Regional Anesthesia for Carotid Provokes Praise But Also Doubt About Its Superiority as Technique
To the Editor: I found Dr. Zvara’s article in the Fall 1999 APSF Newsletter advocating regional anesthesia for carotid surgery to be of great interest. My own experience with cervical plexus blocks for carotid surgery was stimulated by a vascular surgeon who had trained with regional techniques for carotid surgery leading me to research the topic and learn the technique.
When we first started using regional anesthesia with patients awake for carotid surgery in our OR, intra-operative EEG monitoring was felt to be a “community standard” and so a number of patients were initially done awake with EEG monitoring. One of our early experiences involved a patient sustaining severe bradycardia and brief asystole upon manipulation of the carotid body leading to loss of cerebral profusion. The patient became unconscious literally in midsentence. Atropine and ephedrine were administered, pulse and blood pressure promptly returned and the patient resumed the conversation totally unaware that anything had transpired. Only after the whole episode was complete and we were again conversing with the patient did the EEG show any change at all. After a repeat of similar occurrence shortly thereafter, we adopted having an awake patient conversing with the anesthesiologist as the gold standard in neurological monitoring, and I have been sold on the value of the technique since. The only caveat is that success depends upon a committed, skilled and well-prepared anesthesiologist, and an adept, gentle, and invested surgeon, and a suitable patient.
That said, I have great difficulty with concluding that regional anesthesia is the technique of choice for carotid surgery in absence of better, more methodologically consistent, and powerful data to support that conclusion. Dr. Zvara is correct to observe that there is tremendous variation in techniques and outcomes. The statement that many teams have excellent outcomes with general anesthesia is an important one, and in the absence of further data, suggest caution – in touting the superiority of one technique over another. Regional anesthesia is indeed an important option in our armamentarium, and should be considered for carotid procedures, but it is not yet proven to be a superior technique with regard to patient outcome.
R. Screven Farmer, M.D. Tucson, AZ