Risk of Methemoglobinemia in Scalp Block and İnfiltration Anesthesia in Patients Undergoing Deep Brain Stimulation

Öz

The application of local anesthetics in areas with a high blood supply, such as scalp block, is more susceptible to systemic effects of local anesthetics such as methemoglobinemia because of the high absorption rate and the risk of intravascular injection. In this study, we aimed to evaluate the risk of methemoglobinemia by reviewing methemoglobin values after scalp block in patients with a deep brain stimulation (DBS) due to neurological diseases, especially Parkinson’s.The study included 41 patients aged >18 years who were admitted between January 2017 and December 2018 for DBS and underwent regional anesthesia (n = 41). Patients were administered scalp block (n = 10) and infiltration anesthesia (n = 31). Using data from the patients’ medical records, we statistically analyzed the patients’ age, American Society of Anesthesiologists (ASA) status, gender, DBS indication, scalp block/infiltration anesthesia, highest methemoglobin level in arterial blood gas, pH, pO2, SpO2, and clinical symptoms.The indications for DBS were Parkinson’s disease in 29 patients hyperreactivity, dystonia and tremor in the remaining patients. Furthermore, 33 patients were classified as ASA class II. The methemoglobinemia level was >2% in two patients who underwent scalp block and six patients who underwent infiltration anesthesia. However, there was no statistically significant difference in methemoglobin levels between scalp and infiltration anesthesia.In areas with high blood flow, such as the scalp, caution should be exercised in administering local anesthesia because of the patient’s risk of developing methemoglobinemia, although there are no clinical findings on this topic.

Anahtar Kelimeler

• Deep brain stimulation
• methaemoglobinemia
• scalp block
• infiltration anaesthesia

Derin Beyin Stimulatörü Uygulanan Hastalarda Skalp Bloğu ve İnfiltrasyon Anestezisinde Methemoglobinemi Riski

Öz

Skalp bloğu gibi kanlanması yüksek olan bölgelerde lokal anesteziklerin uygulanması, emilim hızının ve intravasküler enjeksiyon riskinin yüksekliği nedeniyle methemoglobinemi gibi lokal anesteziklerin sistemik etkilerine karşı daha hassastır. Çalışmamızda, özellikle Parkinson olmak üzere nörolojik hastalıklara bağlı derin beyin stimülatörü (DBS) yerleştirilen hastalarda skalp bloğu sonrası methemoglobin değerlerini retrospektif inceleyerek methemoglobinemi riskini değerlendirmeyi amaçladık.Çalışmaya DBS için Ocak 2017 ve Aralık 2018 tarihleri arasında başvuran, 18 yaş üstü ve rejyonel anestezi uygulanan 41 hasta dahil edildi. Hastalara skalp bloğu (n: 10) ve infiltrasyon anestezisi (n: 31) uygulandı. Hastaların yaş, Amerikan Anesteziyologlar Derneği fiziksel sınıflaması (ASA), cinsiyet, DBS endikasyonu, skalp bloğu / infiltrasyon anestezisi, arteriyel kan gazında pH, pO2, Spo2, en yüksek methemoglobin düzeyleri ve klinik semptomlar istatistiksel olarak analiz edildi.DBS endikasyonları 29 hastada Parkinson hastalığı, diğerleri hiper-reaktivite, distoni ve titremeydi. Ayrıca 33 hasta ASA Sınıf II olarak sınıflandırıldı. Skalp bloğu yapılan 2 hastada ve infiltrasyon anestezisi uygulanan 6 hastada MeHb düzeyi% 2'nin üzerindeydi. Ancak skalp bloğu ve infiltrasyon anestezisi arasında methemoglobin düzeylerinde istatiksel olarak anlamlı bir fark gözlenmedi.Skalp gibi kanlanmanın yüksek olduğu bölgelerde klinik bulgu olmadan, lokal anestezi uygulamalarında methemoglobinemia gelişme riski nedeniyle dikkatli olunmalıdır.

Anahtar Kelimeler

• Derin beyin stimulatörü
• methemoglobinemi
• skalp blok
• infiltrasyon anestezisi

Kaynakça

1. 1. Krauss P, Marahori N.A, Oertel M.F, et al, Better Hemodynamics and Less Antihypertensive Medication: Comparison of Scalp Block and Local Infiltration Anesthesia for Skull-Pin Placement in Awake Deep Brain Stimulation Surgery, World Neurosurg 2018;120:E991–E999.
2. 2. Yeoh T.Y, Manninen P, Kalia S.K, et al, Anesthesia considerations for patients with an implanted deep brain stimulator undergoing surgery: a review and update, Can J Anesth 2017 64:308–319. doi: 10.1007/s12630-016-0794-8
3. 3. Bindu B, Bithal P.K, Anaesthesia and deep brain stimulation. J Neuroanaesth Crit Care 2016;3.
4. 4. Kılıç B.B, Peker S, Deep Brain Stimulation (DBS): History, Mechanisms of Action and Indications, Türk Nöroşir Derg 2014, Cilt: 24, Sayı: 3, 250-256
5. 5. Grant R, Gruenbaum S.E, Gerrard J, Anaesthesia for deep brain stimulation: a review, Curr Opin Anaesthesiol 2015;28(5):505–510. doi:10.1097/ACO0000000000000230
6. 6. Bala R, Chaturvedi A, Pandia M.P, Bithal P.K., Anaesthetic management and perioperative complications during deep brain stimulation surgery: Our institutional experience, J Neuroanaesth Crit Care 2016;3(2).
7. 7. Erkuran M.K, Duran A, Kurt B.B, et al, Methemoglobinemia after local anesthesia with prilocaine: a case report, Am J Emerg Med 2015;33:602.e1–602.e2.
8. 8. Öztürk E, Aktaş B.T, Öztarhan K, et al, Lokal Anestezik Uygulanması Sonrası Gelişen Methemoglobinemi, JOPP Derg 2(1):46-48, 2010

9. 9. Cortazzo J.A, Lichtman A.D, Methemoglobinemia: A Review and Recommendations for Management, J Cardiothorac Vasc Anesth 2013.
10. 10. Trivedi D.J, Joshira B, Bidkar V, et al, Methemoglobinemia: Living with Dormant Devil, Ind J Clin Biochem 2017;32(2):248–250. doi: 10.1007/s12291-016-0586-5
11. 11. Imani F, Behseresht A, Pourfakhr P, et al, Prevelance of Abnormal Methemoglobinemia and Its Determinants in Patients Receiving Nitroglycerin During Anesthesia , Anest Pain Med, 2019 June;9:e85852, doi:10.5812/aapm.85852
12. 12. Sarsu S.B, Şahin K, Saraç F, A case of methemoglobinemia due to lidocaine-prilocaine cream used in burn, J Pediatr Surg 2014;28(2):45–48. doi:10.5222/JTAPS.2014.045
13. 13. Vallapu S, Panda N.B, Samagh N, et al, Efficacy of Dexmedetomidine as an Adjuvant to Local Anesthetic Agent in Scalp Block and Scalp Infiltration to Control Postcraniotomy Pain: A Double‑Blind Randomized Trial, J Neurosci Rural Pract 2018;9(1). doi:10.4103/jnrp.jnrp_310_17
14. 14.Venkatraghavan L. Anesthesia for patients who undergo deep brain stimulator implantation, Uptodate, Jan 2019
15. 15. Bala I, Gupta B, Bhardwaj N, et al, Effect of Scalp Block on Postoperative Pain Relief in Craniotomy Patients, Anaesth Intensive Care 2006;34:224–227.
16. 16. Akcil E.F, Dilmen O.K, Vehid H, et al, Which one is more effective for analgesia in infratentorial craniotomy? The scalp block or local anesthetic infiltration, Clin Neurol Neurosurg 2017;154: 98–103.
17. 17. Kara M.Y, Turhan S.Ç, Ökten F, Skalp Bloğun Yeniden Gözden Geçirilmesi, derleme, Anestezi Dergisi 2014;22(2):67–73.
18. 18. Rozet I, Muangman S, Vavilala MS, et al, Clinical experience with dexmedetomidinefor implantation of deep brain stimulators in Parkinson’s disease. Anesth Analg 2006;103:1224–1228
19. 19. Chaki T, Sugino S, Janicki P.K, et al, Efficacy and Safety of a Lidocaine and Ropivacaine Mixture for Scalp Nerve Block and Local Infiltration Anesthesia in Patients Undergoing Awake Craniotomy, J Neurosurg Anesthesiol _2016;28.
20. 20. Yamaji F, Soeda A, Shibata H, et al, A new mutation of congenital methemoglobinemia exacerbated after methylene blue treatment, Acute Med Surg 2018;5:199–201. doi: 10.1002/ams2.335