CAROTIDS! help

[turnupthevapor]

Looking for some insight into doing regionals for carotids. Our old surgeon did his own local but the new guys are looking to us to help.....Let me start by saying I have absolutely no interest in doing the traditional deep cervical block (i'd actually rather not even do the blind intermediate). I am wondering you all are doing around this great nation? I am hoping I could just hit up a quick superficial cervical plexus block and call it a day (as this has been compared with the intermediate cervical plexus block with = results). I was considering following the technique seen below:

http://www.usra.ca/cpanatomy.php

Think this makes sense? 20 ml under the SCM? why bupi? why not more dilute local? why such a large volume? will this get the sheath and the vessels? throw me a bone here

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[Noyac]

It's been a while since I've done an awake carotid and I'm happy to say that.
They are pretty cool when you do the first couple but after that they are just a pain.
I recall, but I'd have to review again before doing another one, I would do a superficial cervical block along the SCM and two separate injections just shy of the transverse processes of C 4/7. Usually c4 and c6 best I can remember without looking it up.
Sorry I am not more help here.

Oh, and a big help is if the surgeon is good at injecting local at the carotid bifurcation/bulb. This makes a huge difference in my experience.

 

[Urzuz]

Looking for some insight into doing regionals for carotids. Our old surgeon did his own local but the new guys are looking to us to help.....Let me start by saying I have absolutely no interest in doing the traditional deep cervical block (i'd actually rather not even do the blind intermediate). I am wondering you all are doing around this great nation? I am hoping I could just hit up a quick superficial cervical plexus block and call it a day (as this has been compared with the intermediate cervical plexus block with = results). I was considering following the technique seen below:

http://www.usra.ca/cpanatomy.php

Think this makes sense? 20 ml under the SCM? why bupi? why not more dilute local? why such a large volume? will this get the sheath and the vessels? throw me a bone here

They want it done for an awake surgery or for postop pain control?

Superficial cervical plexus blocks are easy to learn and perform, and take all of 20 seconds to do.

 

[Chloroform4Life]

We did our awake with just a superficial cervical plexus block and surgeon supplements as needed with more local. Block's pretty easy. Just a field block along the posterior border of Sternocleidomastoid, concentrating most in the middle since that's where most of the plexus emerges. Mepi 1.5% usually works fine performed in OR with quick enough onset. If you want to get fancy, you can use ultrasound. Look at NYSORA website for technique.

 

[fakin' the funk]

Looking for some insight into doing regionals for carotids. Our old surgeon did his own local but the new guys are looking to us to help.....Let me start by saying I have absolutely no interest in doing the traditional deep cervical block (i'd actually rather not even do the blind intermediate). I am wondering you all are doing around this great nation? I am hoping I could just hit up a quick superficial cervical plexus block and call it a day (as this has been compared with the intermediate cervical plexus block with = results). I was considering following the technique seen below:

I learned these in PP.

With ultrasound, full sterile prep and drape (since it's the eventual surgical field), I do 15-20ml 2% lido w/ 1:400000 epi with a B bevel block needle, in plane short axis, just below the level of the carotid bifurcation. Basically, get into the neurovascular sheath deep to the SCM, superficial to the ASM, and lateral to the IJ and infiltrate the sheath with your 2%. Sets up nicely.

As an aside, I like to do a bit of hydromorphone and very low dose dexmedetomidine for sedation. Patient selection goes a long way, as with any "awake" procedure.

 

[Planktonmd]

Just do old fashion deep and superficial cervical blocks, What's the big deal???
Alternatively do a superficial + Intermediate with ultrasound.
About 50% of the patients as you will find out are not good candidates for this block and they would go crazy at some point.

 

[Chloroform4Life]

There's a million ways to skin a carotid. Awake, shunt everyone, eeg, ssep, cerebral ox..... I don't think there's been one method that is shown to be consistently superior to the other. Correct me if I'm wrong. So why are we still doing these awake? They are a pain in the ass.

 

[deleted171991]

There's a million ways to skin a carotid. Awake, shunt everyone, eeg, ssep, cerebral ox..... I don't think there's been one method that is shown to be consistently superior to the other. Correct me if I'm wrong. So why are we still doing these awake? They are a pain in the ass.

Because you have the best monitor: the patient's mental status.

 

[pgg]

Because you have the best monitor: the patient's mental status.

Does it matter?

 

[deleted171991]

Does it matter?

Some surgeons like it. It's better than any alternative.

 

[Planktonmd]

Because you have the best monitor: the patient's mental status.

Actually the reason usually is the surgeon's preference, since there is no evidence supporting that local or regional produces better outcomes compared to GA.
The GALA study in 2008 examined this issue:
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61699-2/abstract
It's usually old fashion surgeons or those who are overly concerned about being sued who push for carotid surgery awake, fortunately we are now seeing less of these characters.

 

[pgg]

It's better than any alternative.

Is it?

That's a bold statement from a CCM'er who prides himself on data driven decisions.

I suspect that any data suggesting outcomes are better with awake carotids is hopelessly polluted and confounded by the fact that only excellent surgeons can get them done efficiently enough to do them awake in the first place, and it's harder for lousy anesthesiologists/CRNAs to mess up an awake anesthetic. I also suspect that if those same excellent surgeons did the procedure asleep, they'd have the same excellent outcomes, given an anesthesiologist diligent enough to keep MAPs where they should be.

(If you look at that abortion of a carotid anesthetic record posted recently with 100+ point BP swings you'll see what I mean about lousy anesthesia.)

I'm of the opinion that outcome (i.e. stroke rate) has approximately zero real correlation to awake vs asleep technique.

 

[deleted171991]

Is it?

That's a bold statement from a CCM'er who prides himself on data driven decisions.

I suspect that any data suggesting outcomes are better with awake carotids is hopelessly polluted and confounded by the fact that only excellent surgeons can get them done efficiently enough to do them awake in the first place, and it's harder for lousy anesthesiologists/CRNAs to mess up an awake anesthetic. I also suspect that if those same excellent surgeons did the procedure asleep, they'd have the same excellent outcomes, given an anesthesiologist diligent enough to keep MAPs where they should be.

(If you look at that abortion of a carotid anesthetic record posted recently with 100+ point BP swings you'll see what I mean about lousy anesthesia.)

I'm of the opinion that outcome (i.e. stroke rate) has approximately zero real correlation to awake vs asleep technique.

When I have an elderly patient in the ICU, there is no data that I like more than a neuro/mental status exam. Heck, I almost don't care about hypotension and other numbers as long as my patient feels fine and has no changes. How is that for evidence-based medicine? I don't treat numbers, I treat patients.

Between an awake/MAC and a general anesthetic in elderly, I will always choose the former, as long as the patient can tolerate it. Btw, an awake carotid is way more work for the "lousy" anesthesiologist.

 

[Gas]

http://bja.oxfordjournals.org/content/99/2/159.full

Link above says superficial is probably safer than deep, and I agree. I used to do superficials and deeps (combined) and had an intrathecal injection (had to cancel case), and one of my partners had an intravascular injection (led to a seizure and cancellation). This was before the ultrasound, but I don't think deeps are easy to do with ultrasound anyway. Therefore, I do a superficial only, and it is sufficient. Surgeon has to supplement occasionally no matter what you do, so why not do what is safest and associated with the fewest complications?

There is good info on NYSORA website. Inject some local lateral to the SCM, and fan out in couple different directions. Need the right patient personality, and the right surgeon personality/speed. That combination is getting harder and harder to come by nowadays...