Stellate Ganglion Block Clinical Trial
Official title:
Effect of Stellate Ganglion Block on Blood Flow in the Cannulated Radial Artery in Septic Shock Patients on Vasopressors, A Feasibility Study
To evaluate the value of US-guided Stellate ganglion block for improving radial arterial blood flow and peripheral perfusion in Septic shock patients on vasopressor support with an indwelling radial arterial cannula, which can result in reduced incidence premature failure of the catheter (due to vasospasm or thrombosis) and incidence of ischemic complications in the cannulated arm.
Radial artery cannulation is a well-established procedure in the ICU, especially in
critically ill hemodynamically unstable patients. The first description of arterial
cannulation in humans dates back to 1856, when the blood pressure was measured int the
femoral artery. It can be used for continuous blood pressure monitoring, obtaining
func¬tional hemodynamic parameters derived from the arterial waveform, to predict the
physiologic response to fluid resuscitation and also for blood sampling.
The most common complications for the procedure are temporary radial artery occlusion
(19.7%), in addition to hematoma (14.4%), infection at the arterial site (0.72%), hemorrhage
(0.53%) or bacteremia (0.13%), pseudoaneurysm (0.09%) and finally ischemic damage (0.09%).
Larger catheter diameter, presence of vasospasm, female sex (probably related to smaller
vessel diameter) increase the risk of ischemic complications. Inadequate experience (high
number of attempts, multiple arterial sticks and hematoma formation) can also increase the
complication rate.
In a recent study by Numaguchi et al, they found that radial artery cannulation decreases
the distal arterial blood flow measured by power Doppler ultrasound. In another study by Kim
et al, they found that after radial artery cannulation ulnar artery diameters were
significantly increased (compensatory) and radial artery diameters were decreased after
cannulation compared with pre-cannulation values, then returned to pre-cannulation values 5
min after cannulation. They detected radial artery vasospasm in 12 patients with 20-G
cannulas used (31.5%) and in 2 patients with 22-G cannulas used (5.3%) (p < 0.05), which was
observed immediately after cannulation, and had mostly disappeared after 5 min. There was no
data regarding the follow up of the patients afterwards. In both studies the subjects were
not critically ill patients (and not on vasopressors).
Peripheral limb ischemia in ICU patients can be the result of iatrogenic injury, thrombotic
complications or hypoperfusion related to the underlying disease state. The patients at
greatest risk for acute ischemia are those with underlying peripheral artery disease (PAD),
but limb ischemia can also be the consequence of embolism, injury, dissection, or severe
vasoconstriction, even in the absence of preexisting occlusive disease. Repeated arterial
punctures may result in extensive hematoma formation and arterial spasm, The thick muscular
coat and abundance of alpha adrenoreceptors make it prone to develop spasm when traumatized.
Attempts to control bleeding following cannulation through local hemostasis only complicate
matters. While, normally, the likelihood of serious ischemia is minimized by the presence of
the palmar arterial arch.
The use of vasopressors especially nor-epinephrine with its potent α1-adrenergic receptor
agonist activity can aggravate the condition more. We didn't find in the literature any
reliable data regarding the effect of using vasopressors (particularly nor-epinephrine) in
any dosage on the incidence of peripheral arterial vasospasm or ischemic complications
following arterial cannulation. But there were mixed case reports linking both or one of
them: high dose vasopressors and arterial cannulation, to ischemic complications. Such as
developing peripheral gangrene after starting high dose vasopressors, or developing complex
regional pain syndrome (CRPS) following radial artery cannulation.
It is believed that blocking the Stellate ganglion with Local anesthetics can interfere with
the sympathetic out flow to the upper limb resulting in abolishing its vasoconstrictor
action on the arteries thus decreasing arterial spasm and promoting better blood flow in the
peripheral circulation.
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