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

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Carotid Endarterectomy with Local Anesthesia and LMA/General Anesthesia

 Hani Annabi,  Charles Fleischer,  Robert Taylor (corresponding) (2014)
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 information

    10.14293/S2199-1006.1.SOR-MED.ATXB4F.v1.RFOFGE

    This work has been published open access under Creative Commons Attribution License CC BY 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Conditions, terms of use and publishing policy can be found at www.scienceopen.com.

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    Review text

    This is an interesting case report describing the use of general anesthesia with laryngeal mask airway plus local anesthesia for carotid endarterectomy.

    Carotid endarterectomy is a well-established technique for the prevention of stroke in selected patients. However, controversy persists concerning the optimal anesthetic modality. Commonly this type of surgery is accomplished using either regional anesthesia or general anesthesia or a combination of both. However, from randomized trials, there is insufficient evidence of the superiority of one technique over the other.

    I substantially agree with the Authors that their anesthesia technique is feasible in a patient with high-grade carotid occlusion and significant comorbid conditions. However, definitive conclusions cannot be drawn after a single case report. Also, I feel that more details about the procedure would be needed in order to fully understand and possibly replicate the study.

    I remind the Authors to avoid using commercial drug names, since brand names may be different in different countries. Livalo = pitavastatin. Nitrostat = nitroglycerin. Plavix = clopidogrel. Toprol = metoprolol. Tylenol = acetaminophen. Crestor = rosuvastatin. NTG paste 1” = nitroglycerin paste 1 inch.

    What was the ventilation setting during the procedure? What level of pressure support? Any PEEP? What FiO2? What was the respiratory rate of the patient? What were the inspiratory pressures?

    Monitoring should be described in greater detail. What did it include? ECG? SpO2? EtCO2? Non invasive blood pressure? BIS? Etc…

    What where the hemodynamic parameters during the procedure? Was the blood pressure stable? Did SpO2 change at any time?

    The Authors state that local anesthesia was injected into the surgical site. This needs to be detailed. Was the carotid sheath infiltrated? Was the local anesthetic just poured over the site?

    It is stated that the patient emerged from anesthesia and recovered quickly. This times needs to be defined clearly. Similarly, the discharge time should be specified clearly. Was the patient discharged home the same day of surgery? Or the day after? This information is relevant when it comes to the management of possible complications.

    Hematoma at the surgical site is a potentially life-threatening complication after carotid surgery. I would not be comfortable with discharging a patient on the same day of surgery, particularly one that is on antiplatelet drugs (as in this case).

    In the conclusions, the Authors state that their approach avoids deep general anesthesia, eliminates the need for an ETT and arterial line, dispenses with a Foley catheter, promotes good hemodynamic stability, and allows for rapid emergence. I would dispute that the anesthesia they used cannot be defined a light anesthesia (desflurane 4% and fentanyl 150 mcg). It may probably eliminate the need for an EET, but I am not so sure one can light-heartedly avoid having an arterial line. This may vary much according to local policies, but the issue needs discussion at least.

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