P017: BILATERAL SUPERFICIAL CERVICAL PLEXUS BLOCKS: A CASE REPORT OF INDICATIONS AND COMPLICATIONS
Devin Shenkman, DO1; Arina G Ghosh2; 1Jackson Memorial; 2Miami VA Hospital
Introduction/Background: A bilateral superficial cervical plexus block is a regional anesthetic technique that has been used to provide analgesia for patients undergoing a tracheostomy, thyroidectomy, and other select head & neck surgeries. However, anesthesiologists should be aware of the possible risks associated with the regional anesthetic technique. Anesthesiologists should avoid performing a bilateral superficial cervical plexus block in an awake patient without ultrasound guidance, due to the risk of bilateral phrenic nerve blockade and subsequent respiratory arrest.
Methods/Results: This is a case report of a 71 yo male who underwent bilateral superficial cervical plexus blocks for an awake tracheostomy, and experienced preventable complications related to the regional anesthesia technique.
Results: A 71 y/o male with history of alcohol use disorder, history of smoking, GERD, COPD, and SCC of the oropharynx presented emergently to the operating room with a stridor for an urgent awake tracheostomy. A bilateral superficial cervical plexus block was placed by OR anesthesia using landmark technique. A total of 20ml of 4% lidocaine (800mg) was infiltrated. After the regional nerve block, the patient was noted to have diaphragmatic paralysis and EtCo2 0. Subsequently, a generalized seizure was witnessed followed by progressive AV nodal heart block. Intralipid 20% emulsion IV infusion and CPR was started by the OR anesthesia team. A repeat seizure episode was witnessed and treated with 2mg IV versed. Intralipid 20% emulsion 100ml IV push was given, and ROSC was within 2 minutes of intralipid bolus. Postoperatively, the patient was transported to the SICU on norepinephrine 16mcg/min for hemodynamic support and intralipid emulsion at 0.25ml//kg/min and ventilated via tracheostomy. He was transferred out of the unit in a stable condition the next day.
Discussion/Conclusion: A superficial cervical plexus block is a regional technique that offers analgesia of the anterior lateral neck by blocking terminal branches of the superficial cervical plexus as they emerge from the posterior border of the sternocleidomastoid. These nerves include the lesser occipital nerve, greater auricular nerve, transverse cervical nerve, and supraclavicular nerve. Indications for a superficial cervical plexus block include head and neck procedures such as thyroidectomy, carotid endarterectomy, lymph node dissection & tracheostomy. A superficial cervical plexus block is favored over a deep cervical plexus block due to the lower risk of complications. However, the superficial cervical plexus block is not without risks, and may lead to infection, nerve injury, hematoma formation, local anesthetic toxicity, phrenic nerve blockade, and subarachnoid or epidural anesthesia. Numerous studies have shown the analgesic efficacy of bilateral superficial cervical plexus blocks. However successful blocks were performed on patients under general anesthesia or with ultrasound guidance. In this case report, authors review the indications, block technique, and possible complications of superficial cervical plexus blocks and discuss the role of bilateral superficial cervical plexus blocks in anesthesia. The authors also review the signs, symptoms, and management of local anesthetic systemic toxicity.