Ultrasound-guided intermediate cervical plexus block for postoperative analgesia in patients undergoing carotid endarterectomy under general anesthesia: a case-control study

Öz

Aim: The aim of this study is to compare intravenous analgesia (IVA) and intermediate cervical plexus block (ICPB) in terms of acute pain scores and opioid consumption in patients undergoing carotid endarterectomy (CEA) under general anesthesia. Materials and methods: Following the induction of anesthesia, dexketoprofen trometamol 50 mg was administered before the surgical incision, and paracetamol 1 g was given at the end of the surgery and continued at 6 hour intervals for group IVA. Whereas, ultrasound-guided intermediate cervical plexus block was performed in ICPB group. VAS scores, morphine consumption, length of stay, and patient satisfaction status were compared. Results: A total of 109 patients (57 in the IVA group and 52 in the ICPB group) between January 2015 and June 2021 were enrolled. The mean VAS score after extubation was significantly lower in the ICPB group (4.1±1.4 vs 1.2±0.8, p = 0.005). Total morphine consumption was found to be significantly lower in the ICPB group (13.1±4.4 mg vs 3.9±2.4 mg, p < 0.001). The hospital stay was 3.1±1.3 days in the IVA group, while it was 2.2±0.9 days in the ICPB group (p = 0.0014). The patients in the ICPB group were found to be significantly more satisfied (3.4±1.4 vs 1.2±0.8, p < 0.001). Conclusion: Intermediate cervical plexus block provides lower acute pain scores and lower opioid consumption compared to intravenous analgesia in patients undergoing CEA under general anesthesia. In addition, this combined technique shortens the ICU and hospital length of stay and improves patient satisfaction.

Anahtar Kelimeler

• carotid endarterectomy
• intermediate cervical plexus block
• analgesia

Genel anestezi altında karotis endarterektomi uygulanan hastalarda postoperatif analjezi için ultrason eşliğinde intermediate servikal pleksus bloğu: vaka kontrol çalışması

Öz

Amaç: Bu çalışmanın amacı, genel anestezi altında karotis endarterektomi (KEA) uygulanan hastalarda intravenöz analjezi (IVA) ve intermedier servikal pleksus bloğunu (ICPB) akut ağrı skorları ve opioid tüketimi açısından karşılaştırmaktır. Gereç ve yöntem: Anestezi indüksiyonunu takiben, Grup IVA'ya cerrahi kesi öncesi deksketoprofen trometamol 50 mg, operasyon bitiminde 1 gr parasetamol verildi ve 6 saat arayla devam edildi. ICPB grubuna ise ultrason eşliğinde ara servikal pleksus bloğu yapıldı. VAS skorları, morfin tüketimi, hastanede kalış süresi ve hasta memnuniyeti karşılaştırıldı. Bulgular: Ocak 2015 ile Haziran 2021 arasında toplam 109 hasta (IVA grubunda 57 ve ICPB grubunda 52) dahil edildi. Ekstübasyon sonrası ortalama VAS skoru ICPB grubunda anlamlı olarak daha düşüktü (4.1±1.4'e karşı 1.2±0.8, p = 0.005). Toplam morfin tüketimi ICPB grubunda (13.1±4.4 mg vs 3.9±2.4 mg, p < 0.001) anlamlı olarak daha düşük bulundu. Hastanede kalış süresi IVA grubunda 3,1±1,3 gün iken, ICPB grubunda 2,2±0,9 gündü (p=0,0014). ICPB grubundaki hastaların anlamlı olarak daha fazla memnun oldukları bulundu (3.4±1.4'e karşı 1.2±0.8, p < 0.001). Sonuç: İntermediate servikal pleksus bloğu, genel anestezi altında KEA uygulanan hastalarda, intravenöz analjeziye kıyasla daha düşük akut ağrı skorları ve daha düşük opioid tüketimi sağlar. Ayrıca bu kombine teknik, yoğun bakım ve hastanede kalış süresini kısaltır ve hasta memnuniyetini artırır.

Anahtar Kelimeler

• karotis endarterektomi
• intermediate servikal pleksus bloğu
• analjezi

Kaynakça

1. 1. Eastcott HH, Pickering GW, Rob CG. Reconstruction of internal carotid artery in a patient with intermittent attacks of hemiplegia. Lancet. 1954 Nov 13;267(6846):994-6. doi: 10.1016/s0140-6736(54)90544-9.
2. 2. Sastry RA, Pertsch NJ, Sagaityte E, Poggi JA, Toms SA, Weil RJ. Early Outcomes After Carotid Endarterectomy and Carotid Artery Stenting: A Propensity-Matched Cohort Analysis. Neurosurgery. 2021 Jul 28:nyab250. doi: 10.1093/neuros/nyab250. Epub ahead of print.
3. 3. Brott TG, Halperin JL, Abbara S, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. Catheter Cardiovasc Interv. 2013 Jan 1;81(1):E76-123.
4. 4. Kuru V, Aksun M, Karahan N, Girgin S, Şencan A, Gölboyu BE, Aran G, Gökalp O, Tanyeli HF, Gürbüz A. Comparison of General Anesthesia and Regional Anesthesia on Carotis Endarterectomy Operation Patients in terms of Their Perioperative Complications. GKD Anest Yoğ Bak Dern Derg. 2015; 21(3): 134-141.
5. 5. Mracek J, Kletecka J, Holeckova I, Dostal J, Mrackova J, Mork J, Priban V. Patient Satisfaction with General versus Local Anesthesia during Carotid Endarterectomy. J Neurol Surg A Cent Eur Neurosurg. 2019 Sep;80(5):341-344. doi: 10.1055/s-0039-1688692.
6. 6. Gassner M, Bauman Z, Parish S, Koenig C, Martin J, Hans S. Hemodynamic changes in patients undergoing carotid endarterectomy under cervical block and general anesthesia. Ann Vasc Surg. 2014 Oct;28(7):1680-5. doi: 10.1016/j.avsg.2014.03.029.
7. 7. Choquet O, Dadure C, Capdevila X. Ultrasound-guided deep or intermediate cervical plexus block: the target should be the posterior cervical space. Anesth Analg. 2010 Dec;111(6):1563-4; author reply 1564-5.
8. 8. Harky A, Chan JSK, Kot TKM, Sanli D, Rahimli R, Belamaric Z, Ng M, Kwan IYY, Bithas C, Makar R, Chandrasekar R, Dimitri S. General Anesthesia Versus Local Anesthesia in Carotid Endarterectomy: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth. 2020 Jan;34(1):219-234. doi: 10.1053/j.jvca.2019.03.029.

9. 9. Mracek J, Kletecka J, Mork J, Stepanek D, Dostal J, Mrackova J, Priban V. Indications for General versus Local Anesthesia during Carotid Endarterectomy. J Neurol Surg A Cent Eur Neurosurg. 2019 Jul;80(4):250-254. doi: 10.1055/s-0039-1678601.
10. 10. GALA Trial Collaborative Group, Lewis SC, Warlow CP, Bodenham AR, Colam B, Rothwell PM, Torgerson D, Dellagrammaticas D, Horrocks M, Liapis C, Banning AP, Gough M, Gough MJ. General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial. Lancet. 2008 Dec 20;372(9656):2132-42.
11. 11. Hasde Aİ, Baran Ç, Özçınar E, Karakaya HÇ, Bermede AO, Durdu MS, Yazıcıoğlu L, Kaya B. The effect of anesthesia technique in carotid endarterectomy: Regional versus general anesthesia. Turk J Vasc Surg 2021; 30(1): 042-048. http://dx.doi.org/10.9739/tjvs.2021.845
12. 12. Kim JW, Huh U, Song S, Sung SM, Hong JM, Cho A. Outcomes of Carotid Endarterectomy according to the Anesthetic Method: General versus Regional Anesthesia. Korean J Thorac Cardiovasc Surg. 2019 Dec;52(6):392-399. doi: 10.5090/kjtcs.2019.52.6.392.
13. 13. Kumar K, Kirksey MA, Duong S, Wu CL. A Review of Opioid-Sparing Modalities in Perioperative Pain Management: Methods to Decrease Opioid Use Postoperatively. Anesth Analg. 2017 Nov;125(5):1749-1760. doi: 10.1213/ANE.0000000000002497.
14. 14. Alilet A, Petit P, Devaux B, Joly C, Samain E, Pili-Floury S, Besch G. Ultrasound-guided intermediate cervical block versus superficial cervical block for carotid artery endarterectomy: The randomized-controlled CERVECHO trial. Anaesth Crit Care Pain Med. 2017 Apr;36(2):91-95. doi: 10.1016/j.accpm.2016.03.007.
15. 15. Sait Kavaklı A, Kavrut Öztürk N, Umut Ayoğlu R, Sağdıç K, Çakmak G, İnanoğlu K, Emmiler M. Comparison of Combined (Deep and Superficial) and Intermediate Cervical Plexus Block by Use of Ultrasound Guidance for Carotid Endarterectomy. J Cardiothorac Vasc Anesth. 2016 Apr;30(2):317-22. doi: 10.1053/j.jvca.2015.07.032.
16. 16. Samanta S, Samanta S, Panda N, Haldar R. A unique anesthesia approach for carotid endarterectomy: Combination of general and regional anesthesia. Saudi J Anaesth. 2014;8(2):290-293. doi:10.4103/1658-354X.130753.
17. 17. Messner M, Albrecht S, Lang W, Sittl R, Dinkel M. The superficial cervical plexus block for postoperative pain therapy in carotid artery surgery. A prospective randomised controlled trial. Eur J Vasc Endovasc Surg. 2007 Jan;33(1):50-4. doi: 10.1016/j.ejvs.2006.06.024.
18. 18. Cherprenet AL, Rambourdin-Perraud M, Laforêt S, Faure M, Guesmi N, Baud C, Rosset E, Schoeffler P, Dualé C. Local anaesthetic infiltration at the end of carotid endarterectomy improves post-operative analgesia. Acta Anaesthesiol Scand. 2015 Jan;59(1):107-14. doi: 10.1111/aas.12431.
19. 19. Do W, Cho AR, Kim EJ, Kim HJ, Kim E, Lee HJ. Ultrasound-guided superficial cervical plexus block under dexmedetomidine sedation versus general anesthesia for carotid endarterectomy: a retrospective pilot study. Yeungnam Univ J Med. 2018 Jun;35(1):45-53. doi: 10.12701/yujm.2018.35.1.45.
20. 20. Lobo M, Mourão J, Afonso G. Carotid endarterectomy: review of 10 years of practice of general and locoregional anesthesia in a tertiary care hospital in Portugal. Braz J Anesthesiol. 2015 Jul-Aug;65(4):249-54. doi: 10.1016/j.bjane.2014.03.011.
21. 21. Gürer O, Yapıcı F, Yapıcı N, Özler A, Işık Ö. Comparison between local and general anesthesia for carotid endarterectomy: early and late results. Vasc Endovascular Surg. 2012 Feb;46(2):131-8. doi: 10.1177/1538574411431345.
22. 22. Mracek J, Kletecka J, Holeckova I, Dostal J, Mrackova J, Mork J, Priban V. Patient Satisfaction with General versus Local Anesthesia during Carotid Endarterectomy. J Neurol Surg A Cent Eur Neurosurg. 2019 Sep;80(5):341-344. doi: 10.1055/s-0039-1688692.