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Cervical Epidural Anaesthesia for Carotid Artery Surgery

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Cervical Epidural Anaesthesia for Carotid Artery Surgery 353 Cervical epidural Francis Bonnet MD,* Jean Paul Derosier MD,'i" anaesthesia for carotid Frederic Pluskwa MD,* Kou Abhay MD,* A. Gaillard MDt artery surgery A series of 394 patients (251 men, 143 women; mean age 70.0 +- C2 d D4-D8 a ainsi dtd obtenu. Les patients sont restds dveillds 8.4 yr) selected for carotid artery" surgery, (CAS) performed pendant la durde de l'acte opdratoire dans des conditions de under cervical epidural anaesthesia (CEA ) was analysed retro- confort acceptables. Les complications sdrieuses rencontrdes spectively. Carotid endarterectomy was performed in 326 ont dtd la survenue d'une brdche duremdrienne dans deux cas, patients and saphenous vein bypass in 68. The cervical epidural d'une brdche vasculaire dans six cas et d'une insuffisance administration of 15 ml 0.5 per cent bupivacaine or 0.37-0.40 respiratoire chez trois patients. Hypotension (10,9 pour cent et per cent bupivacaine plus fentanyl (50-100 Izg) resulted in an bradycardie (2,8 pour cent) dtaient les effets secondaires les effective sensory blockade from C2 to T4-Ts. Patients were plus frdquemment observds. Un accident neurologique transi- maintained awake during the surgical procedure in comfortable toire s'est produit chez 84 patients pendant I'intervention condition. Serious complications included dural puncture in two chirugicale. Un accident neurologique irrdversible est survenu patients, epidural venipuncture in six patients and respiratory chez 12 patients. Trois infarctus du myocarde ont dtE diagnos- muscle paralysis in three patients. Hypotension (10.9 per cent) tiquds dans les suites opdratoires. La mortalitE de cette sdrie and bradycardia (2.8 per cent) were the most frequent side- Eta# de 2,3 pour cent. L'anesthdsie pdridurale cervicale effects of CEA. Transient neurological events were noticed in 84 apparaft comme une alternative possible pour la chirurgie patients during the surgical procedure. A definite neurological carotidienne qui rEclame de toutes faf.ons une surveillance deficit occurred postoperatively in 12 patients. Three patients h~modynamique serrde. suffered postoperative myocardial infarction. The mortality rate was 2.3 per cent (nine patients). Carotid artery surgery may" be performed under CEA but haemodynamic variables shouM be Carotid artery surgery (CAS) is one of the most common monitored closely and managed closely during the procedure. vascular surgical procedures. It is performed under either general or regional anaesthesia. 1,2 Regional anaesthesia Une dtude retrospective a did effectude sur une sdrie de 394 allows simple and reliable monitoring of cerebral function patients (251 hommes, 143 femmes, d'dge moyen 70,0 +- 8,4 during the procedure by means of verbal communication ans) opdrds de la carotide sous anesthdsie pdridurale cervicale. with the patient and frequent evaluation of motor Trois cent vingt six patients ont subi une endartdriectomie strength. 1,2 Two different techniques can be used for carotidienne et 68 un pontage carotidien. L'anesthdsie pEridu- regional anaesthesia of the neck: cervical block or cervical rale a dtd effectude avec de la bupivacaine gt 0,5 pour cent (49 epidural anaesthesia (CEA). Deep cervical block requires patients) puis 0,37-0,40 pour cent (345 patients) (15 ml) identification of the second, third and sometimes the associde d du fentanyl (50-100 lzg). Un bloc sensitif dtendu de fourth cervical nerve roots on the same side as the surgical field. Moreover, a superficial block must be performed because of frequent cutaneous sensory anastomoses with some branches of the lower cervical plexus and of the Key words trigeminal nerve. Though appealingly simple the cervical ANAESTHESIA: vascular; block has a failure rate of nearly 20 per cent when ANAESTHETIC TECHNIQUES: epidural, cervical; performed by the classical approach) Anatomical diffi- ANAESTHETICS, LOCAL: bupivacaine; culties may be encountered especially in obese patients 8RAIN: blood flow; with a short neck. SURGERY: carotid artery surgery. Cervical epidural anaesthesia (CEA), first described by From the Departement d'Anesthdsie,* Hopital Henri Mondor, Dogliotti in 19334 for thoracic surgery, is used mainly for Creteil and the Service d'Anesthrsie,i" Clinique Poirier, relief of chronic pain in the head and neck or cancer pain Chambery. due to Pancoast syndrome. 5 In only one previous report Address correspondence to: Dr. F. Bonnet, Departement has CEA been described as an anaesthetic technique d'Anesthrsie, 51, avenue du marechal de Lattre de Tassigny, suitable for CAS. 6 In our institution we chose regional 94000 Creteil, France. anaesthesia for CAS and selected CEA because of the CAN J ANAESTH 1990/ 37: 3/pp. 353-8 354 CANADIAN JOURNAL OF ANAESTHESIA familiarity of our anaesthetic team with this technique for momanometer (dynamap | or via a radial artery catheter. chronic pain relief. In the present study we report four Patients were carefully observed for changes in cerebral years' experience of CEA and discuss its advantages and function as evidenced by loss of consciousness, somnol- drawbacks. ence, and neurological deficit of the hand and the arm. Ephedrine 3 to 6 mg was injected IV when systolic arterial Methods pressure decreased more than 30 per cent of the pre- anaesthetic value or to less than 95 mmHg or when Patients neurological symptoms developed during carotid artery From 1984 to 1988,394 consecutive patients submitted to clamping, associated with a decrease in blood pressure. CAS in our institution were operated upon with CEA after Decreases in heart rate to less than 45 beats min -I were they had given their informed consent and were included treated with IV atropine. Heparin, 50 to 70 u. kg -I, was in this study retrospectively. Non-cooperative patients IV injected before carotid artery clamping. and patients who received heparin before surgery were excluded from receiving CEA. Antihypertensive drugs, Postoperative care betablocking adrenergic agents and calcium channel Blood pressure and heart rate were monitored every five blockers were continued until the morning of the opera- minutes with a sphygmomanometer or continuously with tion. Flunitrazepam, 1 mg, was given orally as premedi- a radial artery catheter, during the first 24 hr postopera- cation two hours before surgery. tively. Acute hypertension was treated with calcium channel blockers (10 mg, sublingual nifedipine or 1 v,g" Anaesthetic technique kg- i. h- ~IV nicardipine) and hypotension with ephedrine Patients were placed in the sitting position with the head in IV boli or continuous infusion. The epidural catheter flexed and resting on the thorax, in order to open the was withdrawn in the recovery room when activated lowest cervical interspaces. The spinous process of C7, coagulation time was normal. Electrocardiogram and which is horizontal in this position, was easily identified. myocardial enzymes were obtained during the three first An 18-gauge Tuohy needle was inserted by a midline postoperative days and at the end of the hospital stay. approach into the C6-C 7 or C7-TI interspace after Postoperative myocardial infarction was defined by new cutaneous local anaesthesia. The epidural space was Q waves on the ECG and an increase in CK-MB greater identified by aspiration of a saline solution drop hanging than 50E -3 iu mi -~. at the needle base. Careful aspiration ensured that the needle had not entered the subarachnoid space nor Statistics penetrated an epidural vein, and an epidural catheter was Mean values of arterial PCO2 were compared using inserted gently. In ASA physical status IV patients, CEA ANOVA and paired Student's t test. was performed in the lateral decubitus position, using the loss of resistance technique. In both cases, patients were then placed in the supine or Trendelenberg position and Results the local anaesthetic solution was injected after a test dose The patient demographics are reported in Table I. Carotid of 2 ml of 2 per cent lidocaine. The solution consisted of endarterectomy was performed in 326 patients and saphe- 15 ml, 0.5 per cent bupivacaine in the first 49 patients and nous vein bypass graft in 68. then of 15 ml, 0.37-0.40 per cent solution of the same local anaesthetic in the remainder. Fentanyl 50 to 100 Ixg was administered into the epidural space together with TABLE I Patients' demographics bupivacaine in 303 patients to improve analgesia. Arterial Sex ratio: 251 men; 143 women PCO2 was measured before and 30 min after epidural Mean age: 70.0 --- 8.4 yr anaesthesia in the first 50 patients who received Hypertension:* 268 (68%) bupivacaine-fentanyl solution. Sensory blockade was Documented ischemic cardiopathy:l" 169 (43%) evaluated by pin-prick. After cutaneous incision and Previous myocardial infarction: 5303.5%) Neurological symptoms: 286 (72.5%) dissection, the carotid sheath was opened after infiltration Transient ischaemic attacks: 156(39.5%) with lidocaine. When CAS included a vein bypass graft, Previous stroke: 41 00.5%) the saphenous vein was removed under local anaesthesia. Vertebral insufficiency 114 (29%) Monitoring *Includes patients treated for hypertension or with a systolic blood pressure > 180 mmHg and/or a diastolic blood pressure > 100 mmHg. Routinely, monitoring included electrocardiogram (lead l'Documented by typical chest pain, ECG and/or thallium scintigraphy CM5) and arterial blood pressure measured by a sphyg- or coronary angiography. Bonnet etal.: EPIDURAL ANAESTHESIA FOR CAROTID SURGERY 355 Effectiveness of anaesthesia other patients, the decrease in blood
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