Stellate ganglion block (SBG) is commonly used to diagnose or treat sympathetically mediated pain syndromes. Its use in treating and preventing malignant arrhythmias has also been established in patients who are refractory to traditional therapy or ablation. Injection at C6 (Chassaignac tubercle) with large volume infiltration allows for caudal spread to the stellate ganglion at C7-T1 and ablation of sympathetic tone. Injection is not without risk as nearby vascular anatomy includes the carotid sheath, vertebral arteries, and the inferior (serpentine) thyroid artery. Anticoagulation has traditionally been thought of as a contraindication to performance of a SGB due to the risk of a retropharyngeal hematoma or potentially fatal bleed. Herein we describe the safety profile of performing SGB under anticoagulation in five patients whose cardiac and medical profiles required aggressive anticoagulation.
A total of seven blocks performed in five patients experiencing refractory arrhythmia were examined retrospectively. Patients were selected for review based on anticoagulation status and need for SBG. Anticoagulants considered include heparin, lovenox, aspirin, bivalirudin, fondaparinux, and plavix (see Table 1).
Blocks were performed on one female and four males with ages ranging from 35-74. Two patients were receiving ECMO, while two others were on intra-aortic balloon pumps. All patients received SGB at the level of C6 with 10cc of 0.25% bupivacaine under either ultrasound or landmark guidance. Efficacy was determined by presence of Horner’s Syndrome and/or conversion to sinus conduction. One block (#3) did not demonstrate Horner’s Syndrome and was repeated with success. All patients experienced improved control of their arrhythmias.
Analysis of potential complications included assessment of retropharyngeal hematoma, brachial plexus injury, intrathecal/intravascular/epidural injection, pneumothorax, or esophageal perforation. No complications were observed attributable to SGB up to the time of discharge or in subsequent follow up visits.
Results & Discussion
Selective blockade of the stellate ganglion has been traditionally contraindicated for patients not receiving anticoagulation due to the risk of retropharyngeal hematoma. This case series, while limited in size, may suggest that anticoagulation could be considered a relative contraindication rather than one of an absolute nature. Further studies will be needed to better establish the safety profile of performing SGB under such conditions.
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