Search

This article explores two anesthetic strategies for carotid endarterectomy: cervical plexus block and general anesthesia. Regional anesthesia is increasingly favoured for its ability to enable continuous neurological monitoring and maintain hemodynamic stability. General anesthesia remains essential for certain patients, offering comfort, optimal control of physiological conditions, and extended cerebral protection. We also discuss pathophysiological considerations, crucial elements for understanding patient responses to these techniques. The development of ultrasound-guided cervical plexus block emerges as a promising alternative to general anesthesia, enhancing the options available for safer and more effective anesthetic management. However, an individualized approach remains crucial to optimize clinical outcomes. This approach is part of the concept of «personalized medicine», in which contemporary anesthesia must necessarily be adapted to the specific needs of each individual.

Introduction: Carotid endarterectomy is performed for patients with symptomatic carotid artery occlusions. Surgery can be performed under general and regional anesthesia. Traditionally, surgery is performed under deep cervical plexus block which is technically difficult to perform and can cause serious complications. This case series describes 5 cases in which an intermediate cervical plexus block was used in combination with a superficial cervical plexus block for Carotid endarterectomy surgery., Methods: Five patients who were classified as American Society of Anesthesiologists 2-3 were scheduled for Carotid endarterectomy due to symptoms and more than 70% occlusion of the carotid arteries. The procedures were carried out in the University Teaching Hospital- Peradeniya, Sri Lanka. All patients were given superficial cervical plexus block followed by intermediate cervical plexus block using 2% lignocaine and 0.5% plain bupivacaine., Results: Adequate anesthesia was achieved in 4 patients, and local infiltration was necessary in 1 patient. Two patients developed hoarseness of the voice, which settled 2 h after surgery. Hemodynamic fluctuations were observed in all 5 patients. No serious complications were observed. All 5 patients had uneventful recoveries., Discussions: Regional anesthesia for CEA is preferable in patients who are medically complicated to undergo anesthesia or in patients for whom cerebral monitoring is not available. Intermediate cervical plexus block is described for thyroid surgeries in literature, but not much details on its use for carotid surgeries. Deep cervical plexus blocks has few serious complications which is not there with the use of ICPB making it a good alternative for CEA surgeries ., Conclusions: Superficial cervical plexus block and intermediate cervical plexus block can be used effectively for providing anesthesia for patients undergoing Carotid endarterectomy. It is safe and easier to conduct than deep cervical plexus block and enables monitoring of cerebral function., (© 2024. The Author(s).)

Objective: To compare the effectiveness of the superficial cervical plexus (SCP) and ultrasonography (USG)-guided intermediate cervical plexus (ICP) blocks for patient and operator satisfaction during central venous catheterisation (CVC)., Study Design: Experimental study. Place and Duration of the Study: Department of Anaesthesiology and Reanimation, Konya City Hospital, Konya, Turkiye, between May and July 2022., Methodology: Eighty patients were randomly assigned to the ICP and SCP block groups before CVC. Patients received 10ml of a local anaesthesia. Pain levels were assessed during needle insertion, dilation, catheter insertion, and suturing, and 5 minutes after the procedure using a 10-point numeric rating scale (NRS). Thirty minutes post-procedure, patient and operator satisfaction were evaluated using a 5-point Likert-type scale., Results: The ICP block group had lower mean pain scores than the SCP block group during needle entry, dilation, and 5 minutes after CVC (p = 0.022, p <0.001, and p = 0.005, respectively). However, no significant differences were found in pain scores after the block application, during catheter insertion, and suturing (p = 0.279, p = 0.052, and p = 0.072, respectively). Patient and operator satisfaction scores did not significantly differ between the two groups (p = 0.189 and p = 0.329, respectively)., Conclusion: The study demonstrated that the ICP and SCP blocks resulted in comparable patient and operator satisfaction levels during CVC. Given that the ICP block resulted in lower pain scores at various stages of the procedure, it is a recommended method to enhance overall patient comfort and minimise the pain during CVC., Key Words: Central venous catheterisation, Intermediate cervical plexus block, Superficial cervical plexus block, Patient satisfaction.

Purpose: To assess the effectiveness of bilateral superficial cervical plexus block (BSCPB) in treating post-thyroidectomy pain., Methods: MEDLINE, Embase, Google Scholar, LILACS, and the Cochrane Central Register of Controlled Trials, were extensively searched. The search period extended from 1968 until December 2022. Randomized controlled trials comparing BSCPB to placebo, no block in patients with thyroidectomy for benign or malignant thyroid disease were included. Outcomes were pain in the first 24 h after surgery. Analgesic rescue, period before the first rescue dosage, and 24-h opioid usage were secondary outcomes. The RoB 2 instrument was used to evaluate the risk of bias., Results: 34 of 354 studies were eligible. There were 2,519 patients. BSCPB reduced the intensity of pain postoperatively [SMD: - 1.17 (95% CI: - 1.54 to - 0.81)] and in the first 24 h [- 0.62 (95%: 0.91 to 0.33)]. A considerable delay for the first opioid dose, rescue analgesics, and postoperative opioid usage was also found., Conclusion: BSCPB's 24-h analgesic efficacy minimizes the requirement for rescue analgesia, postoperative opioid intake, and rescue analgesia start time. The choice of anesthetic and different application methods might affect its effectiveness., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Regional analgesia techniques are crucial for pain management after cervical spine surgeries. Anesthesiologists strive to select the most effective and least hazardous regional analgesia technique for the cervical region. Our hypothesis is that an intermediate cervical plexus (IC) block can provide adequate postoperative analgesia compared to a cervical erector spinae (ES) block in patients undergoing anterior cervical spine surgery., Methods: In this double-blind prospective trial, 58 patients were randomly assigned into two equal groups prior to the administration of general anesthesia. Patients in the IC group (n = 29) underwent ultrasound-guided bilateral intermediate cervical plexus block with 15 ml of bupivacaine 0.25% administered to each side. The ES group (n = 29) underwent ultrasound-guided bilateral cervical erector spinae plane blocks with 15 ml of 0.25% bupivacaine administered to each side at the C6 level. The primary outcome was to record the time to the first call for rescue analgesia (nalbuphine), and the secondary outcomes were to measure the performance time, the onset of the sensory block, the intraoperative fentanyl consumption, postoperative pain intensity using VAS, the postoperative total nalbuphine consumption, and postoperative complications such as nausea, vomiting, hypotension, and bradycardia., Results: The performance and onset of sensory block times were significantly shorter in the IC group compared to the ES group. The time to first call for nalbuphine was significantly shorter in the IC group (7.31 ± 1.34 h) compared to the ES group (11.10 ± 1.82 h). The mean postoperative VAS scores were comparable between the two groups at the measured time points, except at 8 h, where it was significantly higher in the IC group, and at 12 h, where it was significantly higher in the ES group. The total nalbuphine consumption was significantly higher in the IC group (33.1 ± 10.13 mg) compared to the ES group (22.76 ± 8.62 mg)., Conclusions: For patients undergoing anterior cervical spine surgery, the intermediate cervical plexus block does not provide better postoperative regional analgesia compared to the cervical erector spinae block. Performance time and onset time were shorter in the IC group, whereas nalbuphine consumption was lower in the ES group., Trial Registration: The trial was registered at clinicaltrials.gov. (NCT05577559, and the date of registration: 13-10-2022)., (© 2024. The Author(s).)

Background: Transaxillary endoscopic thyroidectomy (TAET) is favored for its favorable cosmetic outcomes and the preservation of anterior cervical function. Despite these benefits, postoperative analgesia has traditionally relied on pharmacological interventions, and regional anesthetic procedures may be an alternative method. This study aimed to evaluate the efficacy of an ultrasound-guided pectoserratus plane block (PSPB) combined with an intermediate cervical plexus block (ICPB) for TAET., Methods: Forty patients undergoing TAET were randomized into two groups: the nerve block group (N.=20) received ultrasound guided PSPB with 20 ml of 0.375% ropivacaine and ICPB with 8 mL of 0.3% ropivacaine, while the control group (N.=20) received no block. The primary outcome was the Visual Analog Scale (VAS) scores for postoperative neck and axillary pain at different time points (1, 6, 12, 24 h) during rest and movement post-TAET. The secondary outcomes included intraoperative remifentanil consumption, incidence of postoperative nausea and vomiting (PONV), number of remedial analgesic requirements, and patient satisfaction postoperatively., Results: Compared to the control group, patients in the nerve block had significantly lower VAS scores of the neck and axilla whether at rest or movement, and 1, 6, 12, and 24 h postoperatively (P<0.0125). The nerve block group showed higher patient satisfaction (P<0.001). No difference was observed in intraoperative remifentanil consumption, need for rescue analgesics, or other adverse effects 48 h postoperatively., Conclusions: Ultrasound-guided PSPB with ICPB significantly alleviated postoperative pain and improved patient satisfaction with TAET.

Background: Thermage is a monopolar radiofrequency (RF). It has become an indispensable part of facial and body youthful methods. Although the current device is constantly improving in epidermal cooling techniques and even automatically measures the local impedance value, applying surface anesthesia can take some of the pain away caused by thermage, and the patient's severe pain in the jaw and neck areas is still difficult to resolve., Methods: The author describes how he uses the combination of the buccal nerve block (BNB) and the superficial cervical plexus block (SCPB) to improve the comfort of the patient's face and neck treatment of patients. It can improve the quality, elasticity, and texture of the skin., Results: According to the author's knowledge of oral and maxillofacial surgery, the combination of BNB and SCPB is applied to the neck and facial analgesia. Combining the BNB and SCPB effectively provides facial and neck anesthesia. The BNB in this technique provides pain relief to the facial skin in the mandibular area and SCPB offers pain relief to the skin of the neck. RF facial rejuvenation treatment often involves the junction of the face and neck to improve the contour of the mandibular margin. Therefore, Whether the RF treatment is aimed at the face or neck, or the treatment is performed simultaneously, we advocate the block both of the buccal nerve and the superficial cervical plexus nerves to achieve perfect analgesia. Still, the dosage of anesthetic medication for the nerve block can be adjusted according to the treatment area., Conclusion: We applied these two nerve blocks and their combination to improve skin laxity with RF therapy for the first time., (© 2023 The Authors. Journal of Cosmetic Dermatology published by Wiley Periodicals LLC.)

Purpose: In the context of the current comfort medicine and enhanced recovery after surgery, there is a demand for a new anesthesia method to reduce adverse reactions and accelerate recovery after surgery. This randomized controlled trial aimed to compare the efficacy and safety between opioid-free anesthesia (OFA) combined with ultrasound-guided intermediate cervical plexus block (ICPB) and opioid-based anesthesia in patients after thyroid surgery., Methods: In this study, 75 patients scheduled for thyroid surgery under general anesthesia were randomly allocated into two groups. The primary outcome included the incidence of nausea within 24 h after surgery. The main secondary outcomes included the incidence of vomiting and the visual analog score (VAS) scores within 24 h after surgery as well as the quality of recovery 40 questionnaires (QoR-40) scores 24 h after surgery., Results: In the OFA group, the incidence of postoperative nausea was 6.1%, compared to 39.4% in the control group (p = 0.001). No patient presented with postoperative vomiting in the OFA group, while 15.2% of patients suffered from postoperative vomiting in the control group (p = 0.063). The VAS scores of patients in the postanesthetic care unit (PACU) and 2 h, 4 h, and 6 h after surgery were lower in the OFA group, and the difference is statistically significant. Besides, the VAS scores of patients at rest (p = 1.000) and during swallowing (p = 1.000) 24 h after surgery were comparable., Conclusion: Compared with opioid-based anesthesia, the OFA combined with the ultrasound-guided ICPB can better improve patients' postoperative recovery, reduce nausea, and decrease pain scores., Trial Registration: Chinese Clinical Trial Regisrty, ChiCTR2200056344, https://www.chictr.org.cn., (© 2023. The Author(s).)

Background: Parathyroidectomy has been proposed as a method for reducing parathyroid hormone levels. We evaluated the effects of ultrasound-guided bilateral superficial cervical plexus block (BSCPB) on the quality of recovery of uremia patients with secondary hyperparathyroidism (SHPT) following parathyroidectomy., Methods: Eighty-two uremia patients who underwent parathyroidectomy and exhibited SHPT were randomly allocated to the BSCPB group or the control group (CON group). The patients received ultrasound-guided BSCPB with 7.5 ml of ropivacaine 0.5% on each side (BSCPB group) or equal amount of 0.9% normal saline (CON group). The primary outcome of the Quality of Recovery-40(QoR-40) score was recorded on the day before surgery and postoperative day 1(POD1). Secondary outcomes including total consumption of remifentanil, time to first required rescue analgesia, number of patients requiring rescue analgesia, and total consumption of tramadol during the first 24 h after surgery were recorded. The occurrence of postoperative nausea or vomiting (PONV) and the visual analogue scale (VAS) scores were assessed and recorded., Results: The scores on the pain and emotional state dimensions of the QoR-40 and the total QoR-40 score were higher in the BSCPB group than in the CON group on POD1 (P = 0.000). Compared with the CON group, the total consumption of remifentanil was significantly decreased in the BSCPB group (P = 0.000). The BSCPB group exhibited longer time to first required rescue analgesia (P = 0.018), fewer patients requiring rescue analgesia (P = 0.000), and lower postoperative total consumption of tramadol during the first 24 h after surgery (P = 0.000) than the CON group. The incidence of PONV was significantly lower in the BSCPB group than in the CON group (P = 0.013). The VAS scores in the BSCPB group were lower than those in the CON group at all time-points after surgery (P = 0.000)., Conclusion: Ultrasound-guided BSCPB with ropivacaine 0.5% can enhance the quality of recovery, postoperative analgesia, and reduce the incidence of PONV in uremia patients with SHPT following parathyroidectomy., Trial Registration: ChiCTR1900027185 . (Prospective registered). Initial registration date was 04/11/2019., (© 2021. The Author(s).)

Background: The mechanisms of persistent postoperative pain (PPP) with neuropathic features after carotid endarterectomy (CEA) are multifaceted and are incompletely understood., Objectives: The aim of this research was to assess whether the ultrasound-guided (USG) intermediate cervical plexus block (ICPB) could provide better control of PPP and neuropathic disturbances (NPDs) after CEA than the USG superficial cervical plexus block (SCPB)., Study Design: Prospective, randomized, controlled, clinical trial., Setting: This clinical trial was conducted at the SS Filippo and Nicola Academic Hospital of Avezzano (L'Aquila, Italy)., Methods: Patients who were scheduled for primary CEA were chosen. In the experimental group, the USG-ICPB was performed unilaterally, at the level of the third cervical vertebra. The needle was inserted into the deep lamina of the deep fascia of the neck, between the posterior border of the middle scalene muscle and the anterior border of the posterior scalene muscle. Three milliliters saline solution was injected into the opening of the deep lamina, and 20 mL 0.375% levobupivacaine was injected. In the control group, the anesthetic target was located at the inferior border of the sternocleidomastoid muscle at the level of the third cervical vertebra. The needle was superficially inserted below the skin, and 2 to 3 mL saline solution was injected into the opening of the superficial lamina of the deep fascia of the neck. A total of 20 mL 0.375% isobaric levobupivacaine was subsequently injected.The primary outcome measure was the proportion of patients with PPP on movement and at rest 3 months after surgery. The secondary outcome measures were NPD assessment scores using the von Frey hair test and the Lindblom test, opioid and pregabalin consumption. Adverse effects were also recorded., Results: A total of 98 consecutive patients were enrolled and randomized to receive either a USG-SCPB (control group, n = 49) or a USG-ICPB (experimental group, n = 49). The sensory blockade was longer in the experimental group. Three months after surgery, the proportions of patients with PPP on movement were significantly different between the experimental and control groups (33%, 95% confidence intervals [CI], 20%-47% vs. 71%, 95% CI, 57%-83%; P < 0.001), whereas there were no differences in the proportions of patients with pain at rest between groups (31%, 95% CI, 18%-45% vs. 49%, 95% CI, 34%-64%; P = 0.063). The proportions of patients with NPDs were not different between the groups, whereas the sizes of the areas of interest (cm2) were significantly different., Limitations: A limitation of this study is that we assessed NPDs for only 3 months using the von Frey hair test and the Lindblom test without additional instrumental techniques. Additionally, there are many risk factors for NPDs after CEA. For this reason, another limitation of this research is that we neglected to consider the relationship between the choice of anesthetic block and the presence of these risk factors., Conclusions: The USG-ICPB provided long-lasting analgesia during the postoperative period and might mitigate the development of NPDs, thereby decreasing the analgesic drug requirement., Key Words: Carotid endarterectomy, intermediate cervical plexus block, myofascial planes of neck, neuropathic disturbances, persistent postoperative pain, superficial cervical plexus blocks, ultrasound guidance, vascular disease.

Introduction: Thyroid surgery, which is usually followed by moderate postoperative pain, has gained increasing attention in recent years. A systematic review and meta-analysis was conducted to assess the effect of prophylactic bupivacaine on postoperative pain following thyroidectomy., Evidence Acquisition: We searched the PubMed, Web of Science, Embase, and Cochrane Library databases for specific keywords. RevMan 5.0 and Stata 12.0 software were used to perform meta-analyses. The endpoints were postoperative pain, rescue analgesic requirement, and postoperative nausea and vomiting (PONV) during the immediate 24 h postoperative period., Evidence Synthesis: A total of 18 randomized controlled trials (RCTs) with 1308 patients were included in the meta-analysis. A significant reduction of pain according to the postoperative pain scale at 1 hour (P<0.05) and rescue analgesic requirement (P<0.05) was observed following local infiltration with bupivacaine. A bilateral superficial cervical plexus block (BSCPB) with bupivacaine also significantly reduced postoperative pain at 1 hour (P<0.01) and 24 hours (P<0.01), as well as rescue analgesic requirement (P<0.00001) and PONV (P<0.01). Compared with BSCPB, local infiltration with bupivacaine provides a better effect in terms of postoperative analgesia (P<0.05)., Conclusions: We recommend local infiltration with bupivacaine ranged from 20 to 75 mg before or after skin closure or BSCPB with bupivacaine ranged from 25 to 100 mg to reduce postoperative pain after thyroidectomy.

Backgroud/objective: Multiple approaches have been devised for pain control in patients undergoing thyroid surgery, with local wound infiltration (LWI) of analgesia and bilateral superficial cervical plexus block (BSCPB) among the popular choices cited. However, the results comparing these methods had either been contradictory or equivocal. This study was carried out to assess the efficacy of BSCPB in comparison to LWI in reducing post-operative pain, as well as any additional opioid requirement in the first 24 h after thyroid surgery., Methods: A prospective, double-blinded randomized controlled trial comparing the post-operative pain score between BSCPB and LWI was conducted among patients undergoing thyroid surgery. Ropivacaine 0.50% was used in the study. Pain score was measured at 4, 12, 16 and 24 h after surgery using the visual analog scale (VAS). Subcutaneous injection of Tramadol was given whenever the pain score was ≥4 or requested by patients., Results: A total of 70 patients were recruited, with 35 patients on each arm. There was no statistical difference in the post-operative pain score between the two groups at 4 h (p = 0.208), 12 h (p = 0.860), 16 h (p = 0.376) and 24 h (p = 0.375) after surgery. Time to the first rescue dose of Tramadol between the two arms was also insignificant (p = 0.949). One patient in the BSCPB arm developed transient left upper limb weakness, which resolved 12 h after surgery., Conclusion: LWI remains the simplest, safest and most economical method of pain management. While BSCPB is comparable, it does however, come with potential regional block related complications., (Copyright © 2019. Published by Elsevier Taiwan LLC.)

Background: The ultrasound guided intermediate cervical plexus block with perivascular infiltration of the internal carotid artery (PVB) is a new technique for regional anesthesia in carotid endarterectomy (CEA). We conducted a pilot study investigating the effects of deep cervical block (DCB), intermediate cervical block alone (ICB) and PVB on perioperative complications in patients undergoing elective CEA. We hypothesized, that the ropivacaine plasma concentration is higher in patients receiving DCB compared to PVB and ICB., Methods: In a randomized controlled pilot study thirty patients scheduled for elective CEA were randomly assigned into three groups: DCB receiving 20 mL ropivacaine 0.5% (n = 10), ICB receiving 20 mL ropivacaine 0.5% (n = 10) and PVB receiving 20 mL ropivacaine 0.5% and 10 mL ropivacaine 0,3% (n = 10). As primary outcome, plasma levels of ropivacaine were measured with high performance liquid chromatography before, 5, 10, 20, 60, and 180 min after the injection of ropivacaine. Secondary outcomes were vascular and neurological complications as well as patients' and surgeons' satisfaction. All analyses were performed on an intention-to-treat basis. Statistical significance was accepted at p < 0.05., Results: No conversion to general anesthesia was necessary and we observed no signs of local anesthetic intoxication or accidental vascular puncture. Plasma concentration of ropivacaine was significantly higher in the DCB group compared to PVB and ICB (p < 0.001) and in the PVB group compared to ICB (p = 0.008). Surgeons' satisfaction was higher in the PVB group compared to ICB (p = 0.003) and patients' satisfaction was higher in the PVB group compared to ICB (p = 0.010) and DCB group (p = 0.029). Phrenic nerve paralysis was observed frequently in the DCB group (p < 0.05). None of these patients with hemi-diaphragmatic paralysis showed signs of respiratory distress., Conclusion: The ultrasound guided PVB is a safe and effective technique for CEA which is associated with lower plasma levels of local anesthetic than the standard DCB. Considering the low rate of complications in all types of regional anesthesia for CEA, larger randomized controlled trials are warranted to assess potential side effects among the blocks., Trial Registration: The trial was registered at German Clinical Trials Register (DRKS) on 04/05/2019 (DRKS00016705, retrospectively registered).

Introduction: Bilateral superficial cervical plexus block (BSCPB) is a common method used for analgesia in thyroid surgery. We investigated the analgesic efficacy of bilateral superficial cervical plexus block in the intraoperative and postoperative periods., Materials and Methods: Patients (n = 46) undergoing thyroidectomy were randomly separated into the following 2 groups: the general anesthesia group (GA; n = 23) and the general anesthesia plus BSCPB group (GS; n = 23). The intraoperative analgesic requirement (remifentanil) visual analog scale (VAS) score at multiple time points during the postoperative period (after extubation, at 15 and 30 minutes and 1, 2, 6, 12, 24 and 48 hours post operation) were evaluated. Total tramadol and paracetamol consumption as well as the amount of ondansetron used was recorded., Results: The intraoperative remifentanil requirement was significantly lower in the GS Group than in the GA Group (p = 0.009). The postoperative pain scores were significantly lower in the GS Group than in the GA Group at 15 (p < 0.01) and 30 (p < 0.01) minutes and 1 (p < 0.01), 2 (p < 0.01), 6 (p < 0.01), 12 (p < 0.01) and 24 (p = 0.03) hours. The postoperative tramadol requirement was significantly lower in the GS Group than in the GA Group (p = 0.01). The number of patients that used ondansetron was significantly lower in the GS Group than in the GA Group (p = 0.004)., Conclusion: We concluded that BSCPB with 0.25% bupivacaine reduces the postoperative pain intensity and opioid dependency in thyroid surgery patients., (Copyright © 2019 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.)

Background: A classical approach to produce interscalene brachial plexus block (ISBPB) consistently spares the posterior aspect of the shoulder and ulnar sides of the elbow, forearm, and hand, which are innervated by the lower trunk of the brachial plexus (C8-T1). As an alternative to the classical approach, a caudal approach to ISBPB successfully produces anesthesia of the ulnar sides of the elbow, forearm, and hand. However, its beneficial effects on anesthesia in the posterior aspect of the shoulder have not been investigated. In addition, the C8 nerve root is not routinely selectively blocked during ISBPB. Therefore, we will compare the C5 to C7 and C5 to C8 nerve root blocks during a caudal approach to ISBPB to assess the clinical benefit of C8 nerve blocks for the surgical anesthesia of the posterior aspect of the shoulder., Methods/design: In this prospective parallel-group single-blind randomized controlled trial, 74 patients scheduled to undergo arthroscopic shoulder surgery under ISBPB are randomly allocated to receive the C5 to C7 or C5 to C8 nerve root block at a 1:1 ratio. The primary outcome is pain intensity, which is rated as 0 (no pain), 1 (mild pain), or 2 (severe pain), during the introduction of a posterior portal into the glenohumeral joint. The secondary outcomes are (1) the extent of the ipsilateral sensory, motor, hemidiaphragmatic, and stellate ganglion blockade, (2) changes in the results of a pulmonary function test, (3) incidence of complications related to ISBPB, (4) postoperative numerical pain rating scale scores, (5) patients' satisfaction with the ISBPB, (6) dose and frequency of analgesic use, and (7) incidence of conversion to general anesthesia., Discussion: This study is the first to evaluate the beneficial effects of the C8 nerve root block during ISBPB, which has rarely been performed due to the technical challenge in visualizing and blocking the C8 nerve root. It is expected that a C8 nerve root block performed during ISBPB will provide sufficient surgical anesthesia of the posterior aspect of the shoulder, which cannot be achieved by a classical approach to ISBPB., Trial Registration: ClicnicalTrials.gov, NCT03487874 . Registered on 4 April 2018.

Background: To the authors' knowledge, there has not been an ultrasound study of the vulnerable vessels in a C3-7 cervical nerve root block (CNRB)., Objectives: To evaluate the prevalence of vulnerable vessels around the target of a CNRB at the cervical nerve root of C3-7 levels in a clinical setting., Design: Retrospective, cross-sectional study., Setting: General teaching hospital, rehabilitation unit., Participants: A total of 104 patients complaining of neck or arm pain with no prior surgical history and who had undergone a CNRB at an outpatient clinic from May 2015 to December 2017 were included., Main Outcome Measurements: The prevalence of vulnerable vessels as seen on a preprocedure ultrasound scan around the target of a CNRB at the cervical nerve root of C3-7 levels., Results: Out of 104 cases, the C3 level had 7 blood vessels (8.33%), the C4 level had 14 blood vessels (13.86%), the C5 level had 17 blood vessels (16.35%), the C6 level had 27 blood vessels (25.96%), and the C7 level had 31 blood vessels (29.81%) either at the targeted cervical nerve root or at the site of the imaginary needle's projected pathway to the targeted cervical nerve root., Conclusion: There was a substantial prevalence of vulnerable vessels either at the targeted nerve root or at the site of the needle's projected pathway to the nerve root., (© 2018 American Academy of Physical Medicine and Rehabilitation.)

Ojectives: The aim was to evaluate the ability of bilateral superficial cervical plexus blockade to control pain and to reduce the side effects of general anesthesia in patients submitted to thyroidectomy., Methods: In this randomized controlled trial, we prospectively studied 100 consecutive patients who underwent total thyroidectomy. The simple random patient sample was divided into two groups: 50 patients received general anesthesia alone (group 1 [G1]), and 50 patients received general anesthesia with bilateral superficial cervical plexus blockade (group 2 [G2]). Statistical analyses were performed, and a 5% significance level was adopted., Results: The mean arterial blood pressure and heart rate were 12% lower in G2 patients than in G1 patients 60 minutes after surgery (101 mmHg for G1 vs. 92.3 mmHg for G2; p<0.001). G2 patients reported less pain than G1 patients, and opioid consumption was lower in G2 patients than in G1 patients, not upon postanesthesia care unit arrival, but at 30 minutes (2% vs. 34%; p<0.001, respectively), 45 minutes (0% vs. 16%; p=0.006, respectively), and 4 hours postoperatively (6% vs. 20%; p=0.037, respectively). The incidence of nausea and vomiting was lower in G2 patients than in G1 patients from 45 minutes (0% vs. 16%; p=0.006, respectively) to 8 hours postoperatively (0% vs. 14%; p=0.012, respectively)., Conclusions: The present study demonstrated that the combination of bilateral superficial cervical plexus blockade with general anesthesia for thyroidectomy is feasible, safe, and effective for achieving pain control and improving patient outcomes.

Background and Objectives: Ultrasound-guided intermediate cervical plexus block with perivascular local anesthetic infiltration is an established anesthetic procedure for carotid endarterectomy. In this prospective pilot study an additional subplatysmal block of the superficial ansa cervicalis is presented for the first time. The target structures are the anastomoses between the facial nerve (cervical and marginal mandibular branches) and cervical plexus., Methods: An ultrasound-guided intermediate cervical plexus block (20 ml of ropivacaine 0.75%) was performed (n = 28). Then, depending on the individual sonoanatomy, 5 ml of prilocaine 1% was injected into the carotid sheath (group 1: no perivascular infiltration, n = 14, group 2: perivascular infiltration, n = 14). The third step was subplatysmal injection of 5 ml of prilocaine 1% between the medial edge of the sternocleidomastoid muscle and the submandibular gland (n = 28). The investigated parameters included the need for supplementation and block-related side effects., Results: The requirement for supplemental local anesthetic infiltration in the skin incision area was minimal at mean (M) 1.1 ml (standard deviation (SD) ±2.4 ml). Perivascular infiltration in group 2 significantly decreased the total amount of local anesthetic supplemented: group 1 M = 4.2 ml (SD = ±3.1 ml), group 2 M = 1.7 ml (SD = ±2.0 ml) (p = 0.018). The incidence of block-related side effects was not significantly different between the two groups., Conclusion: This study presents an ultrasound-guided subplatysmal block of the superficial ansa cervicalis for the first time, with the aim of optimizing anesthesia quality during surgical interventions in the carotid triangle.

Background and Objectives: Unipolar sternocleidomastoid release with myectomy (USRM) for correction of congenital muscular torticollis in pediatric patients produces moderate to severe postoperative pain. The objective of this trial was to examine the effect of ultrasound-guided intermediate cervical plexus block on postoperative pain after USRM., Methods: Thirty-two patients (1-7 years old) were enrolled in this parallel-group, patient- and observer-blinded, randomized controlled trial. In the block group, 0.25% ropivacaine (0.2 mL/kg) was injected into the interfascial plane between the sternocleidomastoid muscle and the prevertebral fascia under ultrasound guidance at the fourth to fifth cervical vertebral level. The primary outcome measure was the face, legs, activity, cry, and consolability (FLACC) score at 5 minutes after entering the postanesthesia care unit (PACU), and secondary outcome measures were the FLACC score at discharge from the PACU and 3, 6, and 24 hours after operation and the use of rescue analgesic in the PACU and ward., Results: The FLACC score at 5 minutes after admission to the PACU was significantly reduced (3 vs 8; median difference, 4; 95% confidence interval, 1-7; P = 0.044), and the fentanyl dose and the number of patients requiring rescue analgesics in the PACU were significantly lower (0.0 vs 0.5 μg/kg, P = 0.014; 5 [29.4%] vs 12 [75.0%], P = 0.032) in the block than in the control group. However, after discharge from PACU, there was no difference in FLACC scores and use of rescue analgesics between groups., Conclusions: Ultrasound-guided intermediate cervical plexus block decreased immediate postoperative pain and opioid requirements in the PACU in pediatric patients who underwent USRM., Clinical Trial Registration: This study was registered at ClinicalTrials.gov, identifier NCT02651311.

Background: Although use of the superficial cervical plexus block (SCPB) by anesthesia for perioperative indications is well described, there is a paucity of research on use of SCPB in the emergency department (ED)., Objective: This prospective observational study aims to prospectively characterize the feasibility, potential for efficacy, and safety of ultrasound-guided SCPB in a convenience sample of ED patients presenting with painful conditions of the "cape" distribution of the neck and shoulder., Methods: Data were gathered prospectively on a convenience sample of 27 patients presenting to a community ED with painful conditions involving the distribution of the SCPB: para-cervical muscle spasm/pain (n = 8), clavicle fractures (n = 7), acromioclavicular joint injuries (n = 3), radicular pain (n = 3), and rotator cuff disorders (n = 6). Pre- and post-block 11-point verbal numeric pain scores (VNPS) were recorded, as was the incidence of any immediate complications. A retrospective chart review looked for delayed complications in the 14-day post-block period., Results: The mean 11-point VNPS reduction was 5.4 points (62%). There were no early serious complications and one case each of self-limiting vocal hoarseness and asymptomatic hemi-diaphragmatic paresis. No delayed block-related complications were found., Conclusions: While limited by the fact that this was a nonrandomized observational experience with no control group, our findings suggest that SCBP may be safe and have potential for efficacy, and warrants further evaluation in a randomized controlled trial., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

Background: Presentation of hyperparathyroidism varies and is highly non-specific. The automated calcium analyzer has made the diagnosis easy. Similarly, the advent of Sestamibi scan has paved the way to minimally invasive parathyroidectomy indicated for parathyroid adenoma. There is no uniformity in the extent of minimally invasive parathyroidectomy that is done through limited incision under radio or sonar guidance and endoscopically. In this study, we are presenting the focused parathyroidectomy performed under sonar guidance and superficial cervical block (SCB). The prerequisite is concordant preoperative Sestamibi and ultrasound imaging., Method: A two-year review of parathyroidectomies performed between January 2013 and December 2014., Objective: To reflect on the result of sonar-guided focused parathyroidectomy under SCB., Results: There was good correlation between the pre-operative imaging, the intra-operative findings and the postoperative histology result of the 15 cases analysed., Conclusion: The focused parathyroidectomy under SCB yielded a good result with concordant preoperative Sestamibi and ultrasound findings., (Copyright© Authors.)

Objectives: Although the cervical plexus block generally provides adequate analgesia for carotid endarterectomy, pain caused by metal retractors on the inferior surface of the mandible is not prevented by the cervical block. Different pain relief methods can be performed for patients who experience discomfort in these areas. In this study, the authors evaluated the effect of mandibular block in addition to cervical plexus block on pain scores in carotid endarterectomy., Design: A prospective, randomized, controlled trial., Setting: Training and research hospital., Participants: Patients who underwent a carotid endarterectomy., Interventions: Patients scheduled for carotid endarterectomy under cervical plexus block were randomized into 2 groups: group 1 (those who did not receive a mandibular block) and group 2 (those who received a mandibular block). The main purpose of the study was to evaluate the mandibular block in addition to cervical plexus block in terms of intraoperative pain scores., Measurements and Main Results: Intraoperative visual analog scale scores were significantly higher in group 1 (p = 0.001). The amounts of supplemental 1% lidocaine and intraoperative intravenous analgesic used were significantly higher in group 1 (p = 0.001 and p = 0.035, respectively). Patient satisfaction scores were significantly lower in group 1 (p = 0.044). The amount of postoperative analgesic used, time to first analgesic requirement, postoperative visual analog scale scores, and surgeon satisfaction scores were similar in both groups. There was no significant difference between the groups with respect to complications. No major neurologic deficits or perioperative mortality were observed., Conclusions: Mandibular block in addition to cervical plexus block provides better intraoperative pain control and greater patient satisfaction than cervical plexus block alone., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Acute ipsilateral shoulder pain (ISP) is a common complaint in patients after thoracotomy. The incidence ranges from 21% to 97%. Unfortunately, clinical studies did not put enough focus on ISP post thoracic surgery., Aim of the Work: This study was designed to compare the effectiveness of suprascapular nerve block (SNB) and phrenic nerve infiltration (PNI) for controlling ISP., Patients and Methods: One hundred and thirty-five lung cancer patients (135) scheduled for open-lung surgery were randomly allocated into three equal groups; control group: received thoracic epidural with general anesthesia, suprascapular group: (SNB) one hour before the operation with 10 ml bupivacaine plus thoracic epidural with general anesthesia and phrenic nerve group: (PNI) was performed by the operating surgeon with 10 ml bupivacaine plus thoracic epidural with general anesthesia. The visual analogue score (VAS) of ISP, rescue of ketorolac for break through shoulder pain, peak expiratory flow rate (PEFR) and arterial blood gases were measured every 6 h postoperatively for 48 h., Results: The VAS, rescue doses of ketorolc and PEFR were significantly lower in the phrenic nerve group (P-value <0.05). There was no statistically significant difference between the three groups postoperatively as regards arterial blood gases (P-value >0.05)., Conclusion: PNI is more effective than SNB for ISP., (Production and hosting by Elsevier B.V.)

Blockades of the cervical plexus are established anesthesia procedures, not only in the context of operative carotid revascularizations. Recent investigations define inner sonoanatomic landmarks as well as the importance of brain nerves for innervation in the neck region. The present practice-oriented article discusses current study results, alternative techniques (ultrasound- versus landmark-guided) and fields of application (carotid desobliteration, surgery of the shoulder, ear and infraclavicular region)., Competing Interests: Interessenkonflikt: Der Autor gibt an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective To explore the efficacy and safety of ultrasound-guided cervical root block (CRB) in patients undergoing minimally invasive parathyroidectomy (MIP).Methods We enrolled 35 patients with hyperparathyroidism undergoing MIP in Peking Union Medical College Hospital.C4-7 nerve roots were identified in ultrasound imaging by the shape of the transverse process.A 50 mm insulated needle was gently introduced by an in-plane approach toward the posterior edge of the nerve root located at the inside of the posterior tubercle.After careful aspiration,a total of 3-4 ml of a mixture of 0.5% ropivacaine and 1% lidocaine was slowly injected.The superficial block was administered at the midpoint of the posterior border of the sternocleidomastoid by injecting 5-6 ml of the same mixture.The patients were administrated with dexmedetomidine during the surgery.All patients were assessed for sensory following the procedure and for pain after the surgery.Results Totally 35 patients successfully received MIP under ultrasound-guided CRB plus superficial block.There was no conversion to general anesthesia,no toxic reaction of local anesthetics,and no intravertebral injection.Hoarseness occurred in 6 patients (17.1%) and Horner syndrome occurred in 3 patients (8.6%).The median cold sensory visual analogue scale score was 1.2 [0,5] points at 10 minutes after the procedure.Patient's satisfaction score was 9.5 points.Conclusion Ultrasound-guided CRB plus superficial block can achieve accurate and safe anesthesia,and it provides lasting analgesic effect during and after MIP.

In routine practice, regional anaesthesia is less commonly used for clavicular fracture compared to general anaesthesia. We report two cases of clavicle fracture for which operative treatment was done under combined superficial cervical plexus and interscalene brachial plexus block. In both the cases combination of ropivacaine and dexmeditomidine was used for block. Both the patients exhibited comfort and there was no additional analgesic demand in both the cases. Thus combination of interscalene and superficial cervical plexus block can prove to be useful in patients with clavicle fracture where administration of general anaesthesia and its adverse effects could be avoided.

Both general anesthesia (GA) and cervical plexus anesthesia (CPA) can be used for anterior cervical discectomy and fusion (ACDF) surgery. The aim of this study was to evaluate the influence of anesthetic techniques on perioperative mortality and morbidity in patients undergoing cervical surgery.From January 2008 to December 2015, 356 patients who underwent 1-level ACDF for cervical spinal myelopathy were prospectively reviewed. They were assigned to receive GA (group A) and CPA (group B). The analgesic efficacy of the block was assessed by anesthesia preparation time, the maximum heart rate, and mean arterial blood pressure changes compared with the baseline, time of postoperative revival, and duration of recovery stay. Duration of surgery, blood loss, and anesthesia medical cost were also recorded. Numerical rating scale (NRS) was used to evaluate pain at different time points. Postoperative nausea and vomiting (PONV) was assessed, and postoperative average administered dosages of meperidine and metoclopramide were also recorded. The spinal surgeon satisfaction, anesthetist satisfaction, and patient satisfaction were assessed.Both the anesthesia induction time and postoperative revival time were longer in group A than that in group B; both the duration of surgery and recovery stay were also longer in group A than that in group B, whereas there was no difference in blood loss between the 2 groups. The average dosage of both meperidine and metoclopramide was more in group A than that in group B, and the anesthesia medical cost was greater in group A than that in group B. There were no significant differences in baseline data of systolic blood pressure, diastolic blood pressure, and heart rate between the 2 groups. But the intraoperative data of systolic blood pressure, diastolic blood pressure, and heart rate were higher/larger in group B than that in group A. In group A, there was no complaint of pain in the surgery procedure, but the pain increased after GA, with highest degree at 8 hours postoperation; then the pain degree decreased, and the NRS was 1 at 24 hours postoperation. In group B, intraoperative pain was NRS 4, and pain degree decreased from 4 hours postoperation; the NRS was 2 at 24 hours postoperation. The incidence of severe PONV was higher in group A than that in group B. There was no significant difference in the spinal surgeon satisfaction and anesthetist satisfaction for the anesthetic techniques. There was significant difference in patient satisfaction between the 2 groups, with high satisfaction for GA.General anesthesia is superior to CPA in maintaining better intraoperative hemodynamic stability and providing high patient satisfaction with no intraoperative pain for patients receiving ACDF, but it entails longer surgery and anesthesia time, and requires more postoperative analgesic and anesthesia cost.

Objective . The aim of this study was to compare the efficacy of ultrasound-guided deep cervical plexus block with fluoroscopy-guided deep cervical plexus block for patients with cervicogenic headache (CeH). Methods . A total of 56 patients with CeH were recruited and randomly assigned to either the ultrasound-guided (US) or the fluoroscopy-guided (FL) injection group. A mixture of 2-4 mL 1% lidocaine and 7 mg betamethasone was injected along C 2 and/or C 3 transverse process. The measurement of pain was evaluated by patients' ratings of a 10-point numerical pain scale (NPS) before and 2 wks, 12 wks, and 24 wks after treatments. Results . The blocking procedures were well tolerated. The pain intensity, as measured by NPS, significantly decreased at 2 wks after injection treatment in both US and FL groups, respectively, compared with that of baseline ( P < 0.05). The blocking procedures had continued, and comparable pain relieving effects appeared at 12 wks and 24 wks after treatment in both US and FL groups. There were no significant differences observed in the NPS before and 2 wks, 12 wks, and 24 wks after treatment between US and FL groups. Conclusions . The US-guided approach showed similar satisfactory effect as the FL-guided block. Ultrasonography can be an alternative method for its convenience and efficacy in deep cervical plexus block for CeH patients without radiation exposure., Competing Interests: All named authors declare that they have no conflict of interests.

Introduction: Accessory innervation (AI) may account for the persistent sensation perceived after successful mandibular anesthesia in the adult patient. The purpose of this systematic review was to record the quality of evidence pertaining to the cervical plexus (CP) AI in dental anesthesia., Materials and Methods: Electronic and manual searches were conducted using Ovid and Medline of articles published from 1922 to March of 2015. Studies written in any language were included as long as they involved: (i) humans, animals, and/or cadavers AND (ii) anatomical and/or research anesthetic-technique approaches and/or clinical approaches. Exclusion criteria were (i) maxillary buccal infiltration, (ii) no abstract/paper available, (iii) studies that do not comprise the description of the branches of the CP branches in dentistry and (iv) duplicated articles. The articles were reviewed and graded by levels of evidence (LOE) through a methodological scoring index (MSI)., Results: Forty-four out of 185 papers fulfilled the inclusion criteria. One randomized control trial, 3 comprehensive reviews, 1 cohort study, 5 case series/reports, 16 poor-quality cohort and case series/reports and 18 reviews/case, reports/expert opinions were found. Of the 44 publications, there were 4 LOE 1, 1 LOE 2, 5 LOE 3, 20 LOE 4 and 14 LOE 5 studies., Conclusions: The MSI helped to classify papers LOE in a standardized and objective approach. The objective evidence quality occurrence recorded was found to be LOE 4 (n = 20) > LOE 5 (n = 14) > LOE 3 (n = 5) > LOE 1 (n = 4) > LOE 2 (n = 1). The anatomy of the CP needs to be reexamined and understood in the anatomical literature., (Copyright © 2016 Anesthesia History Association. Published by Elsevier Inc. All rights reserved.)

Study Objective: To evaluate intra-abdominal needle trajectories of the classic transcrural celiac plexus block (tCPB) with a simulation technique., Design: Classic tCPB technique cited from 10 latest authoritative textbooks were simulated on abdominal computed tomography images retrospectively., Setting: University-affiliated community hospital., Measurements: One hundred axial computed tomography images across the celiac trunk were retrieved. Three lines simulating classic tCPB were executed on each image. The organs traversed by each line were noted and analyzed. The frequencies of organ traverse were compared with the incidences described in the literature., Main Results: All 3 lines traversed various organs with different frequencies. The right side line frequently traversed the right kidney (36%). The left side line always traversed the aorta (100%). The modified line on the right side frequently traversed the inferior vena cava (32%). The highest kidney traverse percentage on both sides and the highest aorta traverse percentage on the right side were observed in pancreatic cancer patients., Conclusions: Despite uncommon clinical complications, classic tCPB needle placement frequently traversed through several key organs in this simulation series. Organ penetrations could be avoided by needle trajectory adjustment., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: Carotid endarterectomy under regional anesthesia may be performed by using superficial, intermediate, deep or combined cervical plexus block. The authors compared the combined and intermediate cervical plexus block by use of ultrasound guidance in patients undergoing carotid endarterectomy., Design: A prospective, randomized, double-blinded trial., Setting: Education and research hospital., Participants: Adult patients undergoing carotid artery surgery., Interventions: Forty-eight patients were randomized to receive either combined cervical plexus block (deep plus superficial) or intermediate cervical plexus block by use of ultrasound guidance for carotid endarterectomy. The primary outcome measure was the amount of supplemental 1% lidocaine used by the surgeon. Secondary outcome measures were the time for the first analgesic requirement after surgery, block-related complications, postoperative visual analog scale score, and patient and surgeon satisfaction., Measurements and Main Results: Intraoperative supplemental lidocaine requirements were 3.0±1.9 mL in the combined-block group and 7.8±3.8 mL in the intermediate block group. These differences were statistically significant. There were no significant differences between the 2 groups in block-related complications and the time between the block completion and the first administration of the first dose of intravenous analgesic. In the combined-block group, maximum visual analog scale score was lower at 3 hours (2.2 [1-5] v 5.3 [3-8]), and patient satisfaction score was higher than the intermediate-block group (4.3 [3-5] v 3.1 [1-4]). One regional anesthesia procedure was converted to general anesthesia in the combined-block group., Conclusions: Ultrasound-guided combined cervical plexus block compared to intermediate cervical plexus block led to less additional analgesic use, lower visual analog scale score, and higher patient satisfaction., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: Regional anesthesia for patients undergoing carotid endarterectomy is associated with improved intraoperative hemodynamic stability compared with general anesthesia. The authors hypothesized that the reported advantages might be related to attenuated ipsilateral baroreflex control of blood pressure, caused by chemical denervation of the carotid bulb baroreceptor nerve fibers., Design: A prospective cohort study., Setting: Single-center university hospital., Participants: The study included 46 patients undergoing carotid endarterectomy using superficial cervical block., Interventions: A noninvasive computational periprocedural measurement of baroreceptor sensitivity was performed in all patients. Two groups were formed, depending on the patients' subjective response to surgical stimulation regarding the necessity of additional intraoperative local anesthesia (LA) administration on the carotid bulb. Group A (block alone) included 23 patients who required no additional anesthesia, and group B (block + LA) consisted of 23 patients who required additional anesthesia., Measurements and Main Results: Baroreceptor sensitivity showed no significant change after application of the block in both groups (group A: median [IQR], 5.19 [3.07-8.54] v 4.96 [3.1-9.07]; p = 0.20) (group B: median [IQR], 4.47 [3.36-8.09] v 4.53 [3.29-8.01]; p = 0.55). There was a significant decrease in baroreceptor sensitivity in group B after intraoperative LA administration (median [IQR], 4.53 [3.29-8.01] v 3.31 [2.26-7.31]; p = 0.04)., Conclusions: Standard superficial cervical plexus block did not impair local baroreceptor function, and, therefore, it was not related to improved cerebral perfusion in awake patients undergoing carotid endarterectomy. However, direct infiltration of the carotid bulb was associated with the expected attenuation of baroreflex sensitivity., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Carotid endarterectomy carries a significant risk of intraoperative brain ischaemia. Various methods for intraoperative cerebral function monitoring can be utilized, but the assessment of the patient's consciousness remains the easiest and most available method, requiring that the patient remain awake and under local/regional anaesthesia. The aim of this study was to compare infiltration anaesthesia with an ultrasound-guided superficial/combined cervical plexus block for patient safety and comfort., Methods: Ninety-eight patients scheduled for carotid endarterectomy were randomly assigned to receive either infiltration anaesthesia performed by the surgeon or an US-guided superficial/combined cervical plexus block. The pain intensity using the numerical rating scale (NRS), the volume of local anaesthetic used and the anaesthesia-related complications were recorded. The data were analysed using selected statistical tools., Results: In the US-guided group, a significantly lower volume of local anaesthetic was used (25 mL vs. 30 mL), and lower mean (1 vs. 3) and maximal (2 vs. 6) NRS scores were observed. However, hoarseness, cough and difficulty swallowing were significantly more frequent among those patients (90% vs. 27%, 30% vs. 12%, and 36% vs. 6%, respectively)., Conclusions: Compared with infiltration anaesthesia, an US-guided superficial/combined cervical plexus block is an effective method for improving the comfort of the patient and the surgeon. The technique is safe, relatively simple and easy to master and requires little time to perform.

Background: Carotid endarterectomy is widely performed under regional anaesthesia. Ultrasound guidance is increasingly used in many regional anaesthetic procedures to improve safety and efficacy, and because it can reduce the amount of local anaesthetic required. Despite this, an ideal approach and dosing regimen for cervical plexus block remain elusive., Objective: The aim of this study was to compare two different concentrations of ropivacaine in terms of analgesic adequacy, haemodynamic effects and plasma concentration using an ultrasound-guided triple approach for intermediate cervical plexus blockade., Design: A randomised, placebo-controlled, blinded study., Setting: University Clinic Salzburg, Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Paracelsus Medical University, Salzburg, Austria, from 16 November 2012 to 17 September 2013., Patients: Forty-six patients prospectively randomised to receive ultrasound-guided intermediate cervical block with either 20 ml ropivacaine 0.75% or 20 ml ropivacaine 0.375% each with 20 ml prilocaine 1%., Intervention: After subcutaneous infiltration, blocks were performed using ultrasound-guided infiltration below the sternocleidomastoid muscle, and ultrasound-guided infiltration of the carotid sheath. Ropivacaine and prilocaine plasma concentrations were measured at intervals., Main Outcome: The primary study endpoint was the volume of supplementary lidocaine 1% required to achieve adequate surgical anaesthesia. Perioperative haemodynamic variables and pain scores were recorded., Results: There was no statistical difference in the volume of supplementary lidocaine given: 5.0 (±3.63) ml in the ropivacaine 0.375% group and 5.17 (±2.76) ml in the ropivacaine 0.75% group (P = 0.846). Pain scores were similarly low across both groups. Measured concentrations of ropivacaine and prilocaine did not reach toxic levels in either group. Levels of ropivacaine were approximately two-fold higher in the 0.75% group [mean area under the curve (AUC) 10 531.11 (±2912.84) vs. 5264.34 ng (±1594.69), P < 0.0001]. Perioperative cardiovascular stability was excellent in both groups. There were no serious block-related complications., Conclusion: An ultrasound-guided intermediate block provides adequate anaesthesia for carotid thrombendarterectomy with a little need for supplementary local anaesthetic. Use of 0.375% ropivacaine provided similarly effective analgesia as 0.75%, but resulted in significantly lower plasma concentrations., Trial Registration: The study was registered at the European Clinical Trial Database (Eudra CT No.: 2012-002769) as well as at ClinicalTrials.gov (NCT01759940).

This is the case of an 80-year-old female who presented for evacuation of a neck hematoma on POD#3 after a parathyroidectomy. Her medical history included coronary artery disease with a drug-eluding stent, off aspirin for 2 weeks. She had a significant hematoma from the hyoid bone extending down to below the suprasternal notch. She reported hoarseness. The anesthesiology team provided regional anesthesia with bilateral superficial cervical blocks, supplemented with minimal sedation for patient compliance. The surgical team used no adjuvant local anesthetic. A deep exploration was performed and significant clot was evacuated. The patient went home safely from the PACU.