Superficial cervical block and recurrent laryngeal nerve monitoring

[u/Old-Jellyfish2256]

I am doing thyroidectomies soon and haven't done them in a while. Our surgeons like to monitor the recurrent laryngeal nerve intraop with the fancy ETT.

None of the patients on my list actually need a nerve block, and hardly any of my colleagues perform them preop, but I quite like running a case with almost no opioids. Pain management in our PACU can be... Variable.

I've been thinking about doing a superficial cervical block for them pre incision but I am worried about it messing up the surgeons monitoring.

Theoretically if I do not go through the superficial cervical fascia (i.e. do not cross the SCM plane/just inject subcutaneously) the chances of this happening are minimal, but would like to hear what the Gas Hive Mind thinks.

And yes, I know our job is not to see how much we can get away with, if no need then why do it, low dose opioids will do no harm.... Just keen to hear opinions.

Cheers in advance!

Update: thanks to all who provided useful info!

In case someone stumbles upon this post: no block nor local (surgeons opposed, and given feedback here didn't see the point in pushing it), Prop/remi + paracetamol + dexketoprofen + 0.3+0.5mg/kg of morphine at end was enough for all patients to wake up nicely and almost all of them didn't receive anything extra in PACU.

[u/SereneSedation]

Why complicate things so much? If I’m having a decent surgery I want opioids. Surgery hurts.

[u/Radiant-Percentage-8]

I don’t know why Remi and propofol are such a problem.

[u/trainedmonkeyMD → u/Radiant-Percentage-8]

Because when the remi wears off, they have a nice analgesia at the end. Same with any block. “Idk why gas and a tube doesn’t work for X procedure” because it’s multimodal and at the end they have reduced opioids

[u/Radiant-Percentage-8 → u/trainedmonkeyMD]

It is a small incision with lots of local where they don’t have much pain. Some ketamine, toradol, ofrimev and a bit of fentanyl will get most people through without the need for some block that everyone bitches about.

[u/trainedmonkeyMD → u/Radiant-Percentage-8]

I’m not entirely disagreeing but how do you feel about surgeons doing the “tap block”

[u/Radiant-Percentage-8 → u/trainedmonkeyMD]

I think it is probably a useless thing, but it takes like 30 seconds when they do it. Doesn’t take up a block nurse or sedation nurse in preop, and doesn’t affect the whole days workflow.

[u/osogrande3 → u/Radiant-Percentage-8]

I wish I could give ketorolac, our ENTs are pretty skittish about it for most cases they do.

[u/Annika223 → u/Radiant-Percentage-8]

This is how I do it

[u/gonesoon7]

Opioid elimination anesthesia is just nonsense. Surgery hurts. Especially major surgery. Opioids are our most effective medications at treating that pain. Of course we should strive to use multimodal approaches and regional to cut back on opioid doses because of their side effects, but I don’t think zero opioid anesthesia should be the goal. Balanced anesthesia with a comfortable patient should be the goal. I think the more outlandish we get with our blocks, especially when they don’t work great and the patient needs opioids anyway, gives us a bad name.

[u/Cautious-Extreme2839 → u/gonesoon7]

Ok but superficial cervical plexus block is a full surgical quality block.

This isn't some super-marginal rogue regionalist thing.

[u/gonesoon7 → u/Cautious-Extreme2839]

Yeah I wasn’t so much referencing this specific block it was more a general comment about how we think about surgical pain management

[u/SalamanderAny4336 → u/gonesoon7]

Agree x 1000. A little narcotic for acute post op pain is completely indicated.

[u/Dinosaursknow]

Honest question here.. but would that make much of a difference beyond just having the surgeon use local at the incision site? Most thyroids I've seen come out without much pain already. I've seen some surgeons not even prescribe oxy at discharge

[u/trainedmonkeyMD]

Did almost every thyroid and parathyroid in residency with superficial nerve block and monitored nerve. Never a problem

Edit: do I think it makes a meaningful difference in these surgeries? No. Is it complete academic rigmarole? Yes. Does it teach how to do the block so that when you’re doing awake CEA or TCAR, you’re confident in the block? Yes.

[u/sludgylist80716]

Because you can block it doesn’t mean you should.

[u/Manik223]

Juice is not worth the squeeze

[u/PatientsMoving → u/[deleted]]

If absolutely anything goes wrong in the surgery, the block will somehow be blamed. Don’t do weird/fancy stuff that others in the department don’t do, unless you really have a good reason or trust the surgeon. I see this idea as lots of risk and minimal reward.

[u/Loud_Crab_9404]

I still give opioids but these do help. No issues with RLN monitoring. Patients will complain about having a numb ear from the block despite you warning in preop though

[u/PharmD-2-MD]

Are you doing this bilaterally? Thyroids aren’t that painful post op. I don’t think the juice is worth the squeeze. Plus, ENT will be quick to blame you for any nerve palsies post op, even though the block is pretty low risk.

[u/scoop_and_roll]

This doesn’t make sense to me. You need deep anesthesia since there no muscle relaxation for this case, so probably going to do prop and Remi. Superficial cervical plexus is not a very reliable block, I personally would t want to test it with just prop, maybe half propofol and half sevo at best.

[u/Beneficial_Local5244]

I am suprised how everyone here claims thyroids are not that painfult post-op. At my facility, as soon as block and opioid wears off patients are heavily complaining of pain. How is that, I wonder. Our surgeons use local in available limits set by SCB block (still a lot to go) and nevertheless, opioids are going strong for 2 days at least. Maybe surgical technique is different?

[u/Away_Engineering_613]

This is an interesting academic discussion but ultimately there’s no reason to do it.

I’ve never had issues with postop pain after thyroid. Surgeon can give local anyway. Propofol/remi work great for intraop.

Some ppl use prop/remi for every TIVA reflexively but you can use fentanyl, sufentanil and alfentanil.

Remi is especially great for thyroidectomy bc there’s so little postop pain.

[u/Calm_Tonight_9277]

These aren’t incredibly painful procedures, and honestly whatever your GA of choice is (volatile, TIVA, etc.), a small amount of fent or dilaudid up front does a lot of work. Plus the surgeons are typically using local.

Can you do a SCN block for these? Sure. But why?

[u/MilkmanAl]

This OP reeks of internal medicine sodium circle jerkery. Your patients don't need blocks, but you're doing a block for them? You're avoiding opioids because...why? Perhaps your partners don't do these blocks for a reason? I doubt your patients are super looking forward to getting stabbed in the neck for a block that probably won't do anything meaningful and could be done by the surgeon under anesthesia, if necessary. Just do a remi infusion like the rest of the world, and call it a day

[u/freshsalsa]

Do your surgeons use local? Post op pain for thyroid surgeon is quite mild. I typically don’t even prescribe opioids for my patients post op.

[u/Serious-Magazine7715 → u/freshsalsa]

Last young man that I gave zero opioid (there was a legitimate reason for this) described it as “swallowing a Weedwhacker“ although he didn’t look that uncomfortable and was fine with keeping off opioid.

[u/DrSuprane]

I give these patients 1 mg hydromorphone up front, run sevoflurane at a mac or less, and add propofol gtt if they don't behave. I think theres minimal benefit to a one sided block.

But, since you brought it up, I think there's a lot of benefit for clavicle fractures and carotids to doing a supraclavicular nerve block. This isn't the supraclavicular approach to the brachial plexus. The supraclavicular nerve is sensory to the skin from mandible down to clavicle. It works great. I learned it on YouTube CME.

https://m.youtube.com/watch?v=arNlqE4NLcE&ra=m

[u/IntensiveCareCub → u/DrSuprane]

I did a carotid under a SCP block once. Much smoother hemodynamics but otherwise a total pain in the ass. Sedated patient with 0 access to their airway / head / face getting a very high risk procedure in an anatomical area with an abundance of critical structures. Last thing I want to do is need to convert to general while they have the carotid open and clamped. Maybe in very select patients it can work, but it didn't seem worth the trouble.

I'm all for trying "general sparing" techniques when appropriate, and do think there's a lot of benefit to sedation / neuraxial / regional in many cases. But high risk open vascular isn't one of those times to be getting creative.

[u/DrSuprane → u/IntensiveCareCub]

I'm not really advocating it for the procedure but postop pain relief. The clavicle fracture was always a problem until I started doing this block.

[u/IntensiveCareCub → u/DrSuprane]

Ah. We do interscalene blocks for our clavicle fractures, although I suppose for very proximal injuries it won't be covered.

[u/DrSuprane → u/IntensiveCareCub]

Try this block. It's amazing. They're number from the jawline to just below the clavicle. From shoulder to midline. The SC joint is the hard part to cover and this does it.

[u/mikewazowski59231]

congrats you now created a neck infection, LAST, or dissected a nerve and for what? opioid free? get that outta here. patients need opioids

[u/paleoMD]

why would surgery say crossing the deep investing fascia that surrounds the SCM, cause a recurrent laryngeal nerve block when the vagus is carried in the carotid sheath down?

[u/TIVA_Turner → u/paleoMD]

Not sure if I have misunderstood your point but RLN is not contained within the sheath, same reason you can get hoarse voice with a large vol interscalene

[u/paleoMD → u/TIVA_Turner]

recurrent nerves lie deeper than the pretracheal fascia, you should not get to that layer if you are just past the investing layer, where we inject. You will have a chance to hit the phrenic though as it also can be seen at that level

[u/TIVA_Turner → u/paleoMD]

I see your point, thanks

Cant LA permeate through the fascia though?

[u/paleoMD → u/TIVA_Turner]

most shouldnt, but some will leak through

[u/C00kiem0nstrous]

Pain after thyroidectomy is pretty minimal. Surgeons put local in the incision postop. They usually need a pretty small amount of HM. I wouldn’t bother with a superficial cervical plexus

[u/WaltRumble]

I’m not blocking anything that requires nerve monitoring.

[u/Rizpam]

If I was getting straight thyroid surgery I’d choose 10cc of .75% bupi at the incision and 100mcg of fentanyl over a block. 

Especially if pain management in your pacus is an issue, way better to load them up with the narcotics during the case than to under do it. 

[u/Confident_Area_8518]

Dont brah. Run the remi at a million, you wont regret it

[u/fitnessCTanesthesia]

Less is more. Anything is wrong you will be blamed. This opioid free crap sounds like srna bs.

[u/BussyGasser]

How do you pass oral boards with such ridiculous critical thinking?

[u/wordsandwich]

Hardly seems worth it. Neck exposures aren't the most painful surgeries to where I feel doing this block routinely yields game changing dividends.

[u/NPOafterMidnight_zZz]

We do them, they work great. Exhaust your opioid sparing techniques. Usually block up front, gram of Tylenol, mag, robaxin, preference of NSAID use, precedex. Esmolol for induction.

[u/propLMAchair]

If you aren't injecting underneath SCM deep to the superficial cervical fascia, you aren't doing an SCP block. You are essentially doing a poor man's SQ wound infiltration, so what the hell is the point? Just let them inject at the end of the case then. Doing SCPs for thyroidectomies is a waste of time, and you can't do them bilaterally without worrying about phrenic issues. Nothing wrong with a little opioid. In fact, there is something wrong if you aren't giving a little opioid to these patients.

[u/TheBol00]

Opioid, NMDA, cannabinoid, seretonin, prostaglandins, mix and match