Intermediate Cervical Plexus Block for Carotid Endarterectomy: A Case Series of the Spread of Injectate

Abstract

IntroductionWe aimed to show the spread of local anesthetic following an ultrasound-guided, double-injection technique of a carotid sheath block before carotid endarterectomy.MethodsThe study included 15 patients scheduled for elective carotid endarterectomy. The carotid sheath block was performed after ultrasound-guided localization of the carotid bifurcation (level C4-C6) at the posterior border of the sternocleidomastoid muscle. A mix of 7.5 mL ropivacaine 0.75%, 7.5 mL prilocaine1% and 3 mL iopromidum was injected at the base of the carotid bifurcation. An additional 15 mL of the mixture was administered subcutaneously at the surgical incision line. Thirty minutes after the block, a computed tomography scan of the head, neck region and upper thorax was performed to reconstruct a 3-D distribution of the injectate.ResultsAll patients achieved C2-C4 dermatomal sensory blockade. None required conversion to general anesthesia. The injectate spread ranged from the vertebral body of C1 to the vertebral body of T3. The mean volume of distribution was 97±13 mL, the craniocaudal spread 138±19 mm, dorsoventral 57±8 mm and coronal 53±8 mm. The mean carotid artery circumference contact was 252°±77, with four patients (27%) presenting with a ring formation (360°) around the carotid artery.ConclusionsUltrasound-guided carotid sheath block provided an extensive spread of local anesthetic. A complete ring formation of local anesthetic around the artery does not seem necessary for a successful anesthesia. The resulting nerve blockade thus appears sufficient for surgery, with minor risks compared to blind methods.

Postoperative Analgesic Effect of Ultrasound-Guided Intermediate Cervical Plexus Block on Unipolar Sternocleidomastoid Release With Myectomy in Pediatric Patients With Congenital Muscular Torticollis

“…The recognition and description of cervical fasciae, including the investing fascia, 30 prevertebral fascia, 21,31 and carotid sheath, 32 remain controversial, and anatomical variations related to the cervical fascial layers have been reported. 33 23,31,35 Nonetheless, considering the unverified permeable nature of the prevertebral fascia, 21,31 the possibility of variable spread of local anesthetics in the PCS, 30,36 and the complicated cervical fascial layers in the narrow space of the neck, particularly in children, use of a small volume of local anesthetics under ultrasound guidance, followed by meticulous postprocedural monitoring of patients, is recommended. Even unilateral intermediate CPB may be contraindicated in patients with preexisting contralateral recurrent laryngeal nerve injury or contralateral lung or diaphragmatic disease.…”

Carotid Endarterectomy in Awake Patient: Review Article

“…• Control of ventilation (tight control of arterial carbon dioxide concentration) (13)(14)(15)(16)(17) • Cerebral protection afforded by volatile anaethesia (especially during the cross-clamp) (13,18,15,(19)(20)(21) • Airway security (anaesthetist preference) (13,22,15,19,17) • Excellent and comfortable operation conditions (especially in patients with high carotid bifurcation) (14,17,(19)(20)(21) • Prevent myocardial ischemia (19) • Less stressful than a regional procedure (14,20) • Prevent patients from coughing and straining (19) • Possibility of inducing hypothermia if required (15) Disadvantages of GA are:…”

“…• Awake patient is the gold standart cerebral function monitoring (14,15,17,20,21) • Reduce cardiac and respiratory related morbidity (15,16,18,20) • Lower shunt insertion rate (14,15,17,19,21,24) • Shorten hospital stay (14,15,17,19,21,24) • Lower cost (14,15,18,21) • Improves outcomes after surgery (better postoperative analgesia, reduce blood loss, lower risk of tromboembolic events) (15,18,20,22) • Safer (14) • Safe method to identify the patients at risk for crossclamp intolerance (1,3,12) • Hemodynamic stability (14,17,18,21,22,24,27) • Preserved cerebral autoregulation (14,16,18,24,25) • Reduce vasopressor requirement (25) • Reduces operative time (24) Disadvantages of regional anest...…”

A Short Note on Cancer

“…According to the National Cancer Institute, smoking causes 30% of all cancer deaths in the U.S. and is responsible for 87% of cases of lung cancer [53]. Not only does it affect the lungs, it can cause kidney, pancreatic, cervical [54], and stomach cancers and acute myeloid leukemia [55]. Quitting smoking immediately decreases your risk factor for cancer.…”