[Cervical plexus block as an alternative anesthetic approach for type I thyroplasty: a case report]. / Bloqueio do plexo cervical como técnica anestésica alternativa para tireoplastia tipo I: relato de caso.

BACKGROUND: The role of type I thyroplasty (TIP) is well established as the treatment for glottal insufficiency due to vocal fold paralysis, but the ideal anesthetic management for this procedure is still largely debated. We present the case of a novel anesthetic approach for TIP using combined intermediate and superficial Cervical Plexus Block (CPB) and intermittent mild sedation analgesia. CASE REPORT: A 51-year-old presenting with left vocal fold paralysis and obstructive sleep apnea was scheduled for TIP. An ultrasound-guided intermediate CPB was performed using the posterior approach, and 15 mL of ropivacaine 0.5% were injected in the posterior cervical space between the sternocleidomastoid muscle and the prevertebral fascia. Then, for the superficial CPB, a total of 10 mL 0.5% ropivacaine was injected subcutaneously, adjacently to the posterior border of the sternocleidomastoid muscle, without penetrating the investing fascia. An intermittent sedation analgesia with a target-controlled infusion of remifentanyl (target 0.5 ng.mL-1) was used to facilitate prosthesis insertion and the fiberoptic laryngoscopy. This technique offered a safe anesthetic airway and good operating conditions for the surgeon, as well as feasible voice monitoring and optimal patient comfort. CONCLUSION: The use of regional technique is a promising method for the anesthetic management in TIP, especially in patients with compromised airway.

Cervical plexus block as an alternative anesthetic approach for type I thyroplasty: a case report / Bloqueio do plexo cervical como técnica anestésica alternativa para tireoplastia tipo I: relato de caso

Abstract Background: The role of type I thyroplasty (TIP) is well established as the treatment for glottal insufficiency due to vocal fold paralysis, but the ideal anesthetic management for this procedure is still largely debated. We present the case of a novel anesthetic approach for TIP using combined intermediate and superficial Cervical Plexus Block (CPB) and intermittent mild sedation analgesia. Case report: A 51-year-old presenting with left vocal fold paralysis and obstructive sleep apnea was scheduled for TIP. An ultrasound-guided intermediate CPB was performed using the posterior approach, and 15 mL of ropivacaine 0.5% were injected in the posterior cervical space between the sternocleidomastoid muscle and the prevertebral fascia. Then, for the superficial CPB, a total of 10 mL 0.5% ropivacaine was injected subcutaneously, adjacently to the posterior border of the sternocleidomastoid muscle, without penetrating the investing fascia An intermittent sedation analgesia with a target-controlled infusion of remifentanyl (target 0.5 ng.mL-1) was used to facilitate prosthesis insertion and the fiberoptic laryngoscopy. This technique offered a safe anesthetic airway and good operating conditions for the surgeon, as well as feasible voice monitoring and optimal patient comfort. Conclusion: The use of a regional technique is a promising method for the anesthetic management in TIP, especially in patients with compromised airway.

Resumo Introdução: O papel da tireoplastia tipo I (TPI) está bem estabelecido no tratamento de insuficiência glótica após a paralisia das pregas vocais, mas o manejo anestésico ideal para a TPI ainda é controverso. Descrevemos uma nova técnica anestésica para a TPI usando o Bloqueio do Plexo Cervical (BPC) superficial e o BPC intermediário associados, em presença de analgo-sedação leve e intermitente. Relato de caso: Paciente de 51 anos de idade com paralisia da prega vocal esquerda e apneia obstrutiva do sono foi agendada para TPI. BPC intermediário guiado por ultrassom foi realizado usando acesso posterior, e 15 mL de ropivacaína a 0,5% foram injetados no espaço cervical posterior entre o músculo esternocleidomastoideo e a fáscia prevertebral. A seguir, para o BPC superficial, 10 mL de ropivacaína a 0,5% foram injetados na região subcutânea adjacente à borda posterior do músculo esternocleidomastoideo, sem transfixar a fáscia de revestimento. Analgo-sedação intermitente com infusão alvo-controlada de remifentanil (alvo de 0,5 ng.mL-1) foi usada para facilitar a inserção da prótese e a laringoscopia com fibra ótica. A técnica ofereceu via aérea segura durante a anestesia, boa condição para o cirurgião, possibilidade de monitorar a voz, além de ótimo conforto à paciente. Conclusões: O uso de anestesia regional é uma técnica promissora para o cuidado anestésico durante a TPI, especialmente em pacientes com via aérea comprometida.

Postoperative oral amiodarone versus oral bisoprolol as prophylaxis against atrial fibrillation after coronary artery bypass graft surgery: a prospective randomized trial.

BACKGROUND: Postoperative atrial fibrillation (AF) occurs in up to 50% of patients undergoing coronary artery bypass (CABG) surgery and is associated with complications. Amiodarone and beta blockers are effective as prophylaxis for AF after CABG. The purpose of this study was to compare oral amiodarone versus oral bisoprolol for prevention of AF after CABG. METHODS: In this randomized study, 200 patients admitted for elective CABG were given oral amiodarone (n=98 patients) or oral bisoprolol (n=102 patients) beginning 6 h after surgery. Amiodarone patients received 15 mg/Kg then 7 mg/Kg/day for one month. Bisoprolol patients received 2.5 mg then 2.5 mg bid indefinitely. RESULTS: Postoperative AF occurred in 15.3% of the patients in the amiodarone group and 12.7% of the patients in the bisoprolol group (p=0.60). Maximal ventricular rate tended to be lower in the bisoprolol group (125+/-6 beats/min) compared with the amiodarone group (144+/-7 beats/min, p=.06). Preoperative beta blockage did not affect AF incidence in either study group. There was no difference between the 2 groups for the onset time of AF episodes, total AF duration, AF recurrence and postoperative length of hospital stay. No serious postoperative complications occurred in the two study groups. Two reversible low cardiac output cases occurred with bisoprolol. CONCLUSIONS: Postoperative oral bisoprolol and amiodarone are equally effective for prophylaxis of AF after CABG. Treatment with bisoprolol resulted in a trend to lower ventricular response rate in AF cases. Both regimens were well tolerated.

Can femoral artery pressure monitoring be used routinely in cardiac surgery?

OBJECTIVE: The purpose of this study was to evaluate the safety of femoral arterial pressure monitoring in cardiac surgery. DESIGN: Prospective, observational study. SETTING: Cardiac surgery unit (CSU) in a university hospital. PARTICIPANTS: Of a total of 2,350 consecutive patients scheduled for elective cardiac surgery with cardiopulmonary bypass, 2,264 patients with femoral artery pressure monitoring were included. INTERVENTIONS: A femoral arterial catheter was inserted percutaneously before the induction of anesthesia. The catheter was withdrawn 40 to 96 hours after surgery. It was replaced by a radial artery catheter in patients staying for more than 4 days in the CSU or in case of pulse loss or lower limb ischemia. The catheter was removed and sent for cultures whenever it showed local changes, discharge, or if sepsis was suspected. MEASUREMENTS AND MAIN RESULTS: Pain on insertion ranged from 0 to 20 mm on the 100-mm visual analog scale. Complications related to femoral artery cannulation were recorded. No cases of femoral artery thrombosis, lower extremity ischemia, or hematoma requiring surgery were noted. Small hematomas were observed in 3.3% of patients. The incidence of oozing was 2.1% after the insertion of the catheter and 4.9% after its removal. Three cases (0.13%) of serious bleeding occurred; 2 required surgery. Eight percent of catheter tips were sent for culture, and positive bacterial growth was recorded in 18.6% of them. Catheter-related blood stream infection occurred in 0.5% of the total patient population included. CONCLUSIONS: Femoral artery pressure monitoring was associated with a low complication rate and, therefore, it can be used routinely in cardiac surgery.

Comparison of central venous to mixed venous oxygen saturation in patients with low cardiac index and filling pressures after coronary artery surgery.

OBJECTIVE: To evaluate the correlation and agreement between mixed venous oxygen saturation (SvO(2)) and central venous oxygen saturation (ScvO(2)) in patients with low cardiac index and filling pressures after coronary artery surgery. DESIGN: Prospective observational study. SETTING: Tertiary care academic hospital. PARTICIPANTS: Sixty consecutive patients with a cardiac index <2 L/min/m(2) and a pulmonary artery occlusion pressure <12 mmHg after coronary artery surgery were included. INTERVENTIONS: Patients were monitored by a pulmonary artery catheter and a central venous catheter positioned in the superior vena cava. MEASUREMENTS AND RESULTS: SvO(2) and ScvO(2) were simultaneously measured before (T0) and after (T1) normalization of the cardiac index (>2.5 L/min/m(2)) by fluid therapy. Sixty pairs of measures were obtained at T0 and at T1. Bias between SvO(2) and ScvO(2) was -0.6% (T0) and -0.8% (T1). Limits of agreement were from -19.2% to 18% (T0) and from -15.6% to 14% (T1), and the correlation coefficient was 0.463 (T0) and 0.72 (T1). SvO(2) and ScvO(2) changes from T0 to T1 (DeltaSvO(2) and DeltaScvO(2)) were calculated. The bias between DeltaSvO(2) and DeltaScvO(2) was -0.25. Limits of agreement were from -20% to 19.5%, and the correlation coefficient was 0.6. CONCLUSIONS: In patients with low cardiac index and filling pressures after coronary artery surgery, ScvO(2) could not be used as a direct alternative for SvO(2). After fluid therapy and normalization of the cardiac index, differences between individual values remained large, and the disagreement between ScvO(2) and SvO(2) changes was significant.

Cervical plexus block for carotid endarterectomy followed by general anesthesia for abdominal aortic surgery--a case report.

The aim of this clinical report is to describe the use of sequential regional and general anesthesia for concomitant carotid and abdominal aortic surgery. We performed, in a 70-year-old man, a cervical plexus block for carotid endarterectomy (CEA) followed immediately by general anesthesia for resection of an abdominal aortic aneurysm. This anesthetic approach provided adequate surgical conditions. Intraoperative neurological status and cardiovascular parameters were stable and postoperative course was uneventful. Sequential regional and general anesthesia may be an alternative to general anesthesia for concomitant carotid and abdominal aortic surgery. This approach offers an adequate neurological monitoring during the CEA phase of the combined surgery and the opportunity to postpone the aortic surgery should the CEA be associated with a non-reversible neurological deficit.

Intraoperative myocardial ischemia in peripheral vascular surgery: general anesthesia vs combined sciatic and femoral nerve blocks.

STUDY OBJECTIVE: The aim of this study was to compare the frequency of intraoperative myocardial ischemia in lower extremity vascular surgery with general anesthesia vs regional anesthesia via combined sciatic and femoral nerve blocks. DESIGN: This is a prospective, randomized study. SETTING: This study was set at an academic medical center. PATIENTS: The study included 50 patients scheduled for elective lower extremity vascular surgery. INTERVENTIONS: Patients in group 1 received balanced general anesthesia, whereas patients in group 2 received combined sciatic and femoral nerve blocks with 40 mL of 0.375% bupivacaine. Monitoring included a radial artery catheter and multilead, dual-channel electrocardiogram with computerized ST-segment analysis. Blood pressure and heart rate variations were maintained within 10% of preoperative values by adjusting anesthetic depth, fluid replacement, and vasoactive drug dosages. MEASUREMENTS AND MAIN RESULTS: An ST-segment depression of at least 1 mm or elevation of at least 2 mm lasting for more than 1 minute was considered a significant episode of myocardial ischemia. Intraoperative hemodynamic data and the frequency of significant ST-segment change episodes were recorded. The number of patients with ischemic episodes and the total number of these episodes were lower in group 2 than in group 1 (1 patient vs 7 patients, P = 0.02; and 2 vs 14 episodes, P = 0.04). No significant difference was found between groups 1 and 2 regarding systolic or diastolic arterial pressures, or heart rate. CONCLUSION: Compared with general anesthesia, combined sciatic and femoral nerve blocks reduce the frequency of intraoperative myocardial ischemia in patients undergoing lower extremity vascular surgery.