DOI: 10.14260/jemds/2014/2415

ORIGINAL ARTICLE

BILATERAL CERVICAL PLEXUS BLOCK FOR THYROIDECTOMYOUR EXPERIENCE

A. Naveen Kumar1,K. Sampath Kumar2,S. Jagadeeshacharulu3,M. Ramaswamy Naik4,V. Vijayalakshmi5

HOW TO CITE THIS ARTICLE:

A. Naveen Kumar, K. Sampath Kumar, S. Jagadeeshacharulu, M. Ramaswamy Naik, V. Vijayalakshmi.“Bilateral Cervical Plexus Block for ThyroidectomyOur Experience”. Journal of Evolution of Medical and Dental Sciences 2014; Vol. 3, Issue 16, April21; Page: 4176-4182,DOI: 10.14260/jemds/2014/2415

ABSTRACT: We evaluated the benefits of bilateral superficial and deep cervical plexus block regional anesthesia in 30 consenting patients of age group between 20-70 years of age and assessed its efficacy of providing surgical anesthesia, intra operative complications and postoperative complications and benefits. Bilateral superficial and deep cervical plexus block were performed in all patients with local anesthetic solution of 30ml of 0.25% Bupivacaine and 10ml of 1%xylocaine separately. To allay anxiety inj.midazolam1mg intravenous was given prior to block and intravenous Butorphanol 2mg was given before starting of surgery. Forced vital capacity was measured before block, 10 minutes after the block and in the recovery room.27 patients tolerated the procedure very well with 2mg Butorphanol sedation, only 3patients required supplementary i.v.analgesia of Propofol via mask. Only ASA 1, 2, 3 groups were selected.13 patients were ASA -1 group, 7patients were ASA 2group and 10 patients were ASA 3 group.Postoperatively patients had longer pain free period, lower dose requirement of opioid analgesic, lower incidence of postoperative nausea and vomiting. There was no significant differences in the baseline forced vital capacity vs. forced vital capacity measured after the block and in the recovery room. Our experience indicates that regional anesthesia is an appropriate alternative to general anesthesia in selected patients undergoing thyroid surgery and did not compromise respiratory function.

KEYWORDS:Bilateral cervical plexus block, Thyroidectomy, Bupivacaine, Xylocaine.

INTRODUCTION: Thyroid surgeries are most common surgeries especially in the female population. Nearly more than 40%of the postoperative thyroid surgery patients experience significant postoperative pain with pain score above 4 reflecting inadequate postoperative analgesia which is considered as an independent risk factor.

It has been proposed that injection of local anesthetic drug into cervical plexus1, 2, 3bilaterally could easily lead to establishment of block appropriate for thyroid surgery without any significant side effects. It is associated with decreased need of opioids for controlling postoperative pain. It also decreases post-operative nausea &vomiting, postoperative pulmonary complications and finally ICU stay of the patient. Cervical plexus block has also been effectively used in other surgeries like carotid endarterectomy, lymph node biopsy (or) excision.

In the present study an effort has made to know the efficacy of bilateral cervical plexus block4,5 as an anesthetic procedure for thyroid surgeries.

MATERIALS ANDMETHODS: After obtaining institutional ethics committee approval, 30 consenting patients (29 females and 1 male) ASA status 1, 2, 3 of age group 20-70 years in euthyroid state scheduled for thyroid surgery are enrolled in this clinical study. Patients who refused, age less than 20 years, age more than 70 years, ASA status of 4& 5, bleeding disorders, allergy to any of the study drug, chronic pain syndrome, chronic analgesic use and psychiatric disease were excluded from the study.

During the pre-operative visit on the day before surgery, patients were thoroughly explained about the procedure to be undertaken and the risks and benefits associated. They were made well conversant with the visual analogue scale (VAS) for postoperative pain. Patients were advised preoperative fasting for a period of 6 hours and premedication with Tab. Diazepam 10mg the night before surgery.

On arrival to the O.T complex patients were taken to O.T where bilateral cervical plexus block were performed 5. Intravenous infusion of lactated ringer solution as maintenance fluid was started.All necessary equipment for G.A and resuscitation were kept ready in case of block failure and complications. Baseline vital parameters like pulse rate, NIBP, respiratory rate, spo2 were noted. Time to the block and time to surgical anesthesia were noted. Monitoring was continued throughout the procedure.

Patient were given dose of Midazolam 1mg intravenous in the O.T before block placement to decrease anxiety and discomfort during the procedure, while maintaining meaningful patient contact. Butorphanol 2mg intravenous was given as pre-emptive analgesic block placement.6, 7 30ml of 0.25%bupivacaine and 10ml of 1%xylocaine were usedseparately as local anesthetic drugs for block. Under aseptic precautions bilateral cervical plexus block both superficial and deep block was achieved. Patient is in supine position, head slightly extended, head turned to opposite side, ipsilateral arm at patient side.

Superficial cervical plexus block is achieved by injecting 2ml of 1%xylocaine and 3ml 0.25% Bupivacaine at the point where external jugular vein crosses the posterior border of Sternocleidomastoid muscle in fan shaped manner after negative aspiration for blood and CSF.

Deep cervical plexus block is achieved by injecting 3ml of 1% Xylocaine and 12 ml 0.25% Bupivacaine. Mastoid process is identified, line drawn from tip of mastoid process to transverse process of C6 vertebra (chassaignac’s tubercle), 2nd line drawn 1cm posterior and parallel to 1st line. Locate and mark transverse process of C2, C3, and C4 vertebra. 22 G 5cm needle inserted towards C2 transverse process, after getting contact with transverse process, elicit paresthesia by walking on the transverse process and after negative aspiration for blood and CSF 1ml of 1%xylocaine and 4 ml of 0.25%bupivacaine local anesthetic solution is injected. Repeat the procedure at C3 and C4 levels. Same procedure of both superficial and deep cervical plexus block is repeated on opposite side.

Strict vigilance is kept for the Complications of cervical plexus block like intravascular injection/injury to vertebral artery(loss of consciousness, seizures)temporary partial phrenic nerve block8,CNS toxicity (tinnitus, disorientation, perioral numbness), cardiovascular collapse, recurrent laryngeal nerve blockade (hoarseness of voice), Horner’s syndrome (ptosis, miosis, anhydrosis) vagal nerve blockade, Epidural/ subarachnoid (total spinal), brachial nerve plexus blockade, hematoma.

Patients were monitored with multichannel monitor for spo2, pulse rate, NIBP, respiratory rate, temperature, 6 lead E.C.G. Induction time (time to surgical anesthesia) was defined as the time gap between the completion of local anesthetic injection to pinprick discrimination. Recovery time was defined as the time between applicationof bandage to eye opening on verbal command.

Post operatively all the patients were shifted to the recovery room I.C.U for first 24 hours. Patients were assessed for pain, nausea and vomiting just after shifting to the recovery room I.C.U.

Data were collected at 2, 4, 6, 8, 10, 12 and 24 hours calculated from the time of block. Post-operative pain assessed with visual analogue scale (VAS) score of 0-10(0=no pain, 10=worst imaginable pain). VAS scores > 4 were treated with Butorphanol 1mg intravenous repeated, if necessary after 15 minutes. If analgesia is still inadequate after 30 minutes inj. Diclofenac sodium 75mg intramuscular administered as back up analgesic. The total administered dose of Butorphanol and Diclofenac during the first 24 hours period were recorded. Time for the first analgesic requirement was noted. Duration of post-operative analgesia was defined as the time between last suture application and requirement for first rescue analgesic at VAS score above 4.

Patients were monitored throughout the study period for evidence of feeling of pain during surgery, cough, and acceptance of the procedure. The surgeon assesses the quality of anesthesia following numeric ranking scale (NRS) of 0-100. At the time of discharge patients were asked to mention about the satisfaction of the respective procedure (NRS) of 0-100.

RESULTS: The study was conducted over 24 month period. All the patients tolerated the procedure well under bilateral cervical plexus block, except for 3 patients who required small supplemental doses of Propofol 50mg during surgery. The mean duration of surgery was 78±22.98 minutes. The patients were comfortably maintained with sedation during the procedure with no untoward effect.

We have not observed any incidence of direct epidural/subarachnoid spread, inadvertent intravascular injection, and hemodynamic instability, persistent pain after block, CNS toxicity, phrenic nerve palsy, recurrent laryngeal nerve palsy, vagal nerve blockade and hematoma. 2 patients had Horner’s syndrome (ptosis, miosis and anhydriosis) temporarily and recovered completely after 4 hours. 3 patients required inj. Diclofenac sodium 75mg as back up analgesic. Demographic and pre-operative parameters are represented in Table1, Intraoperative characteristics in Table 2, post-operative analgesia and postoperative nausea and vomiting in Table3, incidence of complications of bilateral cervical plexus inTable 4.

Parameters
Age (years) / 41.3 ±.13.68
Weight (kg) / 51.87±5.32
Height(cm) / 154.97±4.33
BMI (kg/m2) / 21.27±0.02
ASA status (I/II/III) / I - 13/30II - 7/30III - 10/30
Preoperative Pulse (BPM) / 77.33±7.35
Preoperative MAP (mmHg) / 92±8.35
Preoperative Spo2 (%) / 99.1±.0.75
Table 1: Demographic and pre-operative parameters

Data are given as mean+SD, except ASA physical status: BPM: Beats per minute: BMI: Body mass index,MAP: Mean arterial pressure.

Parameters
Induction time (mins) / 6.20 ± 1.6
Duration of surgery (mins) / 78.72 ± 22.98
Recovery time (mins) / 7.51± 2.05
Total OT time (mins) / 94.28±19.74
Intraoperative pulse (BPM) / 77.11±7.05
Intraoperative MAP (mmHg) / 89.93±7.68
Intraoperative Spo2 (%) / 99.05±0.83
Surgeon satisfaction Score (0-100) / 78.67±8.50
Table 2: Intraoperative characteristics

Data are given as mean+ SD:BPM: Beats per minute:MAP: Mean arterial pressure

Parameters
Time to first analgesicAt VAS ≥ 4(mins) / 176.67± 52.08
Total Butorphanol (mgs) / 4.51± 0.78
Patient Diclofenac receiving / 3(10%)
VAS score in immediate Postoperative period / 1.03±0.88
VAS score at 2 hrs. / 2.13±.0.64
VAS score at 4 hrs. / 4.24±.0.58
VAS score at 6 hrs. / 3.37±1.19
VAS score at 12 hrs. / 2.97±0.49
VAS score at 24 hrs. / 2.43±0.50
VAS score at Rescue analgesic first / 4.67±0.88
Maximum VAS score in 24 hours / 4.67±0.88
PONV requiring Treatment / 5(16.6%)
Patient satisfaction Score (0-100) / 80.69±9.13
Table 3: Post-operative analgesia and PONV

Data are given as mean + SD

PONV: Postoperative nausea and vomiting: VAS: Visual analogue scale.

Parameters
Intravascular Injection/ injury / 0
Vertebral artery / 0
Phrenic nerve block / 0
CNS toxicity / 0
Cardiovascular collapse / 0
Recurrent laryngeal nerve blockade / 0
Horner’s syndrome (transient) / 2 (6.66%)
Vagal nerve block / 0
Epidural/Subarachnoid/ (Total spinal) / 0
Table 4: Incidence of complication of bilateral cervical plexus block

DISCUSSION: Regional anesthesia using9 bilateral cervical plexus has been used as an ideal alternative to general anesthesia for selected patients undergoing thyroid surgeries. Low concentration of local anesthetic drugs10, 11 1%xylocaine and12, 13 0.25%bupivacaine are used for thyroid surgery because not much muscular relaxation is needed for thyroid surgery, only sensory blockade is sufficient. Low concentration and higher volume of local an anesthetic drugs have higher success rate of block than high concentration and low volume of drugs. Low concentration and higher volume local anesthetic drugs have lesser systemic toxicity than high concentration and low volume drugs in case of accidental intravascular injection and epidural/subarachnoid spread. Benefits include prolonged post-operative pain relief14-16reduction in dosage of use opioids in post-operative period, reduction in post-operative nausea and vomiting, reduced I.C.U stay, reduced post-operative pulmonary complications and potential for early ambulation.

The means to assess post-operative pain control was the time to first analgesic request 176.67± 52.08 minutes, total amount of analgesic consumed in the first 24 hours period after surgery Butorphanol 4.51±0.78 mg, and the VAS scores at different times in the first post-operative day.

Patients had prolonged post-operative pain relief, lower consumption of Butorphanol 4.51±0.78 mg in the first 24 hours after surgery. Only 3 patients required inj. Diclofenac sodium 75mg as back up analgesic in the first 24 hours after surgery. We had higher surgeon satisfaction scores and patient’s satisfaction scores 78.67±8.50 and 80.69±9.13. There was no significant difference in forced vital capacity before surgery, 10 minutes after block and in the immediate post-operative period signifying absence of phrenic nerve palsy.

In our study patients were having thyroid swellings ranging from small thyroid adenoma to large colloid goiters. Major complications were not encountered in our study expect for incidence of Horner’s syndrome temporarily in 3 patients which recovered completely after 4 hours.To conclude in view of excellent analgesia in the early post-operative period,17-19requirement of significantly lesser amount of post-operative analgesics, decrease in the occurrence of post-operative nausea and vomiting and low rate of serious complications, along with potential for early ambulation and home discharge.20bilateral cervical plexus block can be used as a suitable alternative to general anaesthesia21-24as the anesthetic procedure in thyroid surgery. Probability of inconsistent block, high technical difficulty in performing the block by inexperienced hands and high incidence of serious major complications in inexperienced hands limits its use as conventional anesthetic technique for thyroid surgeries.

CONCLUSION: Bilateral cervical plexus block is safe and effective anesthetic technique in experienced hands for thyroid surgeries in selected group of patients where high risk factors for general anesthesia are present.

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