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    Review of 'Carotid Endarterectomy with Local Anesthesia and LMA/General Anesthesia'

    Carotid Endarterectomy with Local Anesthesia and LMA/General AnesthesiaCrossref
    comprehensible, organized, appropriate references, but missing some relevant clinical studies
    Average rating:
        Rated 3.5 of 5.
    Level of importance:
        Rated 4 of 5.
    Level of validity:
        Rated 2 of 5.
    Level of completeness:
        Rated 3 of 5.
    Level of comprehensibility:
        Rated 4 of 5.
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    Reviewed article

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    • Article: found
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    Carotid Endarterectomy with Local Anesthesia and LMA/General Anesthesia

    There is no clear consensus as to the appropriate anesthetic technique for patients undergoing a carotid endarterectomy. Such patients may have comorbid conditions, such as coronary artery disease, hyperlipidemia, and others. The two main anesthetic approaches are general anesthesia, including an endotracheal tube, with neurological monitoring and regional anesthesia that allows for an awake patient to be assessed neurologically. The objective of our study was to evaluate a novel anesthetic technique that combined general anesthesia with a laryngeal mask airway (LMA) plus regional anesthesia in the form of bupivacaine injected into the surgical site. Anesthesia was maintained with desflurane 4%, so the patient emerged rapidly for neurological assessment at the conclusion of surgery. We report on a case of a 55-year-old patient who underwent a successful carotid endarterectomy using this hybrid technique of general anesthesia with LMA plus regional anesthesia. This technique was safe and effective and the patient experienced no complications other than a hematoma on the left neck that was likely the result of long-term use of aspirin and Plavix. While further study is warranted, this hybrid technique of general anesthesia with LMA plus regional anesthesia holds promise for carotid endarterectomy patients.

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      Review text

      The paper topic is clinically relevant by suggesting an alternative anesthetic protocol for a debated surgical procedure (CEA) bearing a high mortality rate. The paper is comprehensible with good organization and appropriate references, but it is missing some relevant clinical studies. The lack of perioperative clinical data such as intraoperative patient vital parameters or means of brain monitoring doesn’t allow an appraisal of the benefits of the procedure while, by missing patient body weight, the reported drug dosages appear quite loose.

      The reported hybrid technique of general anesthesia with LMA offers a potential for minimizing intraoperative cardiac depression leading to unwanted hypotension during CEA, but it can’t guarantee for the mandatory perioperative hemodynamic stability claimed by the field literature. The choice of desflurane as brain protection from ischemia is supported at clinical effective concentrations, but such potential benefit can be questionable at 0,66 MAC, bearing also the risk of an abrupt anesthetic recovery and of crossclamping or postop hypertension.

      The advantages brought about by the use of a LMA, reported for CEA by Holmstrom et Al. [Br. J. Anaesth. (2007) 99 (1):119-131], are limited to intubation, thus meeting the needs of a difficult airway (Mallampati grade 3 and 4) which doesn’t seem to be a feature of the reported case. A safer and definitive airway control could alternatively be achieved by a preventive awake ETT, by nasotracheal intubation or by a percutaneous tracheotomy.
      As for regional analgesia, the quick and simple technique adopted by the paper authors leaves some doubts about the reported complex and risky procedure including superficial and deep cervical plexus blocks.

      A hesitation about the validity of the paper ensues from the assertion that the proposed hybrid anesthetic procedure eliminates the need for an arterial line, which is instead deemed routine, allowing direct blood pressure and arterial blood gases monitoring. Such critical patients undergoing a CEA procedure should have extensive monitoring of brain function and perfusion, and if at risk of poor ventricular function or myocardial ischaemia more advanced cardiovascular monitoring should be considered.

      Naples, April 12, 2015
      Giancarlo Vesce VMD


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