Awake Carotid

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They're actually pretty easy to do with local and sedation. Of course I thought no friggin' way the first time I did one, but it went great.
 
Definitely make sure that the patient is willing to do it, not that the surgeon is forcing him/her to do it.

Otherwise, the technique is easy to learn, as long as you give the block enough time to set up.
 
I stopped doing them after one of my patients sat up in the middle of surgery , pulled out both his A line and IV and tried to leave!
It's funny what little cerebral ischemia could do to you.
 
My attending recommended an easy, cheap monitoring system for awake carotids.

Place a yellow rubber ducky in the hand opposite the carotid being cleaned, and have the pt. squeeze it about every 10-15 seconds. If the motor cortex on the operative side goes too ischemic during clamping, bad shunt, etc., then bye bye annoying squeaky duck.
 
I actually give the patient a bulb to squeeze attached to a manometer and ask him/her to squeeze - not as annoying as a rubber ducky 🙂.
 
coccygodynia said:
I actually give the patient a bulb to squeeze attached to a manometer and ask him/her to squeeze - not as annoying as a rubber ducky 🙂.
Click to expand...
And if you hook the bulb to a turbine and a generator he can produce electricity to run the anesthsia machine, totally free energy.
:idea:
 
coccygodynia said:
Any of you guys/gals doing cervical blocks for awake carotids? Curious as to your technique.
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The carotid is so superficial, that even if you miss the block, a field block by the surgeon will be enough. Step 1:Inject on the neck some local. Step 2:Have some more local on the field for the surgeon. Voila, you are done.

My problem with this technique is pt sitting up, passing out, vasovagals, freaking out, moving, etc...

There is no way I would ever have that done awake. I don't want to be aware that I'm stroking out, either. Do you think the guy does not know what's going on when he can no longer squeeze the squeaky toy? I want the tube down the throat with EEG or evoked potential monitoring.
 
so, it says to hit the branches of the glossopharyngeal n. by injecting into the carotid sheath. is this done with US guidance?? obviously, you don't want to inject the local INTO the carotid a (or hit the jugular or vagus n.)..... can someone shed some light on this?
 
cfdavid said:
so, it says to hit the branches of the glossopharyngeal n. by injecting into the carotid sheath. is this done with US guidance?? obviously, you don't want to inject the local INTO the carotid a (or hit the jugular or vagus n.)..... can someone shed some light on this?
Click to expand...

Why would you want to block the glosso-pharyngeal nerve for carotid surgery?

You need a superficial + deep cervical plexus block, they are pretty easy and don't really require ultrasound although you could use ultrasound for the deep block.
 
Planktonmd said:
Why would you want to block the glosso-pharyngeal nerve for carotid surgery?

You need a superficial + deep cervical plexus block, they are pretty easy and don't really require ultrasound although you could use ultrasound for the deep block.
Click to expand...

Awake carotids are one of my most unfavorite surgeries if the pt. is squirrelly. On the right patient they are great. All the ones I have done I have used just the superficial block, never the deep. The surgeon usually has to supplement a little bit but I think this is more because of pt. discomfort perceived from retraction and also the bovie. One tip an attending told me was to ask the patient a bunch of questions - serves to keep them occupied. As well you can ask them the same stuff later on once the clamp is applied to assess their cognition.
 
urgewrx said:
There is no way I would ever have that done awake. I don't want to be aware that I'm stroking out, either. Do you think the guy does not know what's going on when he can no longer squeeze the squeaky toy? I want the tube down the throat with EEG or evoked potential monitoring.
Click to expand...

But we have BIS now.:laugh:
 
Planktonmd said:
Why would you want to block the glosso-pharyngeal nerve for carotid surgery?

You need a superficial + deep cervical plexus block, they are pretty easy and don't really require ultrasound although you could use ultrasound for the deep block.
Click to expand...

I'm a med student, but since glossopharyngeal carries back afferents from the carotid body, it seems that without anesthetizing IX it could be inappropriately stimulated during the procedure.

For a refresher, if afferents of IX would be stimulated, it would likely cause an increase in respiration, as IX from carotid body are only stimulated when P02 levels fall. I'm pretty sure you guys are up on this stuff, but for educational purposes, the peripheral chemoreceptors (carotid body and aortic arch) are secondary to the central chemoreceptors which are primarily sensitive to CO2 levels, versus O2 levels.

What do you guys think? Is this the correct logic for anesthetizing IX n.??
 
cfdavid said:
I'm a med student, but since glossopharyngeal carries back afferents from the carotid body, it seems that without anesthetizing IX it could be inappropriately stimulated during the procedure.

For a refresher, if afferents of IX would be stimulated, it would likely cause an increase in respiration, as IX from carotid body are only stimulated when P02 levels fall. I'm pretty sure you guys are up on this stuff, but for educational purposes, the peripheral chemoreceptors (carotid body and aortic arch) are secondary to the central chemoreceptors which are primarily sensitive to CO2 levels, versus O2 levels.

What do you guys think? Is this the correct logic for anesthetizing IX n.??
Click to expand...

Injection of local anesthetics in the carotid bed is usually done intraop by the surgeon under direct vision.
It helps decrease the reflex bradycardia that you see otherwise after carotid surgery.
So you are right.
 
Planktonmd said:
Why would you want to block the glosso-pharyngeal nerve for carotid surgery?

You need a superficial + deep cervical plexus block, they are pretty easy and don't really require ultrasound although you could use ultrasound for the deep block.
Click to expand...

You really only need the superficial block. 10 ml of local under the lateral border of the SCM blindly. Surgeon can supplement if needed, but its usually not.
 
Intubate said:
You really only need the superficial block. 10 ml of local under the lateral border of the SCM blindly. Surgeon can supplement if needed, but its usually not.
Click to expand...
Sure, you could do it with a superficial block or even just local infiltration.
The bottom line, regardless what technique you use for awake carotids
You need a patient who is willing and capable of staying still with head turned to one side for an hour, none of my patients fits the criteria.
 
Planktonmd said:
Sure, you could do it with a superficial block or even just local infiltration.
Click to expand...

this is how they are done, by the one neurosurgeon (yes, not a vascular guy), at our institution when we do awakes.

Planktonmd said:
The bottom line, regardless what technique you use for awake carotids
You need a patient who is willing and capable of staying still with head turned to one side for an hour, none of my patients fits the criteria.
Click to expand...

patient cooperation and choice is always paramount... unless there is a compelling reason not to consider them (ie, an awake gut exploration).
 
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