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

Ultrasound-Guided Blocks for Spine Surgery: Part 1-Cervix

Postoperative pain is common following spine surgery, particularly complex procedures. The main anesthetic efforts are focused on applying multimodal analgesia beforehand, and regional anesthesia is a critical component of it. The purpose of this study is to examine the existing techniques for regional anesthesia in cervical spine surgery and to determine their effect and safety on pain reduction and postoperative patient's recovery. The electronic databases were searched for all literature pertaining to cervical nerve block procedures. The following peripheral, cervical nerve blocks were selected and described: paravertebral block, cervical plexus clock, paraspinal interfascial plane blocks such as multifidus cervicis, retrolaminar, inter-semispinal and interfacial, as well as erector spinae plane block and stellate ganglion block. Clinicians should choose more superficial techniques in the cervical region, as they have been shown to be comparably effective and less hazardous compared to paravertebral blocks.

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.

A Comparative Study on Sedation Efficacy Between General and Regional Anesthesia with Dexmedetomidine in Patients Under Maxillofacial Surgery

BACKGROUND AND OBJECTIVE

Securing the airway in the surgery of maxillofacial disorders and traumas is fundamental during the operation. The present study aims to investigate the beneficial sedative effects of dexmedetomidine (DEX) in patients who underwent maxillofacial surgery with regional anesthesia compared to general anesthesia.

METHODS

Fifty patients, aged 20-45 years old were randomly divided into two groups of regional anesthesia (RA) and general anesthesia (GA) (each n=25). The group RA received regional block with sedation (DEX: 1 μg/kg infused over 10 min followed by the maintenance dose of 0.5 μg/kg/h) and the group GA underwent general anesthesia (DEX: 0.1 μg/kg/min over 10 min followed by 0.4-0.7 μg/kg/h). Postoperative pain scores, anesthesia outcomes, hemodynamic parameters, the time of the post-anesthesia care unit (PACU) discharge and intra and postoperative complications were comparatively assessed in both groups.

RESULTS

The baseline characteristics of the patients (age, gender, BMI, and ASA physical status) showed no differences between the two groups (P>0.05). Although the duration of surgery and recovery time showed no differences between the groups, the duration of anesthesia and extubation time was remarkably lower in the RA group than in the GA group (P<0.01). Administration of nerve blocks demonstrated less pain and longer sleep time in the postoperative phase as compared to the GA group. Heart rate and mean arterial blood pressure were significantly less in the RA group at the end of the loading dose of DEX and incision time (P<0.05). SpO2, respiration rate and Ramsay sedation scale did not exhibit any significant differences between the two groups at all-time points (P>0.05). No significant differences were observed with regard to the adverse events between the two groups (P>0.05).

CONCLUSIONS

Although our findings revealed that both methods are suitable and safe methods for maxillofacial surgery, the outcomes of anesthesia with regional block and sedation include less pain in the postoperative phase, shorter extubation time and earlier discharge from the PACU demonstrated that this method is more reliable for maxillofacial surgery. Further controlled studies are needed to compare the effectiveness and safety profiles of two RA and GA techniques and also to compare DEX with other anesthetic agents to achieve optimum outcomes in maxillofacial surgeries.

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.

Anesthetic and Analgesic Efficient of Regional Nerve Blockade in Otoplasty

AIM

The prominent ear is the most common congenital deformity of the external ear. Otoplasty is performed to correct the appearance of the prominent ear. This study was planned to compare the analgesic and anesthetic effects of local nerve blockade and local infiltration anesthesia in the otoplasties.

METHOD

Thirty-two patients who underwent otoplasty in both ears between February 2018 and March 2019 were included in the study. Three patients were excluded because they refused regional anesthesia. In the patients included in the study, only local infiltration anesthesia was applied to 1 ear and regional nerve blockade was applied to the other ear. Regional nerve blockade was applied to the study group; local infiltration anesthesia was applied to the control group. Surgical and anesthetic complications were recorded. The onset time, duration and severity of pain were followed. Numerical evaluation scale scores were used to evaluate pain levels.

RESULTS

It was observed that the first pain of the patients On the side where regional nerve block (RNB) anesthesia was applied after an average of 10.5 hours. On the other hand on the side where local infiltration anesthesia was applied; the pain was observed to start after an average of 3.5 hours. At the 6th and 12th hours postoperatively, the scores of the numerical evaluation scale were significantly lower in the study group than the control group (P < 0.05). At the 24th-hour pain score, the values were lower in the study group, but the difference was not significant between the groups (P > 0.05). In the regional anesthesia group, can develop such as difficulty in swallowing, weakness in the neck, weakness in the upper extremity, nausea, Horner syndrome; but all side effects resolve spontaneously within 6 to 12 hours.

CONCLUSION

The application of regional anesthesia in prominent ear surgical procedures can be considered as an alternative method to provide better quality preoperative anesthesia and better quality postoperative analgesia in patients.

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.

Base of Skull Blocks for Open Reduction and Internal Fixation of Faciomaxillary Fractures

INTRODUCTION

Faciomaxillary fractures (FMF) occur in a significant proportion of trauma patients. Nearly all polytrauma patients and even those with isolated FMF are managed under general anesthesia for definitive management. We propose the use of regional nerve blocks as a safe and effective means for open reduction and fixation of isolated FMF.

AIM AND OBJECTIVES

The aim is to evaluate the feasibility, effectiveness and safety of base of skull maxillomandibular and distal trigeminal nerve blocks in the management of FMF.

MATERIALS AND METHODS

Ten young adults with fractures of the zygoma, mandible and Le Fort I/II injuries were included in the study. Patients with associated craniocervical and abdominothoracic injuries were excluded.

RESULTS

The patients' ages ranged from 21 to 40 years, with a mean time of onset of anesthesia being 5 to 12 minutes and total duration of 105 to 220 minutes. Supplementary block for patchy anesthesia was needed in three. All underwent unhindered surgery without complication.

CONCLUSION

Base of skull maxillary-mandibular and distal trigeminal blocks are an effective and efficient alternative to general anesthesia for the open reduction and internal fixation of FMF.

Regional anaesthesia for carotid endarterectomy

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.

A unique anesthesia approach for carotid endarterectomy: Combination of general and regional anesthesia

Carotid endarterectomy (CEA), a preventable surgery, reduces the future risks of cerebrovascular stroWke in patients with marked carotid stenosis. Peri-operative management of such patients is challenging due to associated major co-morbidities and high incidence of peri-operative stroke and myocardial infarction. Both general anesthesia (GA) and local regional anesthesia (LRA) can be used with their pros and cons. Most developing countries as well as some developed countries usually perform CEA under GA because of technical easiness. LRA usually comprises superficial, intermediate, deep cervical plexus block or a combination of these techniques. Deep block, particularly, is technically difficult and more complicated, whereas intermediate plexus block is technically easy and equally effective. We did CEA under a combination of GA and LRA using ropivacaine 0.375% with 1 mcg/kg dexmedetomidine (DEX) infiltration. In LRA, we gave combined superficial and intermediate cervical plexus block with infiltration at the incision site and along the lower border of mandible. We observed better hemodynamics in intraoperative as well as postoperative periods and an improved postoperative outcome of the patient. So, we concluded that combination of GA and LRA is a good anesthetic technique for CEA. Larger randomized prospective trials are needed to support our conclusion.