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    Carotid endarterectomy with local anesthesia and laryngeal mask airway/general anesthesia

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        Abstract

        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 report 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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        Most cited references 6

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        Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST)

        (1998)
        Our objective was to assess the risks and benefits of carotid endarterectomy, primarily in terms of stroke prevention, in patients with recently symptomatic carotid stenosis. This multicentre, randomised controlled trial enrolled 3024 patients. We enrolled men and women of any age, with some degree of carotid stenosis, who within the previous 6 months had had at least one transient or mild symptomatic ischaemic vascular event in the distribution of one or both carotid arteries. Between 1981 and 1994, we allocated 1811 (60%) patients to surgery and 1213 (40%) to control (surgery to be avoided for as long as possible). Follow-up was until the end of 1995 (mean 6.1 years), and the main analyses were by intention to treat. The overall outcome (major stroke or death) occurred in 669 (37.0%) surgery-group patients and 442 (36.5%) control-group patients. The risk of major stroke or death complicating surgery (7.0%) did not vary substantially with severity of stenosis. On the other hand, the risk of major ischaemic stroke ipsilateral to the unoperated symptomatic carotid artery increased with severity of stenosis, particularly above about 70-80% of the original luminal diameter, but only for 2-3 years after randomisation. On average, the immediate risk of surgery was worth trading off against the long-term risk of stroke without surgery when the stenosis was greater than about 80% diameter; the Kaplan-Meier estimate of the frequency of a major stroke or death at 3 years was 26.5% for the control group and 14.9% for the surgery group, an absolute benefit from surgery of 11.6%. However, consideration of variations in risk with age and sex modified this simple rule based on stenosis severity. We present a graphical procedure that should improve the selection of patients for surgery. Carotid endarterectomy is indicated for most patients with a recent non-disabling carotid-territory ischaemic event when the symptomatic stenosis is greater than about 80%. Age and sex should also be taken into account in decisions on whether to operate.
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          The relationship between hospital case volume and outcome from carotid endartectomy in England from 2000 to 2005.

          To assess the outcome of carotid endarterectomy in England with respect to the hospital case-volume. Data were from English Hospital Episode Statistics (2000-2005). Admissions were classified as elective or emergency. Risk-adjusted data were analysed through modelling of death rate, complication rate and length of admission with regard to the year of procedure and annual hospital volume of surgery. Hospitals with elevated death rates were identified and the evidence quantified that they had outlying mortality rates. There were 280,081 diagnoses of extra-cranial atherosclerotic arterial disease in which 18,248 CEA were performed. The mean mortality rates were 1.04% for elective and 3.16% for emergency CEA. A volume-related improvement in mortality (p=0.047) was seen for elective CEA. Length of stay decreased as annual volume increased for elective and emergency CEA (p<0.001). 20% of the operations were performed in 67.1% of the hospitals, each of which performed fewer than 10 CEA per annum. A number of hospitals had elevated death rates. Volume-related improvements in outcome were demonstrated for elective CEA. Minimum volume-criteria of 35 CEA per annum should be established in England. Hospitals performing low annual volumes of surgery should consider arrangements to network services.
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            Comparison of regional anesthesia versus combined regional and general anesthesia for elective carotid endarterectomy: a small exploratory study

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              Author and article information

              Affiliations
              [1 ]Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
              [2 ]Department of Pharmacology, Temple University School of Medicine, Philadelphia, PA, USA
              [3 ]Department of Anesthesiology, Georgetown University School of Medicine, Washington, DC, USA
              [4 ]East Brunswick High School, East Brunswick, NJ, USA
              [5 ]Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, MD, USA
              [6 ]NEMA Research Inc., Bonita Springs, FL, USA
              Author notes
              [* ]Corresponding author's e-mail address: robert.taylor.phd@ 123456gmail.com
              Contributors
              (View ORCID Profile)
              Journal
              SOR-MED
              ScienceOpen Research
              ScienceOpen
              2199-1006
              12 December 2014
              : 0 (ID: 27ccddf3-3f6b-42bd-8e29-4b17ba1faaad )
              : 0
              : 1-3
              2230:XE
              10.14293/S2199-1006.1.SOR-MED.ATXB4F.v1
              © 2014 Pergolizzi et al.

              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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              Figures: 0, Tables: 0, References: 7, Pages: 3
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              Clinical Case Report
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              Comments

              The paper describes an interesting case report concerning the evaluation of a new anesthetic technique (a combined general anesthesia (desfluorane 4%) with a laryngeal mask airway (LMA) plus regional anesthesia (bupivacaine injected into the surgical site) for carotid endarterectomy. The Authors report on a case of 1 patient (a 55 year old male with an important history of comorbidities).

              The study is of great clinical relevance in this kind of surgical treatment.

              The paper is well-written, well organized, sufficiently updated, and comprehensible.

              In the paper, the Authors underline that only one patient was considered in order to study the hybrid technique proposed, suppose to be safer and less invasive. Obviously, additional cases would be necessary to confirm their observations and results, and to draw precise conclusions.

              I think that to support better the Authors description (i.e.: “no or minimal hemodynamic changes”, or “hemodymamic stability”, or “the patient recovered quickly”) sentences should be supported by data (hemodynamic parameters, ventilation, blood pressure, the awakening time after anesthesia [the body weight?]).

              Concerning the local anesthesia, the Authors have to detail better the procedure (infiltration?).

              Hematoma: on what basis the Authors can exclude complications due to carotid surgery?

              In the middle of the case report, please, pay attention to “…. Other medications used during the surgery included NTG phase 1” on chest, IV heparin 5000 units through IV,……”: see the words in bold, may be, it is a repetition.

              2015-05-04 08:55 UTC
              +1
              I appreciate the authors for writing this interesting case report describing a novel technique - Use of general anesthesia with laryngeal mask airway plus local anesthesia for carotid endarterectomy. Carotid endarterectomy(CEA) is commonly performed either under regional anesthesia (superficial and deep cervical plexus block) or general anesthesia or a combination of both. No particular technique has proven to be superior to the other. I agree with the authors that patients for CEA present with significant co morbidities. They have described a simple and safe anesthetic technique that may enhance patient recovery after surgery. I appreciate the authors for sharing their experience and describing this novel technique. I wish the authors would have described little more in detail the intra operative ventilator settings and subsequent respiratory and hemodynamic parameters during the procedure. My suggestion to the authors is that patients for CEA have significant comorbidities and invasive blood pressure monitoring for early intervention is advisable. Overall a nice case report for the readers to appreciate. The authors gave new insights to the readers describing a novel less invasive anesthetic technique for CEA surgery.
              2015-04-21 21:57 UTC
              +1

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