group B, intraoperative pain was NRS 4, and pain degree decreased from 4 hours postoperation; the NRS was 2 at 24 hours postoperation. The incidence of severe PONV was higher in group A than that in group B. There was no significant difference in the spinal surgeon satisfaction and anesthetist satisfaction for the anesthetic techniques. There was significant difference in patient satisfaction between the 2 groups, with high satisfaction for GA.General anesthesia is superior to CPA in maintaining better intraoperative hemodynamic stability and providing high patient satisfaction with no intraoperative pain for patients receiving ACDF, but it entails longer surgery and anesthesia time, and requires more postoperative analgesic and anesthesia cost.

Simultaneous Bilateral Carotid Endarterectomy under Cervical Plexus Blockade

In patients with severe carotid artery stenosis who developed transient ischemic attack, carotid endarterectomy is one of the most effective treatments. In particular, in patients with contralateral carotid artery lesions, there is a risk of serious neurologic complications during the intra-operative period. Experienced staff can perform simultaneous bilateral carotid endarterectomy safely in carefully selected patients. The advantages of regional anaesthesia in carotid endarterectomy are evaluation of intra-operative neurological condition and defining correct indications for shunt usage. It is a cheap, reliable and easy method that reduces the length of stay in the intensive care unit and in the hospital and may influence the overall cost of care. However, it is important to make dose adjustments to avoid potential complications of nerve involvement during bilateral procedure. In this case report, we share our experiences regarding bilateral carotid endarterectomy under cervical plexus blockade.

Horner's Syndrome after Superficial Cervical Plexus Block

Ultrasound-guided nerve blocks are becoming more essential for the management of acute pain in the emergency department (ED). With increased block frequency comes unexpected complications that require prompt recognition and treatment. The superficial cervical plexus block (SCPB) has been recently described as a method for ED management of clavicle fracture pain. Horner’s syndrome (HS) is a rare and self-limiting complication of regional anesthesia in neck region such as brachial and cervical plexus blocks. Herein we describe the first reported case of a HS after an ultrasound-guided SCPB performed in the ED and discuss the complex anatomy of the neck that contributes to the occurrence of this complication.

Ultrasound-guided combined intermediate and deep cervical plexus nerve block for regional anaesthesia in oral and maxillofacial surgery

OBJECTIVES

We examined the application of an ultrasound-guided combined intermediate and deep cervical plexus nerve block for regional anaesthesia in patients undergoing oral and maxillofacial surgery.

METHODS

A total of 19 patients receiving ultrasound-guided combined intermediate and deep cervical plexus anaesthesia followed by neck surgery were examined prospectively. The sternocleidomastoid and the levator of the scapula muscles as well as the cervical transverse processes were used as easily depicted ultrasound landmarks for the injection of local anaesthetics. Under ultrasound guidance, a needle was advanced in the fascial band between the sternocleidomastoid and the levator of the scapula muscles and 15 ml of ropivacaine 0.75% was injected. Afterwards, the needle was advanced between the levator of the scapula and the hyperechoic contour of the cervical transverse processes and a further 15 ml of ropivacaine 0.75% was injected. The sensory block of the cervical nerve plexus, the analgesic efficacy of the block within 24 h after injection and potential block-related complications were assessed.

RESULTS

All patients showed a complete cervical plexus nerve block. No patient required analgesics within the first 24 h after anaesthesia. Two cases of blood aspiration were recorded. No further cervical plexus block-related complications were observed.

CONCLUSIONS

Ultrasound-guided combined intermediate and deep cervical plexus block is a feasible, effective and safe method for oral and maxillofacial surgical procedures.

Prevention of Intra-operative Cerebral Ischemia during Carotid Endarterectomy, Loco-regional versus General Anesthesia

Carotid endarterectomy (CEA), as a prophylactic operation is becoming more popular. It is performed in patients who are at risk of stroke from dislodged atheromatous plaque at the carotid bifurcation. The major concern during CEA is the detection of cerebral hypoperfusion or ischemia during carotid cross clamping. Some studies have shown that the introduction of loco-regional anesthesia has lowered the incidence of major complications compared with general anesthesia since ischemia detection is easier in conscious patient.

Local anesthesia in thyroid surgery--own experience and literature review

The local anesthesia in thyroid surgery is rarely used, only in selected patients. Majority of centers performing thyroid surgery with local anesthesia have possibility to convert to the general anesthesia. The aim of the study was to present our experiences with partial thyroidectomy under local anesthesia performed in 49 consecutive subjects in the Central African Republic (bilateral subtotal strumectomy, total resection of the one lobe, subtotal resection of the one lobe).

MATERIAL AND METHODS

All admitted patients with clinically significant goiter were accepted for surgical treatment. For infiltration anesthesia 1% lignocaine was used. Because of the shortage of medical resources, potential conversion to the general anesthesia was impossible. Before the operation patients had received an oral sedation and antibiotic. In 16 patients general anesthesia was used, in other 33 it was impossible.

RESULTS

Subtotal bilateral thyroidectomy was performed in 37 patients, 12 patients underwent lobectomy or partial lobectomy of the affected portion of the gland. There were no intraoperative and postoperative complications noticed in the reported group, including complications related to laryngeal nerve injury. The mean duration of the procedure was 127 minutes and mean medical follow-up was 3 days. General condition of all patients on the day of discharge from hospital was good.

CONCLUSIONS

Surgery for goiter under local anesthesia may be a safe alternative where general anesthesia is not available or contraindicated for medical reasons. The infiltration anesthesia is simple to perform and reduces the number of complications potentially occurred at the C2-C4 neck plexus block.

Unexplained fever after bilateral superficial cervical block in children undergoing cochlear implantation: an observational study

PURPOSE

In an effort to decrease postoperative opioid requirements, intraoperative bilateral superficial cervical plexus block (BSCPB) was recently adopted for all our children undergoing general anesthesia for bilateral simultaneous cochlear implantation (BSiCI). Several cases of early postoperative fever were noted after the adoption of BSCPB. Our aim was to determine if an association exists between BSCPB and early postoperative fever in children undergoing BSiCI. As a secondary outcome, we studied the efficacy of BSCPB in altering postoperative analgesic requirements.

METHODS

We conducted a retrospective cohort study of 91 consecutive children who underwent BSiCI. The series included 34 patients who received BSCPB (Block Group) and 57 patients who did not receive BSCPB (No-block Group).

RESULTS

The median age (range) was 15.4 months (eight months - 15 yr). A significant association was found between BSCPB and postoperative fever (P = 0.006). Eighteen (19.7%) children developed fever in the first 24 hr after surgery (Block Group: 12/34 [35%]; No-block Group: 6/57 [11%]; P = 0.006). The Block Group was 4.8 times more likely to develop early postoperative fever after adjusting for other variables (P = 0.004). The Block Group spent more days in hospital after surgery compared with the No-block Group (P = 0.043). Other vital signs showed no major deviation from the normal ranges, and daily physical examinations revealed no obvious source of infection in children who developed postoperative fever.

CONCLUSION

Bilateral superficial cervical plexus block may increase the risk of postoperative fever in children undergoing BSiCI. In this series, BSCPB was associated with a longer hospital admission. The etiology of the fever is undetermined, although it can be hypothesized that BSCPB resulted in unintended block of the phrenic nerves leading to diaphragmatic paralysis, atelectasis, and early postoperative fever in young children.

A randomized comparison between ultrasound-guided and landmark-based superficial cervical plexus block

BACKGROUND

This prospective, randomized, observer-blinded study compared ultrasound guidance and the conventional landmark-based technique for superficial cervical plexus blockade.

METHODS

Forty patients were randomly allocated to receive a block of the superficial cervical plexus using ultrasound guidance (n = 20) or the traditional landmark-based technique (n = 20). The main outcome, success, was defined as the absence of cold sensation for all 4 branches of the superficial cervical plexus at 15 mins. A blinded observer recorded success rate, onset time, block-related pain scores, and the incidence of complications. Performance time and the number of needle passes were also recorded during the performance of the block. Total anesthesia-related time was defined as the sum of performance and onset times.

RESULTS

Success rate (80%-85%) was similar between the 2 groups. Performance time was slightly longer with ultrasonography (119 versus 61 sec, P < 0.001); however, no differences in onset and total anesthesia-related times were found. There were also no differences in the number of passes and procedural discomfort.

CONCLUSIONS

Ultrasound guidance does not increase the success rate of superficial cervical plexus block compared with a landmark-based technique. Additional confirmatory trials are required.

Bilateral superficial cervical plexus block combined with general anesthesia administered in thyroid operations

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.

Surgical strategy for sporadic primary hyperparathyroidism an evidence-based approach to surgical strategy, patient selection, surgical access, and reoperations

PURPOSE

Progress in parathyroid imaging has brought substantial changes in the surgical strategy to approach patients with sporadic primary hyperparathyroidism (pHPT). The present review is focused on the safety and efficacy of limited parathyroid exploration.

MATERIALS AND METHODS

Review of the literature focused on studies dealing with unilateral (two-gland exploration) or selective parathyroidectomy (one-gland exploration) in selected patients with pHPT and on the classification of published reports according to the degree of evidence.

RESULTS

Parathyroid exploration limited to a solitary parathyroid adenoma can be considered a minimally invasive procedure that can be performed by the minicervicotomy, video-assisted, or endoscopic approaches. In properly selected patients, it affords results comparable to those of four-gland bilateral exploration in terms of cure and recurrence. It causes less postoperative hypocalcemia.

CONCLUSIONS

Selective parathyroidectomy is an option for patients with positive preoperative localization tests undergoing first-time surgery who have no family history of pHPT, no goiter for which surgical therapy is proposed, and are not on lithium therapy.

Thyroid surgery under monitored anesthesia care (MAC)

BACKGROUND

Thyroid surgery is usually performed under general anesthesia, but thyroid surgery under monitored anesthesia care (MAC) has become re-introduced. We report our experiences of 40 cases of thyroid surgery under MAC.

METHODS

Forty patients were enrolled in this study. Bilateral superficial cervical plexus block (BSCPB) was performed by using 1% mepivacaine with 1 : 200,000 epinephrine. After BSCPB, patients were sedated with propofol and fentanyl. Postoperative pain, sore throat, hoarseness, and postoperative nausea and vomiting (PONV) were assessed.

RESULTS

Mean postoperative pain VAS were 1.3, 1.2, 1.0, 0.8 and postoperative sore throat VAS 1.4, 1.4, 1.1, 0.9 at PACU (post-anesthesia care unit) and postoperative 3, 6, 12 h, respectively. The incidence of hoarseness was 25, 5, 2.5%, and 0% and PONV were 0, 5, 10%, and 7.5% at PACU and postoperative 3, 6, 12 h, respectively.

CONCLUSIONS

Thyroid surgery under MAC may be a suitable alternative to general anesthesia.