Continuous stellate ganglion block for ventricular arrhythmias: case series, systematic review, and differences from thoracic epidural anaesthesia

Abstract

Aims: Percutaneous stellate ganglion block (PSGB) through single-bolus injection and thoracic epidural anaesthesia (TEA) have been proposed for the acute management of refractory ventricular arrhythmias (VAs). However, data on continuous PSGB (C-PSGB) are scant. The aim of this study is to report our dual-centre experience with C-PSGB and to perform a systematic review on C-PSGB and TEA.

Methods and results: Consecutive patients receiving C-PSGB at two centres were enrolled. The systematic literature review follows the latest Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. Our case series (26 patients, 88% male, 60 ± 16 years, all with advanced structural heart disease, left ventricular ejection fraction 23 ± 11%, 32 C-PSGBs performed, with a median duration of 3 days) shows that C-PSGB is feasible and safe and leads to complete VAs suppression in 59% and to overall clinical benefit in 94% of cases. Overall, 61 patients received 68 C-PSGBs and 22 TEA, with complete VA suppression in 63% of C-PSGBs (61% of patients). Most TEA procedures (55%) were performed on intubated patients, as opposed to 28% of C-PSGBs (P = 0.02); 63% of cases were on full anticoagulation at C-PSGB, none at TEA (P < 0.001). Ropivacaine and lidocaine were the most used drugs for C-PSGB, and the available data support a starting dose of 12 and 100 mg/h, respectively. No major complications occurred, yet TEA discontinuation rate due to side effects was higher than C-PSGB (18 vs. 1%, P = 0.01).

Conclusion: Continuous PSGB seems feasible, safe, and effective for the acute management of refractory VAs. The antiarrhythmic effect may be accomplished with less concerns for concomitant anticoagulation compared with TEA and with a lower side-effect related discontinuation rate.

Keywords: Cardiac arrest; Electrical storm; Neuromodulation; Refractory ventricular arrhythmias; Stellate ganglion block; Thoracic epidural anaesthesia.

Graphical Abstract

Figure 1

Ultrasound-guided continuous percutaneous left stellate ganglion block at C6 level. at, anterior tubercle; ca, carotid artery; LA, local anaesthetic; Lcol, longus colli muscle; pt, posterior tubercle; scm, sternocleidomastoid muscle; th, thyroid; white arrows, needle’s position; yellow arrow, target region.

Figure 2

Impact of C-PSGB on VA burden in each procedure (n = 31, the only procedure performed due to several episodes of fast non-sustained VT was not included). (A) Twelve hours before vs. after C-PSGB. (B) Twelve hours before vs. the entire duration of the CI (VAs occurring in the first 12 h after C-PSGB and beyond 12 h are depicted in different colours). There was only one case with more VAs in the 12 h after compared with before C-PSGB (two after compared with one before) that both occurred during underdosed ropivacaine infusion (4 mg/h) and disappeared after increasing the infusion rate from 4 to 12 mg/h. C-PSGB, percutaneous stellate ganglion block; CI, continuous infusion; VAs, ventricular arrhythmia; VT, ventricular tachycardia.

Figure 3

Our current approach to acute neuromodulation for refractory VAs. AADs, antiarrhythmic drugs; ACLS, acute cardiac life support; C-PLSGB, continuous percutaneous left stellate ganglion block; LVAD, left ventricular assistance device; TEA, thoracic epidural anaesthesia; US, ultrasound; VA, ventricular arrhythmias; VF, ventricular fibrillation; VT, ventricular tachycardia.