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• W1975108924 abstract "Frequently, regional anesthesia for carotid endarterectomy (CEA) is used to facilitate cerebral function monitoring and control intraoperative and postoperative cardiovascular stability [1-12]. In theory, the combination of a deep and superficial cervical block should provide adequate analgesia for the operation [13,14]. However, in some instances, patients experience discomfort during surgery that is not always relieved by local infiltration anesthesia [14,15]. IV opioids and/or sedatives can help, but they have the disadvantage of reducing the patient's alertness and ability to cooperate with cerebral monitoring. In this report, we describe a case in which an intraoperative mandibular nerve block relieved our patient's discomfort during CEA and our subsequent experience using this block. Case Report A 68-yr-old man was scheduled for a right CEA under regional anesthesia. He had >70% occlusion of the right and 40%-60% occlusion of the left internal carotid artery. Significant medical history included insulin-dependent diabetes, hypertension managed with nifedipine, angina requiring 1-2 nitroglycerin tablets per week, and 40 pack-years of smoking. No premedication was administered. In the operating room, standard physiological monitoring was established, including a left radial artery catheter. The patient was resting comfortably on the operating Table withblood pressure 175/90 mm Hg, heart rate 72 bpm, and SpO2 at 100% while breathing 2 L/min O (2) by nasal cannula. The C2, C3, and C4 nerve roots were blocked with 6 mL of a 1:1 mixture of 2% lidocaine and 0.75% bupivacaine. The superficial cervical plexus was anesthetized along the posterior border of the sternocleidomastoid muscle with 10 mL of this mixture. Sensory testing indicated the onset of anesthesia in the appropriate nerve distribution. At the start of surgery and for one-half hour after the incision was made, the patient did not complain of discomfort. He remained comfortable without sedatives or opioids, and vital signs remained stable as the dissection proceeded to the carotid artery. After completing the exposure, the internal carotid artery was clamped for a 1-min test, during which the patient's left hand grip remained strong and he was able to count to 10 and name the president. The surgeons then performed the arteriotomy and began resecting plaque. As the resection proceeded to the cephalad portion of the internal carotid, the patient began to complain of pain, which five IV doses of 50 [micro sign]g of fentanyl did not relieve. Injection of local anesthetic into the wound by the surgeons also failed to relieve the pain. Conversion to general anesthesia was discussed. However, because of the high location of plaque, the surgeons did not want to use a shunt, and electroencephalographic monitoring was not available on short notice. Further inquiry revealed that the patient's pain seemed to be related to retraction on the mandible and in the submandibular area. The surgical drapes were carefully folded down off the patient's face, and an intraoral right mandibular nerve block was performed using 4 mL of 1.5% lidocaine with epinephrine 1:200,000. The surgical drapes were replaced, and, after 5 min, surgery proceeded with no further complaints of discomfort. Sensory testing at the completion of surgery revealed anesthesia of the right side of the tongue, the right lower lip, and skin overlying the mandible. The patient reported that his right lower teeth felt numb, as though he had been to the dentist. Discussion The advantages of regional anesthesia have made it increasingly popular for CEA with both surgeons and anesthesiologists. Cerebral monitoring of the awake patient is as good or superior to the alternative techniques used during general anesthesia [2-4,6,7,9,16]. An additional benefit of awake cerebral monitoring during regional anesthesia is that shunts need only be used when clearly indicated, reducing the incidence of shunt-related complications and facilitating surgical technique [1-4,6,7,9,17]. Although there is some debate, several studies suggest that patients experience a more stable perioperative cardiovascular course with regional anesthesia as opposed to general anesthesia [1,5,6,8,11,12,18]. Carotid artery disease almost always indicates more extensive vascular disease, in particular coronary artery disease, and the evidence suggests a reduced perioperative cardiovascular morbidity and mortality when regional anesthesia is used for CEA [1,5-7,10,19-21]. Recent studies also suggest that regional anesthesia for CEA may result in shorter intensive care unit stays, as well as shorter hospital stays [1,5,12,18,20,22,23], thus contributing to a decrease in cost. Several regional anesthetic techniques, including local infiltration by the surgeon, deep and superficial cervical blocks, and interscalene block, are used for CEA. We have used the deep cervical block at C2, C3, and C4, and the superficial cervical block along the posterior border of the sternocleidomastoid muscle [13]. In addition to sparing use of intravenous sedatives and opioids, this technique usually provides good operating conditions. We have noted intraoperative anesthetic problems to be usually related to one of four sources. The use of IV drugs, especially midazolam, can lead to either an obtunded, hypoventilating patient or a restless, agitated patient. In either scenario, the solution is usually to convert to a general anesthetic. The second and most frequent problem is incisional pain near the midline, presumably mediated by contralateral fibers. In this case, the discomfort is easily alleviated with local anesthetic infiltration by the surgeon. The third type of problem arises in the patient who occasionally experiences pain during dissection of the carotid sheath. This pain may be carried by variant sensory fibers from either the superior root of the ansa cervicalis or the vagus [14,15]. In either case, supplementation with local anesthetic by the surgeon is sufficient. Finally, especially when plaque extends high or distally in the internal carotid, dissection high in the submandibular region or retractors on the mandible and/or submandibular tissues cause considerable discomfort. This pain is occasionally amenable to local anesthetic infiltration by the surgeon, especially if the discomfort is caused by dissection. However, pain caused by retraction on the mandibular periostium is seldom relieved by local infiltration of anesthetics or additional IV opioids. Although the skin and tissues of the upper anterior neck and much of the submandibular region are innervated by C2 and C3, the mandibular periostium, the lower lip, the skin overlying the mandible, the mucus membranes, and some of the submandibular structures are innervated by the inferior alveolar nerve, the long buccal nerve, and the mylohyoid nerve, all branches of the mandibular division of the trigeminal nerve. Pain caused by dissection high in the neck or, more commonly, by metal retractors on the inferior surface of the mandible is not prevented by the cervical block. We have had considerable success in eliminating this discomfort using a mandibular block. Although the mandibular nerve can be blocked using a percutaneous approach [24], we prefer a modification of the intraoral technique [25]. The percutaneous approach almost invariably results in blocking the anterior division of the mandibular trunk, which innervates most of the ipsilateral muscles of mastication. Likewise, this approach blocks the otic ganglion, which supplies secretomotor innervation to the parotid gland. The intraoral block is easily mastered, requires only 3-5 mL of local anesthetic, and is associated with a very low complication rate. Applying a topical anesthetic to the mucus membrane over the mandibular nerve just before performing the block results in a nearly painless procedure. Since incorporating the mandibular block into our regional anesthetic technique for CEA, our patients seem more comfortable and cooperative, with a reduced need for both IV and local anesthetic supplementation. We have not had to convert any patients with mandibular blocks to general anesthesia. None of the patients have complained of the mandibular block procedure itself or its effects. In summary, we report a case in which a patient undergoing CEA under regional anesthesia was rescued from possible general anesthesia by an intraoral mandibular nerve block. Our results since instituting the mandibular block as part of the anesthetic technique compare favorably with those before its institution. We find it most beneficial for patients with high carotid lesions or short and/or thick necks when more forceful and prolonged retraction on the mandible is likely. The block is simple, easy to learn, and relatively free of complications. In selected patients, we recommend the addition of the mandibular block to the superficial and deep cervical blocks for CEA to improve patient comfort, reduce the need to convert to general anesthesia, and possibly improve patient safety." @default.
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• W1975108924 title "Mandibular Nerve Block in Addition to Cervical Plexus Block for Carotid Endarterectomy" @default.
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