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Ultrasound-guided intermediate cervical plexus block and perivascular local anesthetic infiltration for carotid endarterectomy

A randomized controlled trial

Ultraschallgesteuerte intermediäre Blockade des Plexus cervicalis und perivaskuläre lokale Infiltrationsanästhesie vor Karotisendarteriektomie

Eine randomisierte, kontrollierte Studie

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Abstract

Background and objective

Ultrasound-guided blocks of the cervical plexus are established anesthetic procedures for carotid endarterectomy. This randomized, double-blind, placebo-controlled study tested the hypothesis that an additional ultrasound-guided periarterial injection of local anesthetic leads to a lower frequency of periarterial supplementation by the surgeon.

Methods

A total of 40 patients were randomly assigned to 1 of 2 groups. In both groups an ultrasound-guided intermediate cervical plexus block (20 ml of 0.75 % ropivacaine) at the level of the fourth cervical vertebra was performed. In a second step, the needle was inserted from posterolateral to anteromedial (in-plane technique) relative to the internal carotid artery and then, depending on the randomized group assignment, 5 ml of 0.75 % ropivacaine (group 2) or 5 ml of 0.9 % saline (group 1) was injected. The parameters investigated included the need for supplementation, patient comfort, the incidence of side effects and circulatory changes.

Results

The two groups did not significantly differ (p = 0.459) in terms of the need for intraoperative supplementation with 1 % prilocaine with a mean (range) in group 2 of 4.9 ml (0–20 ml), in group 1 of 3.7 ml (0–16 ml) and patient comfort (p = 0.144). In addition, a trend towards a higher complication rate was observed in group 2.

Conclusion

For ultrasound-guided intermediate blocks of the cervical plexus, an additional periarterial infiltration showed no advantage. Abandoning this technique leads to a relevant simplification of the blocking technique and tends to reduce block-related side effects.

Zusammenfassung

Hintergrund und Zielsetzung

Ultraschallgesteuerte Blockaden des Plexus cervicalis sind etablierte Anästhesieverfahren vor Karotisendarteriektomie. In dieser randomisierten, doppelblinden, placebokontrollierten Studie haben wir die Hypothese geprüft, dass die zusätzliche ultraschallgesteuerte periarterielle Injektion eines Lokalanästhetikums die Häufigkeit einer intraoperativen Supplementierung durch den Chirurgen senkt.

Methoden

Insgesamt 40 Patienten wurden randomisiert einer von zwei Gruppen zugeteilt. In beiden Gruppen wurde ultraschallgesteuert eine intermediäre zervikale Plexusblockade (20 ml 0,75% Ropivacain) auf Höhe des vierten Halswirbels durchgeführt. In einem zweiten Schritt wurde die Nadel von posterolateral (In-plane-Technik) an die Gefäßwand der A. carotis interna geführt. Dann wurden – in Abhängigkeit von der Studiengruppe – 5 ml 0,75% Ropivacain (Gruppe 2) oder 5 ml 0,9% Kochsalzlösung (Gruppe 1) injiziert. Zu den untersuchten Parametern zählten der Bedarf zusätzlicher intraoperativer Injektionen von Lokalanästhetikum, die Patientenzufriedenheit, die Nebenwirkungsrate und kreislaufbezogene Veränderungen.

Ergebnisse

Die zwei Gruppen unterschieden sich nicht signifikant (p = 0,459) bezüglich des Bedarfs einer zusätzlichen intraoperativen Applikation von 1% Prilocain. In Gruppe 2 waren es im Durchschnitt (Wertebereich) 4,9 ml (0–20 ml), in Gruppe 1 3,7 ml (0–16 ml). Auch in der Patientenzufriedenheit unterschieden sich die Gruppen nicht signifikant (p = 0,144). In Gruppe 2 war tendenziell eine höhere Komplikationsrate zu verzeichnen.

Schlussfolgerung

Für eine ultraschallgesteuerte intermediäre Blockade des Plexus cervicalis ergab sich aus der zusätzlichen periarteriellen Infiltration kein klinischer Vorteil. Ein Verzicht auf dieses Verfahren kann die Anästhesietechnik vereinfachen und reduziert blockadebezogene Nebenwirkungen.

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Author information

Correspondence to Dr. med. R. Seidel.

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Conflict of interests

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

All studies on humans described in this 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

Video 1 Intermediate cervical plexus block

Video 1 Intermediate cervical plexus block

Video 2 Perivascular infiltration

Video 2 Perivascular infiltration

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Seidel, R., Zukowski, K., Wree, A. et al. Ultrasound-guided intermediate cervical plexus block and perivascular local anesthetic infiltration for carotid endarterectomy. Anaesthesist 65, 917–924 (2016). https://doi.org/10.1007/s00101-016-0230-z

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Keywords

  • Internal carotid artery stenosis
  • Cervical plexus
  • Anesthesia, regional
  • Ultrasonography
  • Randomized controlled trial

Schlüsselwörter

  • Stenose der A. carotis interna
  • Plexus cervicalis
  • Regionalanästhesie
  • Ultraschall
  • Randomisierte, kontrollierte Studie