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LETTER TO EDITOR
Year : 2019  |  Volume : 63  |  Issue : 1  |  Page : 65-66  

Superficial cervical plexus block for urgent tracheostomy


Department of Anaesthesiology, RCC, Trivandrum, Kerala, India

Date of Web Publication10-Jan-2019

Correspondence Address:
Dr. Hally Thankamony
Department of Anaesthesiology, RCC, Trivandrum - 695 011, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_559_18

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How to cite this article:
Koshy RC, Thankamony H. Superficial cervical plexus block for urgent tracheostomy. Indian J Anaesth 2019;63:65-6

How to cite this URL:
Koshy RC, Thankamony H. Superficial cervical plexus block for urgent tracheostomy. Indian J Anaesth [serial online] 2019 [cited 2019 Jun 18];63:65-6. Available from: http://www.ijaweb.org/text.asp?2019/63/1/65/249784



Sir,

Here, we are reporting a 64-year-old Indian male patient who presented with biphasic stridor due to carcinoma larynx. He had undergone radiotherapy in the past. He did not have any other co-morbid illness. Written informed consent was taken. His saturation was 97% on room air, heart rate was 124/min and blood pressure was 180/100. Humidified oxygen was given via nasal prongs at 4 l/min. Ringer lactate was started intravenously. Patient was premedicated with 0.5 mg midazolam and 8 mg dexamethasone and 30 mcg fentanyl intravenously. With anticipated difficulty of the procedure, we have done the procedure under bilateral superficial cervical plexus block, along with a trans-tracheal block. Bilateral superficial cervical plexus block using landmark technique was given with 2% lignocaine 7 ml on each side. Trans-tracheal block was given with 1 ml 4% lignocaine. Heart rate, blood pressure and SpO2 were monitored. Vitals remained stable with good surgical field. Tracheostomy tube was placed safely with good tube tolerance postoperatively.

Stridor is a high-pitched sound produced during breathing due to turbulence of air flow because of obstruction. It can be inspiratory, expiratory, or biphasic according to the site of obstruction. While waiting for tracheostomy, management of stridor includes administration of humidified oxygen, intravenous dexamethasone, inhaled salbutamol and nebulised adrenaline 1 in 1000.[1] Treatment of the cause of stridor is of primary importance after maintaining the airway. Tracheostomy is indicated in carcinoma larynx patient with stridor for maintaining the airway.

Superficial cervical plexus block is a subcutaneous blockade of nerves of anterolateral neck. Sensory distribution of superficial and deep cervical plexus block is similar but superficial cervical plexus block has lesser complications; hence, it is preferred. Complications associated with deep cervical plexus block are nerve root injury, vertebral arterial puncture, systemic toxicity and neuraxial spread of local anaesthetics.[2] Trans-tracheal instillation of local anaesthetic provides anaesthesia of tracheal mucosa below the vocal cords.

The known indications of superficial cervical plexus blocks are carotid endarterectomy,[3],[4] superficial neck surgeries and excision of cervical lymph nodes. It can be combined with supra-clavicular and infra-clavicular brachial plexus block in shoulder surgery to avoid phrenic nerve injury (which is likely in inter-scalene approach).[5]

The four cutaneous branches of cervical plexus emerge from the posterior margin of sternocledomastoid approximately at its midpoint. All of them are innervated by C2–C4. These cutaneous branches are blocked in superficial cervical plexus block at the midpoint of the posterior margin of sternocledomastiod in a fan-shaped fashion and vertical and cranio-caudal direction. Usually, large volume of local anaesthetic is used, and spread of local anaesthetic leads to bilateral recurrent laryngeal nerve palsy and airway obstruction, so it should be avoided.[6] The ultrasound-guided superficial cervical plexus block needs lesser volume but time consuming in semi-emergency situations such as tracheostomy. Due to urgency of the situation, we preferred to do the block under landmark technique.

A low-dose superficial cervical plexus block with trans-tracheal block is a viable alternative to local infiltration in semi-emergency tracheostomy with anticipated surgical difficulty. It provides excellent pain relief, enhanced tracheostomy tube tolerance, and haemodynamic stability. Surgeons reported operating conditions as excellent. This also helps to minimise sedation, which in the setting of upper airway obstruction is undesirable as it may worsen the obstruction because of loss of tone of muscles.

Conventional local infiltration technique for tracheostomy has less pain relief than superficial cervical plexus block. Superficial cervical plexus block makes the patient more comfortable and co-operative during the procedure. The combination of superficial cervical plexus block with trans-tracheal instillation of local anaesthetic provides easy, safe, quick and excellent analgesia for semi-emergency tracheostomies.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Remington S, Meakin G. Nebulised adrenaline 1:1000 in the treatment of croup. Anaesthesia 1986;41:923-6.  Back to cited text no. 1
    
2.
Singh SK The cervical plexus: Anatomy and ultrasound guided blocks. Anaesth Pain Intensive Care 2015;19:323-32.  Back to cited text no. 2
    
3.
Davies MJ, Silbert BS, Scott DA, Cook RJ, Mooney PH, Blyth C. Superficial and deep cervical plexus block for carotid artery surgery: A prospective study of 1000 blocks. Reg Anesth 1997;22:442-6.  Back to cited text no. 3
    
4.
Pandit JJ, Bree S, Dillon P, Elcock D, McLaren ID, Crider B. A Comparison of superficial versus combined (superficial and deep) cervical plexus block for carotid endarterectomy: A prospective, randomized study. Anesth Analg 2000;91:781-6.  Back to cited text no. 4
    
5.
Halaszynski TM. Ultrasound brachial plexus anesthesia and analgesia for upper extremity surgery: Essentials of our current understanding. Curr Opin Anaesthesiol 2011;24:581-91.  Back to cited text no. 5
    
6.
Kwok AO, Silbert BS, Allen KJ, Bray PJ, Vidovich J. Bilateral vocal cord palsy during carotid endarterectomy under cervical plexus block. Anesth Analg 2006;102:376-7.  Back to cited text no. 6
    




 

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