Superficial Cervical Plexus block for Mastoid/Inner ear surgery?

[VentdependenT]

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We've been doing these at children's for the aforementioned cases. Seems practical. Seems to sort of work. Any thoughts? Have you done these on adults?

0.25 bupi, 2-3cc's at lateral boarder of SCM at level of C-6. Bent 25-27g needle aimed toward the ear. Do a couple of passes and inject as withdrawing.

What cha think?

 

[coprolalia]

Great for the skin incision in CEA, but don't know about mastoid. You are blocking the lesser occiptal nerve and greater auricular (C2-3 distrib), so I guess you are covering the incision area. But, the surgery is so deep (mastoidectomy). Usually these are for cholesteatoma, and that is purely an ear canal thing. So, I don't think that particular block is going to work all that well for the deep pain, maybe incisional pain.

And, 10-20 mL injected as you describe. But, we use mepivicaine-tetracaine mix. You get a much longer block, but it requires more set-up time for the local to be "surgical" level. Do you do awake CEAs there at Rush?

-copro

 

[VentdependenT]

Great for the skin incision in CEA, but don't know about mastoid. You are blocking the lesser occiptal nerve and greater auricular (C2-3 distrib), so I guess you are covering the incision area. But, the surgery is so deep (mastoidectomy). Usually these are for cholesteatoma, and that is purely an ear canal thing. So, I don't think that particular block is going to work all that well for the deep pain, maybe incisional pain.

And, 10-20 mL injected as you describe. But, I use mepivicaine-tetracaine mix. Do you do awake CEAs there at Rush?

-copro

Copro, I was thinking the same thing. We are missing trigeminal/facial or whatever the hell hits the inner ear canal (I can't remember and I ain't lookin it up right now...worken on a couple a brews). Seemed like a good idea. As for the volume of injectate, these are lil' kids. Haven't tried it on adults.

We don't do awake CEA's. We have some EEG guy in the room at downtown AND the surgeon wants a cerebral oximeter on the pt as well. Whatever. Goldstandard and that piece of $hit... At Northshore we use an EEG attached to our anesthesia monitor which gives us a series of numbers adjacent to a crazy graph that continuously goes. We just let the surgeon know if the numbers from either hemisphere of the brain are "off." Then he/she does something, maybe. Very scientific eh?

I've seen and participated in an awake carotid at NW hospital as a 4th year. I didn't witness the block however.

 

[coprolalia]

I've seen and participated in an awake carotid at NW hospital as a 4th year. I didn't witness the block however.

Yeah, I've actually done a few of these. Quite cool. The SCP works great, and then the surgeon can "touch up" the areas (like carotid sheath) that you can't cover.

Gotta be right patient, though. If the patient is prone to freaking out, then you can't have them laying there with their neck wide open and a huge incision down the length of their carotid. But, it's pretty cool when it works. In the ones I've done (and it's not many, like 4), just did the SCP in the pre-op area, MAC with a little midaz and alfenta, and they seemed to go well. Haven't had anyone need to get tubed midway through or the like.

Cool technique for a cool procedure. The patients love it too 'cuz you can talk with them the whole time.

-copro

 

[Planktonmd]

We've been doing these at children's for the aforementioned cases. Seems practical. Seems to sort of work. Any thoughts? Have you done these on adults?

0.25 bupi, 2-3cc's at lateral boarder of SCM at level of C-6. Bent 25-27g needle aimed toward the ear. Do a couple of passes and inject as withdrawing.

What cha think?

Are you guys doing mstoidectomies on children under straight regional?

 

[jetproppilot]

We've been doing these at children's for the aforementioned cases. Seems practical. Seems to sort of work. Any thoughts? Have you done these on adults?

0.25 bupi, 2-3cc's at lateral boarder of SCM at level of C-6. Bent 25-27g needle aimed toward the ear. Do a couple of passes and inject as withdrawing.

What cha think?

I guess as long as you're not doing ITSOKANESTHESIA.........meaning....the kid is hurting like s h it and you start to say "ITS OK BABY!!!! ITS OK!!!!"....

 

[VentdependenT]

I guess as long as you're not doing ITSOKANESTHESIA.........meaning....the kid is hurting like s h it and you start to say "ITS OK BABY!!!! ITS OK!!!!"....

Its hard for me to tell with emergence delirium. Even if I bring the kid out deep into the holding area, with what any of you would agree upon as a good anesthetic, the kid can totally freak out upon awakening. Only thing that really helps is narcotics, and thats not from pain control. Its from being narc'ed out.

In order to really know if the block is worth a damn I need to do this on a pediatric patient of age which can communicate meaningful with me (or perhaps, not a previously deaf kid with a cochlear implant on the anesthetic I just gave) or an adult.

 

[Planktonmd]

Its hard for me to tell with emergence delirium. Even if I bring the kid out deep into the holding area, with what any of you would agree upon as a good anesthetic, the kid can totally freak out upon awakening. Only thing that really helps is narcotics, and thats not from pain control. Its from being narc'ed out.

In order to really know if the block is worth a damn I need to do this on a pediatric patient of age which can communicate meaningful with me (or perhaps, not a previously deaf kid with a cochlear implant on the anesthetic I just gave) or an adult.

Ok, that answers my question.
So, do you think a superficial cervical block is better than the surgeon infiltrating with some local anesthetic?

 

[VentdependenT]

Ok, that answers my question.
So, do you think a superficial cervical block is better than the surgeon infiltrating with some local anesthetic?

No

 

[Noyac]

This is an interesting concept but thats all it is to me. I just don't see any real usefulness in it. I doubt I would enter it into my practice.

 

[coprolalia]

Its hard for me to tell with emergence delirium.

Turn the Sevo off a little earlier. Then, when you're down to about 0.3 MAC, propofol 1mg/kg + lidocaine 1mg/kig before the kid starts to squirm. You will practically obliterate emergence delirium.

-copro

 

[Planktonmd]

Turn the Sevo off a little earlier. Then, when you're down to about 0.3 MAC, propofol 1mg/kg + lidocaine 1mg/kig before the kid starts to squirm. You will practically obliterate emergence delirium.

-copro

I wish life was that simple 😉

 

[coprolalia]

I wish life was that simple 😉

http://www.anesthesiology.org/pt/re...ovft&results=1&count=10&searchid=1&nav=search

Plus the lidocaine, I'm telling you, is magic. Oh, and if you put them in recovery position as well, you're golden.

I'm a believer. I've started doing this, and it's RARE that I have a thrashing crying kid anymore. In fact, I did this technique twice yesterday (on top of dozens of times in recent months when I've done kid cases), and I can only remember a handful of kids who were still out of control in the PACU. The key is to catch them before they wake up.

I'm so convinced of this, in fact, that I've proposed a study at my home institution (to expand on the above, recently published study).

-copro

 

[Planktonmd]

http://www.anesthesiology.org/pt/re...ovft&results=1&count=10&searchid=1&nav=search

Plus the lidocaine, I'm telling you, is magic. Oh, and if you put them in recovery position as well, you're golden.

I'm a believer. I've started doing this, and it's RARE that I have a thrashing crying kid anymore. In fact, I did this technique twice yesterday (on top of dozens of times in recent months when I've done kid cases), and I can only remember a handful of kids who were still out of control in the PACU. The key is to catch them before they wake up.

I'm so convinced of this, in fact, that I've proposed a study at my home institution (to expand on the above, recently published study).

-copro

The idea of giving Propofol and Lidocaine at the end of surgery is not new and many anesthesiologists have been doing it in one way or another for years.
In a place where rapid turnover is important (not academia) the 4-5 extra minutes that giving 1 mg/ kg of Propofol + Lido would add to your emergence time might be too long and undesirable.
I suggest instead replacing the inhaled agent with Propofol infusion after induction and maybe giving some Lido before extubation if you like.
Regardless of what I use I wouldn't go as far as saying that I can "eliminate" emergence delirium.

 

[coprolalia]

I suggest instead replacing the inhaled agent with Propofol infusion after induction and maybe giving some Lido before extubation if you like.

Not a bad idea, except for the relatively short cases where you mask induce and put the IV after. Still going to have a high concentration of agent on board, potentially, but I hear ya.

Regardless of what I use I wouldn't go as far as saying that I can "eliminate" emergence delirium.

I believe I adequately qualified what I claimed with the words "practically" and "handful", and nowhere claimed that anyone can completely eliminate emergence delirium.

It's easy to do this technique, though, with little or no additional risk to the patient. If you use 1% lidocaine and 1% propofol, you just take the kids weight in kilos, divide by ten, and draw-up that many ml's of prop and lido. When they're breathing and start to emerge (at like 0.6-0.7 Et SEV concentration), you hit 'em with it, surgeon finishes, and you pull the tube after putting them in recovery position. Wheel them to the PACU. Then, next. Try it.

I have had my fair share of thrashers and cryers doing it the "old" way, and my assertion is that you can push this mix and pull the tube without them going ****oo a large percentage of the time, if not most of the time. It doesn't delay your time getting to the PACU if you do it right, and it doesn't increase your PACU stay. I've seen it. I've been doing it. And, we do a LOT of kids at my institution.

I'm going to try to prove it (with one other resident and an excellent Peds anesthesia attending), publish it, and will keep everyone posted.

-copro

 

[Noyac]

The idea of giving Propofol and Lidocaine at the end of surgery is not new and many anesthesiologists have been doing it in one way or another for years.
In a place where rapid turnover is important (not academia) the 4-5 extra minutes that giving 1 mg/ kg of Propofol + Lido would add to your emergence time might be too long and undesirable.
I suggest instead replacing the inhaled agent with Propofol infusion after induction and maybe giving some Lido before extubation if you like.
Regardless of what I use I wouldn't go as far as saying that I can "eliminate" emergence delirium.

You are right and I am one of those guys that gives propofol/lido at the end of almost every case I do. As far as the rapid turnover times, just give it a little earlier and extubate deep with them spontaneously breathing and bring them to the pacu in the lateral position with a good airway. They wake up calm and within a few minutes of arrival. The pacu nurses love it because it gives them time to get their paper work in order and one set of vitals and then the kid is awake and mommy comes in.

 

[coprolalia]

You are right and I am one of those guys that gives propofol/lido at the end of almost every case I do. As far as the rapid turnover times, just give it a little earlier and extubate deep with them spontaneously breathing and bring them to the pacu in the lateral position with a good airway. They wake up calm and within a few minutes of arrival. The pacu nurses love it because it gives them time to get their paper work in order and one set of vitals and then the kid is awake and mommy comes in.

That's what I'm talking about! Calm, smooth wake-ups. Especially in kids. 👍

-copro

 

[Planktonmd]

That's what I'm talking about! Calm, smooth wake-ups. Especially in kids. 👍

-copro

Again: Propofol and Lidocaine at the end is not a new idea, it's one trick that you should know in addition to other tricks like titrating narcotics before extubation and more importantly how to properly administer smooth general anesthesia tailored to each patient and each surgery.

 

[coprolalia]

Propofol and Lidocaine at the end is not a new idea...

Plankton, you keep saying that like I'm somehow asserting that it is a new idea. There have been countless studies in various iterations trying to prove that it works, with varying degrees of success. Some give propofol, some give lidocaine. Some give both.

My point is, it is not routinely done, at least if my experience is any indicator. And, I'm suggesting that it should be. And, I think that I can design a study that shows it is safe and effective, something that has not been consistently done and is (at least as is evidenced by recent publication) somehow still important enough to continue being investigated.

-copro

 

[Planktonmd]

Plankton, you keep saying that like I'm somehow asserting that it is a new idea. There have been countless studies in various iterations trying to prove that it works, with varying degrees of success. Some give propofol, some give lidocaine. Some give both.

My point is, it is not routinely done, at least if my experience is any indicator. And, I'm suggesting that it should be. And, I think that I can design a study that shows it is safe and effective, something that has not been consistently done and is (at least as is evidenced by recent publication) somehow still important enough to continue being investigated.

-copro

I don't believe that anything should be done "routinely" but you might prove me wrong in the future when your study get published, so good luck 🙂