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Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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Table of Contents
INVITED COMMENTARY  
Year : 2013  |  Volume : 16  |  Issue : 4  |  Page : 242-244
Stellate ganglion block in cardiac surgery


Department of Anesthesia, Saket City Hospital, Saket, New Delhi, India

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Date of Web Publication1-Oct-2013
 

How to cite this article:
Kapoor MC, Khanna G. Stellate ganglion block in cardiac surgery. Ann Card Anaesth 2013;16:242-4

How to cite this URL:
Kapoor MC, Khanna G. Stellate ganglion block in cardiac surgery. Ann Card Anaesth [serial online] 2013 [cited 2020 Aug 5];16:242-4. Available from: http://www.annals.in/text.asp?2013/16/4/242/119162


Stellate ganglion is formed by the fusion of inferior cervical and first thoracic sympathetic ganglia and is located behind the subclavian artery and anterior to the first rib. Stellate ganglia block (SGB) results in a near complete sympathetic denervation of the head and neck. [1] The inferior cervical cardiac nerves arise from the medial aspect of the stellate ganglia and provide the cardio-accelerator nerve fibers to the cardiac plexus.

Stellate ganglion stimulation augments peak systolic pressure and enhances the rate of the rise of left ventricular pressure. This phenomenon is more marked with the left stellate ganglion stimulation, but has also been demonstrated after the right stellate ganglion manipulation. [2] The enhanced myocardial contractility is secondary to stimulation by postganglionic nerve fibers, which traverse from stellate ganglion down the great vessels and along the coronary arteries into the myocardium. [2] Investigators have shown the effects of stellate ganglion manipulation on cardiac rhythm, regional myocardial blood flow, ventricular fibrillation threshold and stress-testing electrocardiogram changes. [3],[4],[5],[6]

Manipulation of the coronary arteries during cardiac surgery can stimulate the adjacent post-ganglionic sympathetic fibers and mimic stellate ganglion stimulation. SGB can interrupt this reflex by decreasing the efferent cervical sympathetic outflows. [7] The blockage of inferior cervical cardiac nerves is responsible for the bradycardia seen following SGB. [8] SGB has been shown to prevent and control perioperative hypertension induced by increased sympathetic activity. [7],[9],[10] The current indications for SGB include complex regional pain syndrome type 1 and 2 of upper extremities, vaso-occlusive disorders, post-herpetic neuralgia and phantom limb pain. More recently, SGB has been used to alleviate refractory angina pain, which is unresponsive to medical treatment and revascularization. [11]

Successful SGB is characterized by the appearance of Horner's syndrome, which includes appearance of miosis, ptosis, enophthalmos along with conjunctival injection, nasal congestion and facial anhidrosis. Elevation of the temperature by 1-3° is typically indicative of sympathetic blockade. SGB is associated with serious complications because of its proximity to vascular structures, dura and spinal cord. The incidence of these complications is 1.7/1000 blocks performed. [12] Accidental direct intravascular injection into the vertebral artery or the carotid artery, during a SGB provides a common mechanism for unanticipated toxic effects of local anesthetics (LA). When a bolus dose of LA enters the circulation, peak concentrations are higher and occur earlier than if the same dose were to undergo normal systemic absorption resulting in central nervous system toxicity leading to loss of consciousness and convulsions. Subarachnoid injection is a life-threatening complication of SGB, if the LA is injected into the subarachnoid space, it can lead to total spinal resulting in sudden cardiovascular collapse. LA application for SGB may cause dissemination of the drug into adjacent tissues. The LA might infiltrate the carotid sheath and cause partial block of the vagus nerve. [13] Further cephalic spread may block the baroreflex-sensitive carotid sinus (at the bifurcation of the carotid artery) and glossopharyngeal nerve. [14] Other potentially serious complications include vertebral artery puncture, recurrent laryngeal or phrenic nerve block and pneumothorax. [15] Its use is not recommended in daily practice because of discomfort of Horner's syndrome and the above risks associated with it, some of which are but rare life-threatening. [14]

In cardiac surgery, SGB has been reported to prevent radial artery spasm. [16] The explanation offered in this case report on better graft flows following SGB are questionable as it is not understood how a denervated radial graft can benefit from SGB?

In this issue of the journal, Gopal et al., present a clinical study to investigate the effects of left SGB on left internal mammary artery (LIMA) diameter in patients for coronary artery bypass graft surgery. [17] The authors administered SGB block after angiographic estimation of the LIMA diameter by quantitative coronary analysis (QCA). The LIMA diameter was re-estimated by QCA, 20 min after the administration of SGB and found to be significantly more thereby implying enhancement of vessel flow. The change in LIMA diameter has been attributed to cervical sympathetic blockade. [17] The clinical significance of this study however remains under a shadow. The LIMA is denervated when dissected off its vascular bed for grafting and SGB sympathetic blockade will have no effect on it. There are also safety issues in the conduct of SGB to prevent LIMA spasm as it is associated with serious adverse effects and has a low safety margin.

 
   References Top

1.Hogan QH, Erickson SJ. MR imaging of the stellate ganglion: Normal appearance. AJR Am J Roentgenol 1992;158:655-9.  Back to cited text no. 1
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2.Beme RM, Levy MN. Cardiovascular Physiology. 3 rd ed. St. Louis: Mosby; 1977.  Back to cited text no. 2
    
3.Schwartz PJ. The rationale and the role of left stellectomy for the prevention of malignant arrhythmias. Ann N Y Acad Sci 1984;427:199-221.  Back to cited text no. 3
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4.Forrest JB. An unusual complication after stellate ganglion block by the paratracheal approach: A case report. Can Anaesth Soc J 1976;23:435-9.  Back to cited text no. 4
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5.Ruffy R, Lovelace DE, Knoebel SB, Elharrar V, Zipes DP. Relationship between left ventricular electrograms and regional blood flow in acute myocardial ischemia with and without stellate stimulation. Circulation 1977;56 Suppl III):III-137(abst).  Back to cited text no. 5
    
6.Verrier RL, Dickerson LW. Autonomic nervous system and coronary blood flow changes related to emotional activation and sleep. Circulation 1991;83:II81-9.  Back to cited text no. 6
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7.Fee HJ, Viljoen JF, Cukingnan RA, Canas MS. Right stellate ganglion block for treatment of hypertension after cardiopulmonary bypass. Ann Thorac Surg 1979;27:519-22.  Back to cited text no. 7
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8.Moore R, Groves D, Hammond C, Leach A, Chester MR. Temporary sympathectomy in the treatment of chronic refractory angina. J Pain Symptom Manage 2005;30:183-91.  Back to cited text no. 8
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9.Tarazi RC, Estafanous FG, Fouad FM. Unilateral stellate block in the treatment of hypertension after coronary bypass surgery. Implications of a new therapeutic approach. Am J Cardiol 1978;42:1013-8.  Back to cited text no. 9
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10.Bidwai AV, Rogers CR, Pearce M, Stanley TH. Preoperative stellate-ganglion blockade to prevent hypertension following coronary-artery operations. Anesthesiology 1979;51:345-7.  Back to cited text no. 10
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11.Mahli A, Coskun D, Akcali DT. Aetiology of convulsions due to stellate ganglion block: A review and report of two cases. Eur J Anaesthesiol 2002;19:376-80.  Back to cited text no. 11
[PUBMED]    
12.Vadodaria B, Bridgens J, Richmond M. Pyogenic cervical epidural abscess and discitis following stellate ganglion block. Anaesthesia 2001;56:871-8.  Back to cited text no. 12
    
13.Moore DC. Regional Block. 4 th ed. Springfield, Illinois: Charles C. Thomas; 1979.  Back to cited text no. 13
    
14.Kimura T, Nishiwaki K, Yokota S, Komatsu T, Shimada Y. Severe hypertension after stellate ganglion block. Br J Anaesth 2005;94:840-2.  Back to cited text no. 14
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15.Hong JY. The effects of stellate ganglion block on intraoperative hemodynamics and postoperative side effects in laparoscopic day-case surgery. Ambul Surg 2007;13:77-9.  Back to cited text no. 15
    
16.Yildirim V, Akay HT, Bingol H, Bolcal C, Iyem H, Doðanci S, et al . Pre-emptive stellate ganglion block increases the patency of radial artery grafts in coronary artery bypass surgery. Acta Anaesthesiol Scand 2007;51:434-40.  Back to cited text no. 16
    
17.Gopal D, Singh NG, Jagadeesh AM, Ture A, Thimmarayappa A. Comparison of left internal mammary artery diameter before and after left stellate ganglion block. Ann Card Anaesth 2013;16:238-42.  Back to cited text no. 17
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Correspondence Address:
Mukul Chandra Kapoor
Department of Anesthesia, Saket City Hospital, Press Enclave Road, Saket, New Delhi- 110 017
India
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