Early stellate ganglion block for improvement of postoperative cerebral blood flow velocity after aneurysmal subarachnoid hemorrhage: results of a pilot randomized controlled trial

OBJECTIVE

Stellate ganglion block (SGB) is a commonly used sympathetic nerve block technique that may have benefits for patients with aneurysmal subarachnoid hemorrhage (aSAH) in the early stage. Cerebral vasospasm (CVS), one of the most common complications of aSAH, is accompanied by an abnormal increase in cerebral blood flow velocity (CBFV) and neurological dysfunction. In this pilot study the authors sought to determine the feasibility of early SGB for CVS in aSAH patients by observing the incidence of symptomatic CVS.

METHODS

Prior to receiving surgical treatment, patients with aSAH were randomly assigned to the SGB group or the non-SGB group. The primary outcome was the incidence of symptomatic CVS within 14 ± 2 days after the onset of aSAH. As a higher CBFV is often associated with CVS and a poor prognosis, the mean CBFV of the middle cerebral artery was observed immediately after surgery and on postoperative days 1, 2, 3, 5, and 7. Other secondary outcomes included transcranial Doppler (TCD)/CTA-type CVS, delayed cerebral ischemia during hospitalization, new cerebral infarction within 3 months, adverse events (AEs), and clinical prognosis.

RESULTS

Symptomatic CVS occurred in 40% of patients in the non-SGB group and in 20% in the SGB group (RR 0.50, 95% CI 0.22-1.16). Continuous TCD sonography revealed that the postoperative mean CBFV was lower in the SGB group than in the non-SGB group (F = 3.608, p = 0.02). In addition, the percentages of patients with CVS evaluated by TCD (TCD-CVS) and total new infarctions within 3 months were also significantly lower than those in patients with CVS (TCD-CVS 36.7% vs 70%, RR 0.52, 95% CI 0.31-0.89, and total new infarctions 26.7% vs 53.3%, RR 0.50, 95% CI 0.25-0.99). In terms of AEs and mortality, there were no significant differences between the two groups.

CONCLUSIONS

This pilot study demonstrated for the first time, to the authors' knowledge, that early SGB is feasible and has the potential to reduce the risk of CVS and improve the prognosis of aSAH. This method may be a new treatment for patients with aSAH that may have more advantages than traditional therapeutic drugs and is worth further study. Clinical trial registration no.: NCT04691271 (ClinicalTrials.gov).

Utility of Cervical Sympathetic Block in Treating Post-Traumatic Stress Disorder in Multiple Cohorts: A Retrospective Analysis

BACKGROUND

Post-traumatic stress disorder (PTSD) is a prevalent and debilitating condition in the United States. Success rates for evidence-based therapies are inconsistent, and many suffer in silence due to the stigmata associated with seeking traditional mental health care. This has led clinicians to explore new therapeutic options, with cervical sympathetic blockade (CSB), performed at the stellate and/or superior cervical ganglion levels, recently emerging as a promising treatment option. Rapid therapeutic onset, improved compliance, and high clinical efficacy rates have made this an attractive approach for both providers and patients. However, to date, CSB as a treatment of PTSD has primarily been used in male patients with military-related trauma.

OBJECTIVE

To evaluate the efficacy of CSB as a treatment option for PTSD in both genders and multiple etiologies of psychological trauma.

STUDY DESIGN

Retrospective cohort study.

SETTING

An established anesthesia pain clinic in Chicago, IL, USA.

METHODS

Following retroactive IRB approval, 484 consecutive cases of patients diagnosed with PTSD and treated with CSB, performed by a single provider (December 2016 - February 2020) were analyzed. The primary outcome measurement was the PTSD Checklist Score version DSM IV (PCL-4). Patient demographic and clinical information collected included age, gender, type of trauma leading to PTSD, history of suicidal attempts, and psychiatric medication use.

RESULTS

After exclusion of cases due to missing data points, 327 patients were included in the final statistical analysis, having completed both PCL-4 pre and post CSB, between 7- and 30-days post-intervention. The patient population included military men (n = 97), civilian men (n = 85), military women (n = 13) and civilian women (n = 132). We identified 21 types of self-reported trauma leading to PTSD. Average decrease in PCL score for men and women was 28.59 and 29.2, respectively. Statistical analysis of the male population with a military background showed a significantly greater change in corresponding PCL scores than civilians (PCL-M change = -31.83 vs PCL-C change = -24.89). Likewise, women who had a military background had a significantly greater reduction in PCL score than civilians (39.15 vs 28.23). Statistically significant improvements in PTSD symptoms were noted independent of the causative trauma type, gender, age greater than 20, previous suicide attempts, or use of prescription medications for PTSD. Among the 21 types of reported trauma, 19 types reached statistical significance.

LIMITATIONS

Limitations include the limited scope of observation giving exclusive focus on pre- and post-PCL data, the limited duration of observation, the self-reported nature of the patient-provided data, and the provision of treatment by a single physician.

CONCLUSION

CSB seems to be an effective treatment for PTSD symptoms irrespective of gender, trauma type, PTSD-related drug use, suicide attempt, or age.

Tonic-clonic seizure during the ultrasound-guided stellate ganglion block because of an injection into an unrecognized variant vertebral artery: A case report

RATIONALE

Recent years have witnessed a marked improvement in the safety and accuracy of nerve blocks with the help of ultrasound and other visualization technologies. This study reports a challenging case of a severe complication during the ultrasound-guided stellate ganglion block.

PATIENT CONCERNS

A 28-year-old male patient with refractory migraine complained episodic pulsatile pain with photophobia, haphalgesia of the scalp for 3 years.

INTERVENTIONS

Ultrasound-guided stellate ganglion block with 4 ml of 1% lidocaine was administrated.

OUTCOMES

A sudden loss of consciousness and tonic-clonic seizure was occurred after negative aspiration and test dose. Further sonographic examination revealed a variation in the left vertebral artery, which remained unrecognized during the needle insertion because of its sliding ability under the differential pressure applied by the probe.

LESSONS

Inadvertent intra-arterial injection of a local anesthetic agent could be minimized under the ultrasound guidance with various protective strategies, including the determination of any prior variation, optimizing the block route, maintaining a constant probe pressure, and using saline for the test dosage. This case resulted in the implementation of new protocols of the ultrasound-guided stellate ganglion block in our department.

The effect of stellate ganglion block on the function of arteriovenous fistulas for hemodialysis: A randomized trial

BACKGROUND AND PURPOSE

The best access for hemodialysis is an autologous arteriovenous fistula (AVF). The most helpful way for vasodilation in the upper limb is stellate ganglion block. We aim to evaluate the effect of stellate ganglion block on outcome of vascular access for dialysis.

MATERIALS AND METHODS

Some 105 hemodialysis patients were randomly allocated to three groups: In group 1, stellate ganglion block was performed before fistula surgery. Group 2 had stellate ganglion block after surgery and group 3 was control group without any block. Primary outcome for all groups was functional dialysis, which is defined as successful hemodialysis for 1 month.

RESULTS

The three groups were similar in age, gender, and underlying diseases. Stellate ganglion block before operation had a meaningful increase in successful hemodialysis rate, when compared with the other groups (p = 0.02).

CONCLUSION

Stellate ganglion block before arteriovenous fistula surgery in the upper limbs improves hemodialysis success rate.

Extrapyramidal signs occurring after sympathetic block for complex regional pain syndrome responding to diphenhydramine: Two case reports

RATIONALE

To present an unusual extrapyramidal motor response occurring after a sympathetic block in CRPS and its successful treatment with diphenhydramine.

PATIENT CONCERNS

Severe pain related to Complex Regional Pain Syndrome type 1 interfering with activities of daily living.

DIAGNOSES

Complex Regional Pain Syndrome type 1.

INTERVENTIONS

We report a video case reports of two patients with a diagnosis of CRPS type-I. Both patients exhibited similar presentation of unusual extrapyramidal motor response of the affected limb following lumbar sympathetic block. Both patients were treated with intravenous diphenhydramine to abort the extrapyramidal motor response.

OUTCOMES

Both patients similarly responded to treatment with intravenous diphenhydramine with abrupt resolution of the motor response.

LESSONS

Sympathetic blockade may interfere with the adaptive autonomic reflex circuits of the motor balance homeostasis in patients with complex regional pain syndrome. Disinhibition of extrapyramidal system may lead to immediate expression of extrapyramidal signs following the sympathetic block. Diphenhydramine, with its anti-histaminic and anticholinergic properties, may be effective in aborting such extrapyramidal signs, and should be considered as a treatment option in similar cases.

Continuous cervical epidural block: Treatment for intractable hiccups

Intractable hiccups, although rare, may result in severe morbidity, including sleep deprivation, poor food intake, respiratory muscle fatigue, aspiration pneumonia, and death. Despite these potentially fatal complications, the etiology of intractable hiccups and definitive treatment are unknown. This study aimed to evaluate the effectiveness of continuous cervical epidural block in the treatment of intractable hiccups.Records from 28 patients with a history of unsuccessful medical and invasive treatments for hiccups were evaluated. Continuous cervical epidural block was performed with a midline approach at the C7-T1 or T1-T2 intervertebral space with the patient in the prone position. The epidural catheter was advanced through the needle in a cephalad direction to the C3-C5 level. Catheter placement was confirmed using contrast radiography. A 6-mL bolus of 0.25% ropivacaine was injected, and a continuous infusion of 4 mL/h of ropivacaine was administered through the epidural catheter using an infuser containing 0.75% ropivacaine (45 mL ropivacaine and 230 mL normal saline). When the hiccups stopped and did not recur for 48 hours, the catheter was removed.Cumulative complete remission rates were 60.71% after the first cervical epidural block, 92.86% after the second, and 100% after the third. One patient complained of dizziness that subsided. No other adverse effects were reported.Continuous C3-C5 level cervical epidural block has a successful remission rate. We suggest that continuous cervical epidural block is an effective treatment for intractable hiccups.

Two-Year Outcomes of Vagal Nerve Blocking (vBloc) for the Treatment of Obesity in the ReCharge Trial

Background

The ReCharge Trial demonstrated that a vagal blocking device (vBloc) is a safe and effective treatment for moderate to severe obesity. This report summarizes 24-month outcomes.

Methods

Participants with body mass index (BMI) 40 to 45 kg/m², or 35 to 40 kg/m² with at least one comorbid condition were randomized to either vBloc therapy or sham intervention for 12 months. After 12 months, participants randomized to vBloc continued open-label vBloc therapy and are the focus of this report. Weight loss, adverse events, comorbid risk factors, and quality of life (QOL) will be assessed for 5 years.

Results

At 24 months, 123 (76 %) vBloc participants remained in the trial. Participants who presented at 24 months (n = 103) had a mean excess weight loss (EWL) of 21 % (8 % total weight loss [TWL]); 58 % of participants had ≥5 % TWL and 34 % had ≥10 % TWL. Among the subset of participants with abnormal preoperative values, significant improvements were observed in mean LDL (−16 mg/dL) and HDL cholesterol (+4 mg/dL), triglycerides (−46 mg/dL), HbA1c (−0.3 %), and systolic (−11 mmHg) and diastolic blood pressures (−10 mmHg). QOL measures were significantly improved. Heartburn/dyspepsia and implant site pain were the most frequently reported adverse events. The primary related serious adverse event rate was 4.3 %.

Conclusions

vBloc therapy continues to result in medically meaningful weight loss with a favorable safety profile through 2 years.

Trial Registration

https://clinicaltrials.gov/ct2/show/NCT01327976

Efficacy and safety of stellate ganglion block in chronic ulcerative colitis

AIM

To investigate the efficacy and safety of stellate ganglion block for the treatment of patients with chronic ulcerative colitis.

METHODS

A total of 120 randomly selected patients with chronic ulcerative colitis treated in Cangzhou Central Hospital from January 2014 to January 2016 were included in this study. These patients were divided into two groups: control group (n = 30), patients received oral sulfasalazine treatment; experimental group (n = 90), patients received stellate ganglion block treatment. Clinical symptoms and disease activity in these two groups were compared before and after treatment using endoscopy. Blood was collected from patients on day 0, 10, 20 and 30 after treatment. Enzyme-linked immunosorbent assay was performed to determine interleukin-8 (IL-8) level. The changes in IL-8 level post-treatment in the two groups were compared using repeated measures analysis of variance.

RESULTS

After treatment, clinical symptoms and disease activity were shown to be alleviated by endoscopy in both the control and experimental groups. However, patients in the control group did not have obvious abdominal pain relief. In addition, the degree of pain relief in the experimental group was statistically better than that in the control group (P < 0.05). Ten days after treatment, IL-8 level was found to be significantly lower in the experimental group than in the control group, and the difference was statistically significant (P < 0.05). In addition, adverse events were significantly higher in the control group than in the experimental group, and the difference was statistically significant (χ² = 33.215, P = 0.000).

CONCLUSION

The application of stellate ganglion block effectively improves treatment efficacy in chronic ulcerative colitis, relieves clinical symptoms in patients, and reduces the level of inflammatory factors. Furthermore, this approach also had a positive impact on the disease to a certain extent.

Intraprocedural increase in heart rate during EUS-guided celiac plexus neurolysis: Clinically relevant or just a physiologic change?

BACKGROUND AND AIMS

Although EUS-guided celiac plexus neurolysis (EUS-CPN) is performed frequently for palliation of pain in pancreatic cancer, response to treatment is variable. Although intraprocedural increases in heart rate during alcohol injection are observed frequently, their significance and relationship to treatment outcome are unknown. The objective of this study was to examine whether a correlation exists between an increase in heart rate and treatment outcomes in patients undergoing EUS-CPN for pain relief in pancreatic cancer.

METHODS

This is a prospective observational study of patients with abdominal pain caused by inoperable pancreatic cancer who underwent EUS-CPN. Heart rate change was defined as an increase of ≥15 beats per minute (bpm) for ≥30 seconds during alcohol injection. Main outcome measures were to compare pain, quality of life, opioid use, and survival between heart rate change and no-change groups.

RESULTS

Heart rate change was observed in 25 of 51 patients (49.0%) who underwent EUS-CPN over a 12-month period. Although the heart rate change cohort had significantly better adjusted scores for pain (60 vs 73; P = .042) and components of quality of life such as nausea and/or vomiting (65 vs 81; P = .004), financial difficulties (41 vs 57; P = .02), weight loss (45 vs 65; P = .007), and satisfaction with body image (52 vs 62; P = .035), there was no significant difference in postprocedural opioid use or survival between groups.

CONCLUSIONS

Because patients with an increase in intraprocedural heart rate experienced significant improvement in pain and quality of life components, this observation must be further explored in order to improve the technique and outcomes of EUS-CPN.

[Effect of Stellate Ganglion Block on Bilateral Regional Cerebral Oxygen Saturation and Postoperative Cognitive Function]

The present study was to examine the effect of stellate ganglion block (SGB) on bilateral regional cerebral oxygen saturation (rSO2) and postoperative cognitive function. Eighty patients undergoing selective coronary artery bypass graft with cardiopulmonary bypass (CPB) were randomly and equally divided into two groups. The patients in group S were given right SGB with ropivacaine, while the patients in group C were injected with normal saline. We compared the bilateral rSO2 after SGB. Minimum Mental State Examination (MMSE), Visual Verbal Learning Test (VVLT), and Digital Span Test (DST) were applied to observe the effect on cognitive function. We found that the incidence of postoperative cognitive dysfunction (POCD) 7 days after surgery in group S was lower than that in group C. The level of blocked side rSO₂ of S group were significantly higher before CPB time of rewarming than that before SGB (P < 0.05), much higher than corresponding non-blocked side rSO₂ before CPB (P < 0.05), and much higher than rSO₂ level in group C before CPB and after CPB (P < 0.05). The non-blocked side rSO₂ in group S before anesthesia were much lower than basic levels and those in group C (P < 0.05). It could be concluded from the above results that there was significant increase in the blocked-side rSO₂ compared to the non-blocked side and there was significant decrease in the incidence of POCD compared to the control group after SGB.

Pathophysiology and Etiology of Nerve Injury Following Peripheral Nerve Blockade

This review synthesizes anatomical, anesthetic, surgical, and patient factors that may contribute to neurologic complications associated with peripheral nerve blockade. Peripheral nerves have anatomical features unique to a given location that may influence risk of injury. Peripheral nerve blockade-related peripheral nerve injury (PNI) is most severe with intrafascicular injection. Surgery and its associated requirements such as positioning and tourniquet have specific risks. Patients with preexisting neuropathy may be at an increased risk of postoperative neurologic dysfunction. Distinguishing potential causes of PNI require clinical assessment and investigation; a definitive diagnosis, however, is not always possible. Fortunately, most postoperative neurologic dysfunction appears to resolve with time, and the incidence of serious long-term nerve injury directly attributable to peripheral nerve blockade is relatively uncommon. Nonetheless, despite the use of ultrasound guidance, the risk of block-related PNI remains unchanged.

WHAT'S NEW

Since the 2008 Practice Advisory, new information has been published, furthering our understanding of the microanatomy of peripheral nerves, mechanisms of peripheral nerve injection injury, toxicity of local anesthetics, the etiology of and monitoring methods, and technologies that may decrease the risk of nerve block-related peripheral nerve injury.

The Effect of Adductor-Canal-Blockade on Outcome after Medial Unicondylar Knee Arthroplasty: A Preliminary Study

INTRODUCTION

Unicondylar knee arthroplasty (UKA) offers decreased morbidity, faster recovery, better functional outcomes, and equivalent survivorship compared to TKA for certain patients. To fully capture these benefits, regional anesthesia techniques must facilitate rather than compromise patients ability for early postoperative mobilization and safe discharge following UKA. The purpose of this study was to determine whether the predominantly sensory adductor canal blockade (ACB) shortens hospital stay after medial UKA (mUKA). Secondary endpoints were narcotic consumption, steps walked during PT sessions, and total PT sessions required prior to discharge.

METHODS

Twelve patients scheduled for elective mUKA received spinal anesthesia and single-shot ACB. ACB patients were matched by age, gender, body mass index (BMI), and Charlson Comorbidity Index in a 1:2 ratio to 24 lumbar plexus block (LPB) patients. Time to hospital discharge, number of physical therapy (PT) sessions required for safe discharge, and steps taken during PT sessions were retrospectively abstracted from each patient's medical record.

RESULTS

Patients who received ACB had a significantly shorter hospital stay (27.8 ± 3.9 hours) compared with patients who received LPB (39.7 ±18.5 hours, p = 0.025). Patients treated with ACB required significantly fewer PT sessions (1.3 ± 0.6 sessions) compared to patients who received LPB (2.4 ± 1.5 sessions, p = 0.007). Patients treated with ACB walked significantly more steps during their first PT session (225.0 ± 156.6 steps) compared with patients treated with LPB (107.4 ± 170.0, p = 0.045). There was a trend towards decreased narcotic requirements in the ACB group.

DISCUSSION AND CONCLUSIONS

Data from our study suggests that ACB may permit earlier hospital discharge and better participation in PT without compromising the quality of perioperative analgesia. Thus, ACB may represent a promising option for patients undergoing mUKA in terms of improved clinical outcomes, decreased postoperative morbidity, and cost-effectiveness.

The Impact of Popliteal Block on Postoperative Medication Administration and Time to Discharge from the Post-Anesthesia Care Unit

BACKGROUND

Previous studies have demonstrated the efficacy of popliteal block anesthesia in decreasing post - operative narcotic administration, nausea, and length of stay in patients undergoing foot and ankle surgeries. The purpose of this study was to compare the amount of narcotic medication administered, the need for anti-emetic medication, PACU length of stay, and discharge status in patients treated surgically for ankle fractures who received popliteal blocks with those who received general anesthesia alone.

METHODS

All patients being treated with open reduction and internal fixation for ankle fractures were randomized to receive either general anesthesia (GETA) or popliteal block. Postoperatively, data was collected on the duration of time in the PACU before discharge to home or to a hospital floor. Additional information was collection on the amount of anti-emetic and pain medication in the PACU.

RESULTS

Fifty-one patients agreed to participate in the study. There was no significant difference between the two groups with regards to the need for anti-emetic medication, the amount of pain medication received in the PACU, or amount of time spent in the PACU. Patients who received a popliteal block were no more likely to be discharged to home from the PACU than those who received general anesthesia.

DISCUSSION

While previous studies have demonstrated the efficacy of popliteal block in decreasing anti-emetic and pain medication administration in the PACU, we found no difference in the amount of medication administered. We found that popliteal block patients were no more likely to be discharged to home than those who received general anesthesia.

Established EUS-guided therapeutic interventions

Over the three last decades, endosonography ultrasound (EUS) has evolved from a diagnostic tool to an interventional modality through cumulative advances in experience, knowledge, equipment, and devices. EUS-guided therapeutic procedures appear feasible and safe when performed in highly-experienced centers. This review covers the technical aspects, indications, and results of the most commonly performed procedures. Celiac plexus neurolysis and collection drainages are now well-established techniques and considered to be first-line treatments. Biliary and pancreatic EUS-guided drainages are, conversely, more challenging, and there is currently insufficient clinical evidence documenting their superiority over established practice. Well-designed prospective trials are thus needed in order to accurately assess this modality's risks and long-term outcomes compared to radiological or surgical techniques.

[Hemopneumothorax after thoracic sympathetic nerve block; report of a case]

A 72-year-old man, who had been treated pneumothorax 50 years ago, visited a physician complaining of dyspnea after thoracic sympathetic nerve block for postherpetic neuralgia. The patient was diagnosed as pneumothorax, and was consulted to our hospital. Clinical sign and the chest radiography suggested tension hemopneumothorax, and the chest drainage was immediately performed. Although bloody fluid of 1,100 ml was initially drained, no further increase was noted. The patient was discharged on the 21st hospital day.

Bedside ultrasound-guided celiac plexus neurolysis in upper abdominal cancer patients: a randomized, prospective study for comparison of percutaneous bilateral paramedian vs. unilateral paramedian needle-insertion technique

INTRODUCTION

Percutaneous anterior abdominal ultrasound guidance for performing celiac plexus neurolysis is a relatively new but more economical, less time-consuming, more comfortable bedside technique for interventional pain management. Paucity of studies evaluating the efficacy of single-site vs. double-site injections at celiac trunk for ultrasound-guided celiac plexus neurolysis (USCPN) prompted us to conduct a prospective, randomized, single-blind clinical trial to compare USCPN using bilateral paramedian (double needle) technique with unilateral paramedian (single needle) technique.

METHODS

Sixty patients aged 18 years or older with unresectable upper abdominal cancers were randomized into two groups to receive USCPN. A 20-mL mixture of 50% ethanol with 0.25% bupivacaine was injected either unilaterally (20 mL×1 site) or bilaterally (10 mL×2 sites) depending on the randomization group. Subjects were assessed for the pain relief using Numerical rating scale (NRS) to assess their pain relief.

RESULTS

Baseline parameters being comparable (P > 0.05), the site of drug injections (single or double needle) had no bearing on the onset of pain relief and patient satisfaction scores (P > 0.05). Pain relief during follow-up visits was comparable between the two groups (P > 0.05). The discomfort score correlated well with the pain relief scoring without any significant difference between the two groups except in the last visit (at 3 month). Incidences of the complications were comparable in the two groups (P > 0.05).

CONCLUSION

Ultrasound-guided celiac plexus neurolysis using unilateral paramedian (single needle) needle-insertion technique is comparable with bilateral paramedian (double needle) needle-insertion technique with regard to pain relief and side effects.

The effect of oxygen administration on regional cerebral oxygen saturation after stellate ganglion block on the non-blocked side

BACKGROUND

Stellate ganglion block (SGB) causes sympathetic denervation of the head, neck, and upper extremities. In some studies, it has been reported that cerebral blood flow on the non-blocked side decreases after SGB, so when performing an SGB for pain management of the head, neck, and arm, the increased risk of cerebral ischemia should be considered.

OBJECTIVES

To examine the influence of administration of oxygen via nasal cannula after SGB on regional cerebral oxygen saturation (rSO2) of the non-blocked and blocked sides using near-infrared spectroscopy (NIRS).

STUDY DESIGN

Prospective observational study.

SETTING

Outpatient department for interventional pain management at Yonsei University College of Medicine, Seoul, Korea

METHODS

Thirty-eight patients with disease entities in the head, neck, and upper extremity and 3 volunteers were studied. SGB was performed with 10 mL of 1% lidocaine using an anterior paratracheal approach at the C6 transverse process level. A successful block was determined based on the appearance of Horner syndrome at 15 minutes after SGB. Oxygen was supplied at a rate of 5 L/min via nasal cannula starting 15 minutes after SGB. rSO2, blood pressure (BP), and heart rate (HR) were obtained at 5-minute intervals for 30 minutes using NIRS, a non-invasive blood pressure manometer, an electrocardiogram, and a pulse oximetry.

RESULTS

On the non-blocked side, when compared to the baseline values, there were significant decreases in the rSO2 (P < 0.001) and after administration of oxygen, there were significant increases of the rSO2 compared to the rSO2 at 15 minutes (P < 0.001). The lowest rSO2 at 15 minutes on the non-blocked side recovered to greater than the baseline value 5 minutes after starting oxygen administration. On the blocked side, when compared to the baseline values, there were significant increases at all time points (P < 0.001) and after administration of oxygen there were significant increases compared to the rSO2 at 15 minutes (P < 0.001). The rSO2 on the blocked side and the non-blocked side were significantly different at 15 minutes (P = 0.015). After oxygen administration, there were no significant differences of rSO2 between the 2 sides.

LIMITATIONS

This study is limited by its sample size and observational design. It is difficult to precisely define the importance of the effect of SGB and oxygen administration on rSO2 change as we did not examine how the intensity of the nerve block changed with the passage of time.

CONCLUSION

SGB leads to decreased cerebral blood flow of the non-blocked hemisphere, and oxygen administration seems to be a simple method to compensate for this response.

CLINICAL TRIAL

NCT01532713. IRB No.: 4-2011-0358.

Celiac plexus block for pancreatic cancer pain in adults

BACKGROUND

Pancreatic cancer causes severe pain in 50 to 70% of patients and is often difficult to treat. Celiac plexus block (CPB) is thought to be a safe and effective technique for reducing the severity of pain.

OBJECTIVES

To determine the efficacy and safety of celiac plexus neurolysis in reducing pancreatic cancer pain, and to identify adverse effects and differences in efficacy between the different techniques.

SEARCH STRATEGY

We searched Cochrane CENTRAL, MEDLINE, GATEWAY and EMBASE from 1990 to December 2010.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of CPB by the percutaneous approach or endoscopic ultrasonography (EUS)-guided neurolysis in adults with pancreatic cancer at any stage, with a minimum of four weeks follow-up.

DATA COLLECTION AND ANALYSIS

We recorded details of study design, participants, disease, setting, outcome assessors, pain intensity (visual analogue scale (VAS)) and methods of calculation.

MAIN RESULTS

The search identified 102 potentially eligible studies. Judged from the information in the title and abstract six of these concerning the percutaneous block, involving 358 participants, fulfilled the inclusion criteria and were included in the review. All were RCTs in which the participants were followed for at least four weeks. We excluded studies published only as abstracts. We identified one RCT comparing EUS-guided or computed tomography (CT) -guided CPB but its aim was to assess efficacy in controlling chronic abdominal pain associated with chronic pancreatitis rather than pancreatic cancer, so it was excluded.For pain (VAS) at four weeks the mean difference was -0.42 in favour of CPB (95% confidence interval (CI) -0.70 to - 0.13, P = 0.004, fixed-effect model). At eight weeks the mean difference was -0.44 (95% CI -0.89 to - 0.01, random-effects model). At eight weeks there was significant heterogeneity (I(2) = 89%).Opioid consumption was significantly lower in the CPB group than the control group (P < 0.00001). 

AUTHORS' CONCLUSIONS

Although statistical evidence is minimal for the superiority of pain relief over analgesic therapy, the fact that CPB causes fewer adverse effects than opioids is important for patients. Further studies and RCTs are recommended to demonstrate the potential efficacy of a less invasive technique under EUS guidance.

Hemorrhagic gastritis and duodenitis following celiac plexus neurolysis

INTRODUCTION

Neurolytic celiac plexus block is a well established intervention to palliate pain, and it potentially improves quality of life in patients suffering from an upper abdominal malignancy, specifically pancreatic cancer.

METHODS

We describe a 61-year-old female with a history of pancreatic cancer, unexplained transfusion dependent anemia with a normal recent upper endoscopy, and abdominal pain, who had previously undergone gastrojejunostomy and a Roux-en-Y hepaticojejunostomy as well as chemotherapy and radiation therapy. She suffered from intractable abdominal pain and elected to undergo palliative celiac plexus neurolysis.

RESULTS

The patient initially appeared to tolerate celiac plexus block well, however, 45 minutes after the procedure, the patient had bright red blood per rectum followed by bloody diarrhea. Her abdomen was soft and non-tender with minimal distention and positive bowel sounds. The patient's hemoglobin decreased to 7.5 g/dl from 9.0 g/dl, and she received a blood transfusion. Upper endoscopy and enteroscopy demonstrated diffuse hemorrhagic gastritis and duodenitis. The bleeding was controlled and the patient remained hemodynamically stable. Ultimately, the patient did well and was discharged home.

DISCUSSION

We report a case of a patient with known history of gastritis and duodenitis, who developed severe upper GI bleeding immediately following the celiac plexus neurolysis. There are no published reports documenting similar cases. It is difficult to offer a precise physiologic explanation for this complication. However, we speculate that inhibition of sympathetic tone from the celiac plexus neurolysis caused increased blood flow to the GI system, and this resulted in active bleeding from previously indolent hemorrhagic gastritis and duodenitis.

CONCLUSION

It may be beneficial for patients with a history of gastritis, duodenitis or GI bleeding to undergo a careful upper GI evaluation prior to celiac plexus neurolysis.

Botulinum toxin treatment for anal fissure

OBJECTIVES

To evaluate the effectiveness of Botulinum toxin injection in the treatment of anal fissure.

METHODS

38 patients (22 males, 16 females; mean age (SD) of 33.3 (8.3) years) who have presented to Surgical Outpatient Clinic at Al Ain Hospital, United Arab Emirates, with anal fissure in the period between June 2000 and September 2001 and treated with Botulinum toxin injection were retrospectively studied. They were followed up for at least 8 weeks to evaluate the effects of treatment.

RESULTS

Treatment with Botulinum toxin was effective in 89% of patients with chronic uncomplicated anal fissure. Two patients experienced minor incontinence in the form of a fecal soiling which disappeared later.

CONCLUSION

Botulinum toxin injection is an effective alternative for surgery for treatment of uncomplicated idiopathic anal fissure. Surgery should be offered to patients who do not improve with Botulinum toxin injection and to those with complicated anal fissure.

Ultrasound-guided stellate ganglion block successfully prevented esophageal puncture

Stellate ganglion block is utilized in the diagnosis and management of various vascular disorders and sympathetically mediated pain in the upper extremity, head and neck. The cervical sympathetic chain is composed of superior, middle, intermediate, and inferior cervical ganglia. However, in approximately 80% of the population, the inferior cervical ganglion is fused with the first thoracic ganglion, forming the stellate ganglion also known as cervicothoracic ganglion. The stellate ganglion lies medial to the scalene muscles, lateral to the longus coli muscle, esophagus and trachea along with the recurrent laryngeal nerve, anterior to the transverse processes and prevertebral fascia, superior to the subclavian artery and the posterior aspect of the plura, and posterior to the vertebral vessels at C7 level. Consequently, inadvertent placement of the needle into the vertebral artery, thyroid, neural tissues, or esophagus can occur with the fluoroscopic or blind approach. While fluoroscopy is a reliable method for identifying boney structures, ultrasound may identify the vertebral vessels, thyroid gland and vessels, longus coli muscles, nerve roots and the esophagus. Thus, ultrasound may prevent inadvertent placement of the needle into these structures as might happen with either the blind technique or fluoroscopic technique. A patient with complex regional pain syndrome type I of the left upper extremity was scheduled for left stellate ganglion block with the anterior paratracheal approach under fluoroscopy. Real-time ultrasound imaging prevented inadvertent injury to the esophagus as well as the thyroid gland and vessels. Ultrasound-guided block may improve patient safety by avoiding the soft tissue structures in the needle path that can't be readily seen by fluoroscopy. This may be particularly useful in the patient with asymptomatic pharyngoesophageal diverticulum (Zenker diverticulum).

Sub-Tenon's block complicated by subconjunctival cilia

We describe an unusual case of symptomatic eyelash entrapment in the subconjunctival space following a sub-Tenon's block. This case emphasizes the need for vigilance in patients reporting a persistent foreign-body sensation following surgery with this common modality of anesthesia.

Comparison of different injectate volumes for stellate ganglion block: an anatomic and radiologic study

BACKGROUND

Volumes from 5 to 20 mL of local anesthetic are used for stellate ganglion block. The variation of practice gave us the impetus to investigate the distribution of 3 different volumes of solution. We documented the regions reached by each volume to assess the possibility to reduce the injectate to 5 mL.

MATERIALS AND METHOD

A total of 42 cadavers (84 halves), fixed by Thiel's method and on which pulse simulation was performed, were investigated. Of these 84 halves, 28 were injected with 5 mL of contrast (group A), 28 halves with 10 mL (group B), and 28 halves with 20 mL (group C), according to the tissue-displacement method. Immediately after injection, the cadavers were investigated by use of CT scans with a possible 3-dimensional reconstruction. In addition, 4 halves of group A and group B were dissected, and the contrast distribution was determined by photography.

RESULTS

Group A showed a constant dissemination from C4 to Th2-Th3, without spreading to ventral or lateral regions. In group B, a persistent spread from C4 to Th3 was documented. Ventral and lateral regions were also reached in one third of the specimens. Group C showed a constant dissemination from C3 to Th4-Th5, with additional spread to ventral, lateral, and posterior regions of the neck similar to that in group B.

CONCLUSION

The use of 5 mL results in an almost ideal vertical distribution in most of the cadavers, whereas high volumes--20 mL more so than 10 mL--are at risk of spreading extensively in both the vertical direction and also uncontrollably to other regions of the neck.

Complications and Adverse Effects Associated with Continuous Peripheral Nerve Blocks in Orthopedic Patients

BACKGROUND

The increasing popularity of continuous peripheral nerve blocks (CPNBs) warrants further study of their adverse effects and complications.

METHODS

Anterior sciatic, femoral, and interscalene brachial plexus CPNBs were performed preoperatively using standardized catheter techniques in orthopedic patients prior to general or spinal anesthesia. Complications and adverse effects related to CPNBs were prospectively evaluated.

RESULTS

We analyzed 1398 CPNBs in 849 consecutive patients (mean age 65 +/- 13 yr) between 2002 and 2004. Two-hundred-twenty-one patients received interscalene, 628 patients femoral, and 549 sciatic CPNBs, respectively. In all the latter patients, we performed both femoral and sciatic CPNBs. Overall, there were 9 cases of local inflammation at the insertion site (0.6%), and 3 local infections (pustule) (0.2%, all femoral CPNBs). In one patient undergoing a femoral technique, a retroperitoneal hematoma led to compression injury of the femoral nerve. Complete denervation of the quadriceps femoris muscle was confirmed by electroneuromyography. No other major neurological complications were noted. There was one case of methemoglobinemia associated with an interscalene CPNB. Vascular puncture occurred in approximately 6% of patients undergoing femoral and sciatic CPNBs. Catheter rupture was noted in one patient.

CONCLUSIONS

Our results add to the evidence that major complications from CPNBs are rare. However, minor adverse effects associated with CPNBs may be more common.

Influence of needle position on lumbar segmental nerve root block selectivity

BACKGROUND AND OBJECTIVES

In patients with chronic low back pain radiating to the leg, segmental nerve root blocks (SNRBs) are performed to predict surgical outcome and identify the putative symptomatic spinal nerve. Epidural spread may lead to false interpretation, affecting clinical decision making. Systematic fluoroscopic analysis of epidural local anesthetic spread and its relationship to needle tip location has not been published to date. Study aims include assessment of epidural local anesthetic spread and its relationship to needle position during fluoroscopy-assisted blocks.

METHODS

Patients scheduled for L4, L5, and S1 blocks were included in this prospective observational study. Under fluoroscopy and electrostimulation, they received 0.5 mL of a mixture containing lidocaine 5 mg and iohexol 75 mg. X-rays with needle tip and contrast were scored for no epidural spread (grade 0), local spread epidurally (grade 1), or to adjacent nerve roots (grade 2).

RESULTS

Sixty-five patients were analyzed for epidural spread, 62 for needle position. Grade 1 epidural spread occurred in 47% of L4 and 28% of L5 blocks and grade 2 spread in 3 blocks (5%; L5 n = 1, S1 n = 2). For lumbar blocks, the needle was most frequently found in the lateral upper half of the intervertebral foramen. Epidural spread occurred more frequently with medial needle positions (P = .06).

CONCLUSION

The findings suggest (P = .06) that the risk of grade 1 and 2 lumbar epidural spread, which results in decreased SNRB selectivity, is greater with medial needle positions in the intervertebral foramen. The variability in anatomic position of the dorsal root ganglion necessitates electrostimulation to guide SNRB in addition to fluoroscopy.

Thoracic sympathetic block reduces respiratory system compliance

CONTEXT AND OBJECTIVE

Thoracic epidural anesthesia (TEA) following thoracic surgery presents known analgesic and respiratory benefits. However, intraoperative thoracic sympathetic block may trigger airway hyperreactivity. This study weighed up these beneficial and undesirable effects on intraoperative respiratory mechanics.

DESIGN AND SETTING

Randomized, double-blind clinical study at a tertiary public hospital.

METHODS

Nineteen patients scheduled for partial lung resection were distributed using a random number table into groups receiving active TEA (15 ml 0.5% bupivacaine, n = 9) or placebo (15 ml 0.9% saline, n = 10) solutions that also contained 1:200,000 epinephrine and 2 mg morphine. Under general anesthesia, flows and airway and esophageal pressures were recorded. Pressure-volume curves, lower inflection points (LIP), resistance and compliance at 10 ml/kg tidal volume were established for respiratory system, chest wall and lungs. Students t test was performed, including confidence intervals (CI).

RESULTS

Bupivacaine rose 5 +/- 1 dermatomes upwards and 6 +/- 1 downwards. LIP was higher in the bupivacaine group (6.2 +/- 2.3 versus 3.6 +/- 0.6 cmH2O, p = 0.016, CI = -3.4 to -1.8). Respiratory system and lung compliance were higher in the placebo group (respectively 73.3 +/- 10.6 versus 51.9 +/- 15.5, p = 0.003, CI = 19.1 to 23.7; 127.2 +/- 31.7 versus 70.2 +/- 23.1 ml/cmH2O, p < 0.001, CI = 61 to 53). Resistance and chest wall compliance showed no difference.

CONCLUSION

TEA decreased respiratory system compliance by reducing its lung component. Resistance was unaffected. Under TEA, positive end-expiratory pressure and recruitment maneuvers are advisable.

Techniques and results of neurolysis for chronic pancreatitis and pancreatic cancer pain

Chronic abdominal pain can be associated with benign and malignant disease. Pain associated with pancreatic cancer and chronic pancreatitis can be severely debilitating, with significant impairment in quality of life. Frequently, chronic abdominal pain is not adequately responsive to conventional medical therapies, including nonsteroidal anti-inflammatory drugs and opioids. For this reason, alternative methods to alleviate pain have been developed. Celiac plexus neurolysis and celiac block involve injecting an agent at the celiac axis, with the goal of either selectively destroying the celiac plexus or temporarily blocking visceral afferent nociceptors to alleviate chronic abdominal pain. Agents most commonly used for this purpose include alcohol or phenol for neurolysis and bupivacaine and triamcinolone for temporary block. Methods to administer such agents to the celiac ganglion include CT imaging, percutaneous ultrasound, fluoroscopy, endoscopic ultrasound, or surgery (ganglionectomy). Response rates and complications vary depending on technique but are relatively low. This review highlights the techniques of celiac plexus neurolysis and celiac block and their status in the treatment of chronic pancreatitis and pancreatic cancer pain.

Sympathectomy for hyperhidrosis: should we place the clamps at T2–T3 or T3–T4?

Endoscopic thoracic sympathectomy is routinely used to treat severe hyperhidrosis. It is usually performed at the T2-T3 level of the nerve, but may produce less severe compensatory hidrosis if performed at a lower level. This study evaluates the outcome of 1,274 patients who underwent endoscopic thoracic sympathectomy for plamar, plantar, axillary or facial hyperhidrosis/blushing. Half of the patients were clamped at the T2-T3 level and half were clamped at the T3-T4 level. Postsurgical symptoms and side effects were assessed by interview. All of patients with palmar hyperhidrosis were cured or improved. Patients with plantar and axillary hyperhidrosis were more likely to be improved at T3-T4 level clamping. Patients with facial hyperhidrosis were more likely to be cured at T2-T3 level, but did show improvement at the T3-T4 level. Overall satisfaction was higher in the T3-T4 group. Some degree of mild compensatory sweating occurred in all patients. However, severe compensatory sweating was more common in the T2-T3 group. Around 2% of patients requested a reversal of their surgery. Endoscopic thoracic sympathectomy is a safe and effective treatment for hyperhidrosis. Clamping at the T3-T4 level has a more successful outcome. In particular, it appears to reduce the incidence of severe compensatory hidrosis.

Effects of lumbar sympathetic ganglion block for a patient with amyotrophic lateral sclerosis (ALS)

A 59-year-old man with amyotrophic lateral sclerosis (ALS) received lumbar epidural and sympathetic ganglion blocks to increase regional blood flow and improve his clinical symptoms. After a lumbar epidural block (0.5% mepivacaine), the skin temperature of his affected lower extremities rose by 7.0 degrees C and became close to that of the intact side, and the distance he was able to walk with his cane increased from 2 to 8 m. The clinical effects produced by the lumbar sympathetic ganglion block (99.5% alcohol) were sustained for approximately 8 weeks after the first block and for approximately 6 weeks after the second block. There were no particular adverse effects or complications associated with these nerve block procedures. Epidural and sympathetic ganglion blocks for an ALS patient, albeit their effects are of a transient nature, may improve related clinical symptoms, and were thought to play a contributory role in improving our patient's quality of life.

Severe hypertension after stellate ganglion block

Haemodynamic effects may occur after stellate ganglion block (SGB) arising from autonomic imbalance and local anaesthetic infiltration to barosensitive areas. We report seven patients who developed severe hypertension (systolic arterial pressure >200 mm Hg) after SGB in our pain clinic service. We postulate that diffusion of the local anaesthetic along the carotid sheath may produce vagal blockade causing unopposed sympathetic activity as a result of attenuation of the baroreceptor reflex. We recommend close monitoring of arterial pressure measurement in patients who received SGB.

Laryngospasm during subarachnoid block

Central neuraxial block is associated with increased vagal tone. We report a patient who developed laryngospasm and stridor under spinal anaesthesia. This was treated successfully with i.v. atropine and fluids. We propose that the laryngospasm was secondary to increased vagal tone under the spinal anaesthetic. Such a manifestation of increased vagal tone under spinal anaesthesia has not been reported previously.

ASGE guideline: complications of EUS

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of experts. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement and revision needed to clarify aspects of this statement and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to the recommendations.

A Case of Cervical Spondylitis during Stellate Ganglion Block

We report a case of cervical spondylitis that developed during treatment with a series of stellate ganglion blocks. A 65-year-old man was scheduled for 10 sessions of stellate ganglion block for treatment of right-sided deafness of sudden onset due to Ramsay Hunt syndrome. Administration of betamethasone was started 5 days before the first block and was continued for 6 weeks. After disinfection of the skin by povidone iodine, each stellate ganglion block was performed via the paratracheal approach. The first four block sessions were uneventful. However, during the fifth session, the patient complained of neck pain. After 10 sessions, the deafness improved and the patient was discharged from the hospital. Three weeks after discharge, he was readmitted for sustained neck and bilateral shoulder pain and numbness of the right hand. Cervical roentgenography and magnetic resonance imaging revealed spondylitis of C5 and C6. Antibiotics were administered for 2 weeks. The inflammatory variables on blood examination improved, but cervical roentgenography performed 8 weeks after the last block showed that the vertebral body of C6 was nearly completely destroyed. Four months after the last block, the vertebral bodies of C5 and C6 had fused. This case indicates that when stellate ganglion block is performed in patients who are taking a corticosteroid, the disinfection procedure must be strictly followed and that if the patient complains of neck or shoulder pain, cervical roentgenography or magnetic resonance imaging or both should be immediately performed to assess the presence of spondylitis.

Sequelae of endoscopic sympathetic block

Endoscopic sympathetic block as a treatment for primary hyperhidrosis is associated with certain sequelae. The reported occurrence of side effects still varies in the literature. As the majority of patients describe sequelae after sympathetic surgery, the frequency and importance of these persisting changes are still underestimated. Patient's informed consent should include and define side effects like gustatory sweating, olfactory sweating and bradycardia as likely, and compensatory sweating as obligatory.

[A case of pyogenic osteomyelitis of the cervical spine following stellate ganglion block]

A 56-year-old woman had been treated with stellate ganglion block (SGB) for pigmentation degeneration retinopathy over 6 years. She had no history of diabetes mellitus or immunodeficiency. She complained of high back pain but was afebrile. She was diagnosed as pyogenic osteomyelitis by the MRI findings and hematological examination. Antibiotics was administerd for 3 weeks and inflammatory signs disappeared. We should bear in mind that pyogenic osteomyelitis is very rare but one of the most serious complications with SGB.

Pleural effusion and chest pain after continuous interscalene brachial plexus block

OBJECTIVE

We describe a unique case of a patient who experienced atelectasis of the lower lobe of the left lung and pleural effusion manifested by chest pain after continuous interscalene brachial plexus block for postoperative analgesia.

CASE REPORT

A 45-year-old man with no respiratory disease was scheduled for left shoulder arthroscopy for rotator cuff repair under interscalene brachial plexus block and sedation. A continuous interscalene brachial plexus block provided postoperative analgesia. On the first postoperative day, the patient reported left-sided chest pain. The chest x-ray showed elevation of the left hemidiaphragm associated with a left lower lobe atelectasis and a minor pleural effusion. After catheter removal, clinical and radiologic signs resolved within few days without sequela.

CONCLUSION

If chest pain presents after interscalene brachial plexus block, early postoperative chest x-ray is recommended to rule out pneumothorax, atelectasis, and/or pleural effusion secondary to ipsilateral phrenic block.

Retroperitoneal abscess after neurolytic celiac plexus block from the anterior approach

BACKGROUND AND OBJECTIVES

The anterior approach for celiac plexus block has the potential risks of infection, hemorrhage, and fistula formation. We report a case of a patient who developed a retroperitoneal abscess with the formation of a vascular-enteric fistula after a neurolytic celiac plexus block from the anterior approach.

CASE REPORT

A 60-year-old female with a history of pain secondary to chronic idiopathic calcifying pancreatitis (VAS 7-8) underwent a subtotal resection of the head of the pancreas with an end-to-side pancreatojejunostomy using a Roux-en-Y loop. Pain continued secondary to chronic pancreatitis. Because of intolerance (vomiting and constipation) of morphine and transdermal fentanyl over a 2-month period, it was decided to perform a neurolytic celiac plexus block using the anterior approach with ultrasound guidance. The patient's pain was completely relieved, enabling withdrawal of oral analgesics. Pain reappeared after 2 years, and the same technique was repeated. Ten days later, she was admitted with diabetic ketoacidosis and lower gastrointestinal bleeding. Computed tomography showed a left paravertebral retroperitoneal abscess; arteriography suggested a fistula between the mesenteric vein and the jejunum. Urgent surgery was undertaken, revealing a leak of the pancreatojejunostomy and a large abscess around the celiac plexus. A distal pancreatectomy and partial resection of the Roux-en-Y loop was performed. The patient was discharged 1 month later in good clinical condition. Because of recurrent pain, she has required repeated neurolytic celiac plexus blocks via a posterior approach without complications.

CONCLUSION

The posterior approach for neurolytic celiac plexus block should be considered in particular in patients with previous pancreatic surgery.