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Ultrasound-guided intermediate cervical plexus and additional peripheral facial nerve block for carotid endarterectomy

A prospective pilot study

Ultraschallgesteuerte intermediäre zervikale Plexusblockade und Block des N. facialis zur Karotisendarteriektomie

Eine prospektive Pilotstudie

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Abstract

Background and objectives

Ultrasound-guided intermediate cervical plexus block with perivascular local anesthetic infiltration is an established anesthetic procedure for carotid endarterectomy. In this prospective pilot study an additional subplatysmal block of the superficial ansa cervicalis is presented for the first time. The target structures are the anastomoses between the facial nerve (cervical and marginal mandibular branches) and cervical plexus.

Methods

An ultrasound-guided intermediate cervical plexus block (20 ml of ropivacaine 0.75%) was performed (n = 28). Then, depending on the individual sonoanatomy, 5 ml of prilocaine 1% was injected into the carotid sheath (group 1: no perivascular infiltration, n = 14, group 2: perivascular infiltration, n = 14). The third step was subplatysmal injection of 5 ml of prilocaine 1% between the medial edge of the sternocleidomastoid muscle and the submandibular gland (n = 28). The investigated parameters included the need for supplementation and block-related side effects.

Results

The requirement for supplemental local anesthetic infiltration in the skin incision area was minimal at mean (M) 1.1 ml (standard deviation (SD) ±2.4 ml). Perivascular infiltration in group 2 significantly decreased the total amount of local anesthetic supplemented: group 1 M = 4.2 ml (SD = ±3.1 ml), group 2 M = 1.7 ml (SD = ±2.0 ml) (p = 0.018). The incidence of block-related side effects was not significantly different between the two groups.

Conclusion

This study presents an ultrasound-guided subplatysmal block of the superficial ansa cervicalis for the first time, with the aim of optimizing anesthesia quality during surgical interventions in the carotid triangle.

Zusammenfassung

Hintergrund und Ziele

Die ultraschallgesteuerte intermediäre zervikale Plexusblockade mit perivaskulärer lokaler Anästhetikainfiltration ist ein etabliertes Anästhesieverfahren für offen-chirurgische Karotisendarteriektomien. In dieser prospektiven Pilotstudie wird erstmals ein zusätzlicher subplatysmaler Block der Ansa cervicalis superficialis vorgestellt. Zielstrukturen sind Anastomosen zwischen dem N. facialis (Rr. colli und marginalis mandibulae) und dem Plexus cervicalis.

Material und Methoden

In beiden Gruppen wurde ultraschallgesteuert eine intermediäre zervikale Plexusblockade (20 ml 0,75 %iges Ropivacain) durchgeführt (n = 28). Eine perivaskuläre Infiltration (5 ml 1 %iges Prilocain) erfolgte in Abhängigkeit von der individuellen Sonoanatomie (Gruppe 1 (n = 14) ohne, Gruppe 2 (n = 14) mit perivaskulärer Infiltration). Der dritte Schritt war die subplatysmale Injektion von 5 ml 1 %igem Prilocain zwischen dem medialen Rand des Kopfwenders und der Unterkieferspeicheldrüse (n = 28). Die untersuchten Parameter umfassten den Bedarf an Supplementierung durch den Operateur (1 %iges Prilocain) sowie blockadebedingte Nebenwirkungen.

Ergebnisse

Der Bedarf an zusätzlicher lokaler Infiltration durch den Operateur im Bereich der Hautinzision war minimal: Mittelwert (M) 1,1 ml (Standardabweichung (SD) ±2,4 ml) 1 %iges Prilocain. Das Einsetzen eines retromandibulären Retraktors war zudem in allen Fällen schmerzfrei möglich. Eine zusätzliche perivaskuläre Infiltration (Gruppe 2) verringerte signifikant den Bedarf an Supplementierung durch den Chirurgen: Gruppe 1 M = 4,2 ml (SD = ±3,1 ml), Gruppe 2 M = 1,7 ml (SD = ±2,0 ml) 1 %iges Prilocain (p = 0,018). Die Inzidenz blockadebedingter Nebenwirkungen zeigte keine signifikanten Gruppenunterschiede.

Fazit

In dieser prospektiven Pilotstudie wurde die zervikale Plexusblockade erstmals durch einen ultraschallgesteuerten subplatysmalen Block der Ansa cervicalis superficialis ergänzt. Ziel war die Verbesserung der Anästhesiequalität bei operativen Karotisdesobliterationen.

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Funding

The study was conducted with financial support from the HELIOS Research Centre, Berlin, Germany (ID 056238).

Contribution of authors

R. Seidel designed and conducted the study, analyzed the data and wrote the manuscript. K. Zukowski conducted the study and revised the manuscript critically for intellectual content. A. Wree revised the manuscript critically for intellectual content. M. Schulze performed the anatomical preparations and revised the manuscript critically for intellectual content.

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Authors and Affiliations

  1. Department of Anesthesiology, HELIOS Medical Center Schwerin, Wismarsche Straße 393–7, 19049, Schwerin, Germany

    R. Seidel MD & K. Zukowski

  2. Institut of Anatomy, Medical University of Rostock, Rostock, Germany

    A. Wree & M. Schulze

Authors
  1. R. Seidel MD
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  2. K. Zukowski
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  3. A. Wree
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  4. M. Schulze
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Corresponding author

Correspondence to R. Seidel MD.

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Conflict of interest

R. Seidel, K. Zukowski, A. Wree and M. Schulze declare that they have no competing interests.

All studies on humans described in the manuscript were carried out with the approval of the responsible ethics committee and in accordance with national law and the Helsinki Declaration from 1975 (in its current revised form). Informed consent was obtained from all patients included in the studies.

Caption Electronic Supplementary Material

ESM1_Video 1: Block of the superficial cervical ansa—sonoanatomic landmarks

ESM2_Video 2: Block of the superficial cervical ansa—injection of local anesthetic

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Seidel, R., Zukowski, K., Wree, A. et al. Ultrasound-guided intermediate cervical plexus and additional peripheral facial nerve block for carotid endarterectomy. Anaesthesist 67, 907–913 (2018). https://doi.org/10.1007/s00101-018-0493-7

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  • DOI: https://doi.org/10.1007/s00101-018-0493-7

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