- Email: [email protected]
Stellate Ganglion Block: Important Weapon in the Anesthesiologists’ Armamentarium
Journal of Cardiothoracic and Vascular Anesthesia ] (]]]]) ]]]–]]]
HOSTED BY
Contents lists available at ScienceDirect
journal homepage: www.jcvaonline.com
Letter to the Editor Stellate Ganglion Block: Important Weapon in the Anesthesiologists’ Armamentarium To the Editor: We read, with great interest, the article, “Near-Death Episode in a Young Adult.”1 Recurrent ventricular tachycardia or fibrillation exacerbates myocardial injury and left ventricular systolic dysfunction.2 Identifying and treating the causative factors are essential for the management of such lethal arrhythmias. As described by the authors, avoiding precipitating factors like electrolyte imbalance, arrhythmogenic drugs, maintaining hemodynamics, instituting proper antiarrhythmic drugs, and implantable cardioverter-defibrillator (ICD) placement are important in the management. The authors mentioned ventricular noncompaction as the likely cause for refractory arrhythmia even after the correction of an anomalous origin of the right coronary artery. Raised sympathetic activity during stress is an important predisposing factor to provoke arrhythmias in patients with left ventricular non-compaction. In such situations, left stellate ganglion block (LSGB) can be effective in suppressing arrhythmias after the above treatment options are used. Cardiac sympathetic blockade using LSGB has been reported to reduce sympathetic surge and can be an adjunct to the antiarrhythmic therapy in treating such fatal ventricular arrhythmias.3 LSGB decreases the risk of arrhythmias in patients with myocardial infarction and prolonged QT-interval syndrome.4 Abolition of electrical storm by a stellate ganglion block can be used as a simple bedside therapeutic test to decide whether the patient would respond to sympathetic denervation. Left cervical sympathectomy raises the threshold for ventricular fibrillation by interrupting release of norepinephrine in the heart. ICD, however, is used for the management of the ventricular arrhythmia, but it can paradoxically aggravate sympathetic stimulation by repeated shocks and can potentially result in a series of shocks with electrical storm. Sympathetic denervation can complement ICD in such
situations. Ultrasound improves the safety of the procedure by visualization of real-time needle entry into the subfascial plane, and thereby it ensures the caudal spread of the local anesthetic drugs. Hence, complications like intravascular, intrathecal, epidural spread or recurrent laryngeal nerve palsy may be minimized. Small injectate volume can provide effective sympathetic block.5 In a study of ultrasound imaging for stellate ganglion block, all the patients in the ultrasoundguided group had more rapid onset of the block, and the control group experienced significant incidences of hematoma.6 Stellate ganglion block is an important tool in the anesthesiologists’ armamentarium in the management of a patient with refractory ventricular arrhythmias. References 1 Maddali MM, Al-Abri IA, Waje ND, et al. Near-death episode in a young adult. J Cardiothorac Vasc Anesth 2016. [In press]. 2 Joglar JA, Kessler DJ, Welch PJ, et al. Effects of repeated electrical defibrillations on cardiac troponin I levels. Am J Cardiol 1999;83: 270–2. A6. 3 Nademanee K, Taylor R, Bailey WE, et al. Treating electrical storm: Sympathetic blockade versus advanced cardiac life support-guided therapy. Circulation 2000;102:742–7. 4 Gadhinglajkar S, Sreedhar R, Unnikrishnan M, et al. Electrical storm: Role of stellate ganglion blockade and anesthetic implications of left cardiac sympathetic denervation. Indian J Anaesth 2013;57:397–400. 5 Ghai A, Kaushik T, Kundu ZS, et al. Evaluation of new approach to ultrasound guided stellate ganglion block. Saudi J Anaesth 2016;10:161–7. 6 Kapral S, Krafft P, Gosch M, et al. Ultrasound imaging for stellate ganglion block: Direct visualization of puncture site and local anesthetic spread. A pilot study. Reg Anesth 1995;20:323–8.
Monish S. Raut, MD, FNB Arun Maheshwari, MD Department of Cardiac Anesthesiology Sir Ganga Ram Hospital New Delhi, India http://dx.doi.org/10.1053/j.jvca.2017.03.005
HOSTED BY
Contents lists available at ScienceDirect
journal homepage: www.jcvaonline.com
Letter to the Editor Stellate Ganglion Block: Important Weapon in the Anesthesiologists’ Armamentarium To the Editor: We read, with great interest, the article, “Near-Death Episode in a Young Adult.”1 Recurrent ventricular tachycardia or fibrillation exacerbates myocardial injury and left ventricular systolic dysfunction.2 Identifying and treating the causative factors are essential for the management of such lethal arrhythmias. As described by the authors, avoiding precipitating factors like electrolyte imbalance, arrhythmogenic drugs, maintaining hemodynamics, instituting proper antiarrhythmic drugs, and implantable cardioverter-defibrillator (ICD) placement are important in the management. The authors mentioned ventricular noncompaction as the likely cause for refractory arrhythmia even after the correction of an anomalous origin of the right coronary artery. Raised sympathetic activity during stress is an important predisposing factor to provoke arrhythmias in patients with left ventricular non-compaction. In such situations, left stellate ganglion block (LSGB) can be effective in suppressing arrhythmias after the above treatment options are used. Cardiac sympathetic blockade using LSGB has been reported to reduce sympathetic surge and can be an adjunct to the antiarrhythmic therapy in treating such fatal ventricular arrhythmias.3 LSGB decreases the risk of arrhythmias in patients with myocardial infarction and prolonged QT-interval syndrome.4 Abolition of electrical storm by a stellate ganglion block can be used as a simple bedside therapeutic test to decide whether the patient would respond to sympathetic denervation. Left cervical sympathectomy raises the threshold for ventricular fibrillation by interrupting release of norepinephrine in the heart. ICD, however, is used for the management of the ventricular arrhythmia, but it can paradoxically aggravate sympathetic stimulation by repeated shocks and can potentially result in a series of shocks with electrical storm. Sympathetic denervation can complement ICD in such
situations. Ultrasound improves the safety of the procedure by visualization of real-time needle entry into the subfascial plane, and thereby it ensures the caudal spread of the local anesthetic drugs. Hence, complications like intravascular, intrathecal, epidural spread or recurrent laryngeal nerve palsy may be minimized. Small injectate volume can provide effective sympathetic block.5 In a study of ultrasound imaging for stellate ganglion block, all the patients in the ultrasoundguided group had more rapid onset of the block, and the control group experienced significant incidences of hematoma.6 Stellate ganglion block is an important tool in the anesthesiologists’ armamentarium in the management of a patient with refractory ventricular arrhythmias. References 1 Maddali MM, Al-Abri IA, Waje ND, et al. Near-death episode in a young adult. J Cardiothorac Vasc Anesth 2016. [In press]. 2 Joglar JA, Kessler DJ, Welch PJ, et al. Effects of repeated electrical defibrillations on cardiac troponin I levels. Am J Cardiol 1999;83: 270–2. A6. 3 Nademanee K, Taylor R, Bailey WE, et al. Treating electrical storm: Sympathetic blockade versus advanced cardiac life support-guided therapy. Circulation 2000;102:742–7. 4 Gadhinglajkar S, Sreedhar R, Unnikrishnan M, et al. Electrical storm: Role of stellate ganglion blockade and anesthetic implications of left cardiac sympathetic denervation. Indian J Anaesth 2013;57:397–400. 5 Ghai A, Kaushik T, Kundu ZS, et al. Evaluation of new approach to ultrasound guided stellate ganglion block. Saudi J Anaesth 2016;10:161–7. 6 Kapral S, Krafft P, Gosch M, et al. Ultrasound imaging for stellate ganglion block: Direct visualization of puncture site and local anesthetic spread. A pilot study. Reg Anesth 1995;20:323–8.
Monish S. Raut, MD, FNB Arun Maheshwari, MD Department of Cardiac Anesthesiology Sir Ganga Ram Hospital New Delhi, India http://dx.doi.org/10.1053/j.jvca.2017.03.005