The effect of a bilateral stellate ganglion block guided by ultrasound on postoperative cognitive function in elderly spinal patients

MORE than 50 yr ago, clinicians reported changes in mental function after anesthesia and surgery in the elderly. As these phenomena have been elucidated in subsequent years, they have been categorized into the distinct syndromes of delirium and postoperative cognitive dysfunction (POCD). These phenomena seem to be increasing in prevalence, concomitant with the increase in the number of elderly patients undergoing surgery. In this brief clinical review, we describe the presentation of, course of, risk factors for, and when applicable, management of these syndromes. Delirium and cognitive function after cardiac and neurosurgical procedures are distinct subjects beyond the scope of this review.Delirium was well described in the writings of Hippocrates 2,500 yr ago. The key diagnostic features, as described in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders are (1) that it is a change in mental status, characterized by a prominent disturbance of attention and reduced clarity of awareness of the environment; and (2) that it has an acute onset, developing within hours to days, and tends to fluctuate during the course of the day. The inability to focus, sustain, and shift attention is accompanied by other cognitive symptoms (e.g ., disorientation, episodic memory dysfunction) and/or perceptual disturbances (misinterpretations, illusions, or hallucinations). Associated features include disturbances of the sleep–wake cycle and activity level, as well as affective disturbance (mood lability, anger, sadness, euphoria) and thought disorder (disorganized thinking, delusions). The symptoms of delirium are numerous, vary from patient to patient, vary within patients over time, and are shared by a variety of other disorders such as dementia, anxiety, depression, and psychosis, all of which contribute to difficulties in diagnosis.The heterogeneous presentation of delirium has led to the identification of hyperactive, hypoactive, and mixed subtypes.1,2The hyperactive form of delirium tends to be clinically obvious. The hypoactive form, however, is often unrecognized, misdiagnosed, mistaken for depression or dementia, or simply attributed to old age, because patients may seem quiet and subdued in their disorientation. Furthermore, the relation between delirium and dementia is complex, and the syndromes may overlap.1,2Delirium can be caused by, or associated with, a wide variety of conditions,1,2and the current Diagnostic and Statistical Manual of Mental Disorders system differentiates subtypes based on the presumed etiology. These are delirium due to a general medical condition , substance-induced delirium (due to medication use or toxin exposure), substance intoxication delirium (due to intoxication), substance withdrawal delirium , delirium due to multiple etiologies , and delirium not otherwise specified (for cases in which there is insufficient evidence to establish a specific etiology).Delirium in the postoperative period can be divided into emergence delirium and postoperative delirium (PD), based on the time of onset (fig. 1). Emergence delirium is seen during or immediately after emergence from general anesthesia and usually resolves within minutes or hours. It occurs in all age groups, with some predominance in children. It seems to be directly correlated with the administration of general anesthesia, because it occurs during the emergence process, mimics stage II (excitation) of ether anesthesia as described by Guedel, and usually resolves without sequelae. Emergence delirium fits the Diagnostic and Statistical Manual of Mental Disorders , fourth edition, diagnostic criteria for a substance-induced delirium . The reader is referred to a more complete review of this subject.3After surgery, another type of delirium occurs that is not clearly related to emergence from anesthesia. Elderly patients commonly emerge from anesthesia smoothly and demonstrate coherence in the postanesthesia care unit. After a lucid interval, some patients develop a syndrome referred to as interval delirium or postoperative delirium .1,4Postoperative delirium tends to first be observed between postoperative days 1 and 3, and usually resolves within hours to days, although symptoms may persist for weeks to months. Postoperative delirium is more likely to result in complete recovery than other forms of delirium.5The term intensive care unit (ICU) delirium describes delirium that occurs in the intensive care unit, primarily in those patients requiring mechanical ventilation; it was previously referred to as ICU psychosis . ICU delirium makes no distinction between medical and surgical patients, so many cases of ICU delirium could also be classified as postoperative delirium.6There are a number of structured instruments available that can be used by a variety of personnel to diagnosis and assess delirium. Three validated methods include the Confusion Assessment Method,7the Delirium Rating Scale Revised-98,1and the Delirium Symptom Interview.1The confusion assessment method has been used for most postoperative delirium research and has been modified and validated for use in critical care patients receiving mechanical ventilation.8The reported incidence of PD is 5–15% in older adults after general anesthesia.9The reported incidence in patients undergoing surgery for hip fracture is higher, ranging from 16% to 62%, with an average rate of 35% across 12 studies of 1,823 patients.10Delirium is indeed the most common complication after hip fracture, but this patient population also has a high incidence of delirium before surgery.In elderly patients hospitalized for reasons other than surgery, the risk of developing delirium while hospitalized is predicted by an interaction between vulnerability factors present at the time of hospitalization and noxious injuries, or precipitating factors that occur during hospitalization.2Among the predisposing risk factors identified are vision impairment, severe illness, cognitive impairment, and serum urea nitrogen:creatinine ratio of 18 or greater. The precipitating factors identified are use of physical restraints, malnutrition, more than three medications added 24–48 h before the onset of delirium, use of a urinary bladder catheter, and iatrogenic events, including fluid and electrolyte abnormalities and infections.2Studies in surgical patients have identified age 70 yr or older, history of delirium, history of alcohol abuse, and preoperative use of narcotic analgesics as preoperative predisposing risk factors for PD.11Preoperative depression also seems to be a risk factor for postoperative delirium.12Perioperative risk factors include greater intraoperative blood loss, more postoperative transfusions, postoperative hematocrit less than 30%, and severe postoperative pain.13There are contradictory reports on the role of perioperative hypotension and hypoxemia in the development of PD. The role that postoperative pain plays in the development of PD is not attributable to method of analgesia, type of opioid analgesia, or cumulative opioid dose.14Drug effects are considered an important cause of delirium. In medical patients, the most important drug classes associated with delirium are the sedative–hypnotics, narcotics, and anticholinergics,1all of which are routinely used in perioperative care. The role of benzodiazepines is controversial.1Lorazepam has been specifically associated with the development of delirium in the ICU.15There is extensive literature investigating the proposition that regional anesthesia would be associated with less delirium than general anesthesia; however, the majority of these studies show no difference.16,17The underlying pathophysiology of delirium in general, and PD specifically, remains elusive. Delirium is the behavioral manifestation of diffuse cortical dysfunction and is associated with diffuse slowing of background activity in the electroencephalogram (except in cases of alcohol withdrawal, in which there is an increase in fast wave activity).1It is also associated with disturbances in a wide variety of neurotransmitter systems, and disruption of cholinergic transmission seems to be especially important.2Toxicity from anticholinergic agents mimics the electroencephalographic and behavioral aspects of delirium and is reversed by physostigmine. Serum anticholinergic activity is associated with delirium in postoperative patients.18Other potential mediators include melatonin, norepinephrine, and lymphokines.1,2Postoperative delirium is associated with increased morbidity (including risk of injury), mortality, duration of hospital stay, nursing home placement, and technical (nonphysician), consultant, and nursing costs.19In a recent study, duration of hospital stay for surgical patients was 6.0 days for those who developed delirium and 4.6 for those who did not.19The average additional in-hospital cost per surgical patient with PD was $2,947, which equates to more than $2 billion additional healthcare dollars per year in the United States.It is possible to prevent PD in some patients using safe and effective interventions for systematic detection and management of predisposing factors.1The most widely studied intervention program to prevent delirium in elderly medical patients is the Hospital Elder Life Program.20Interventions are targeted towards six risk factors for delirium: cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration. Some of the specific interventions include frequent presentation of orienting information (such as prominent display of the date, time, schedule, and names of hospital personnel), cognitive stimulation activities, physical exercise, use of visual aids and adaptations, use of auditory amplifying devices, nonpharmacologic methods to promote sleep (such as drinking warm milk before bed, relaxing music, back massage, noise-reduction strategies), and feeding and fluid assistance. Other protocols have focused on coordinated geriatric services, geriatric–psychiatric consultations, and patient and family education. A series of randomized and nonrandomized trials indicate that a substantial absolute risk reduction (in the range of 13–19%) can be achieved.1,2A trial of proactive geriatric consultation in hip fracture patients reduced delirium by more than one third and reduced cases of severe delirium by more than one half.21Treatment of agitation poses a special problem. Agitation puts the patient, visiting family, and staff at risk for physical injury and interferes with administration of normal postoperative care, but current treatment options are less than optimal. Attempts should be made to avoid the use of physical restraints, which may worsen delirium and agitation. Pharmacologic therapy is used specifically to decrease agitation.22Haloperidol, a typical antipsychotic dopaminergic antagonist, is administered to adults at a dose of 0.5–1 mg intravenously every 10–15 min until the agitated behavior is controlled.∥Intramuscular dosing is less desirable but can be employed using 2–10 mg, waiting 60–90 min between doses. By careful dosing, practitioners should limit the degree of haloperidol's sedative side effect, because this drug has an extended half-life in the elderly (up to 72 h) and deep sedation can last for several days. It is important for the clinician to recognize that haloperidol can be useful in the immediate management of agitation but does not alter the duration of delirium. Newer antipsychotic medications, such as ziprasidone and olanzapine, are administered intramuscularly and are reportedly effective in the management of acute agitation but have not been tested in patients with either medical or surgical comorbidities.22Although most typical antipsychotics increase the corrected QT interval and may predispose to arrhythmias, haloperidol has a relatively lower propensity to do so. Cases of sudden death are rare and have not been clearly related to haloperidol.22Although it is reasonable to assume that benzodiazepines would be an effective treatment for agitation in the context of PD, anecdotal experience has shown that these medications may have a paradoxical effect in elderly patients and may worsen agitation.22If alcohol withdrawal is suspected to be the underlying cause of delirium, however, benzodiazepines are the treatment of choice.The term postoperative cognitive dysfunction (POCD) describes a deterioration of cognition that is temporally associated with surgery. As opposed to delirium, in which pathognomonic behavior must be detected, detecting, assessing the severity of, and characterizing POCD depends on valid assessments of preoperative and postoperative cognitive function. The neuropsychological examination measures the information processing abilities of the brain through a battery of tests (assessing attention, perception, verbal abilities, learning and memory, and abstract thinking) that are sensitive to the effects of brain injury and disease.23The wide variability in normal human cognitive capacities associated with aging and a possible incidence of preexisting mild cognitive impairment in the elderly make baseline (i.e ., preoperative) measures a critical component of these evaluations. In the absence of baseline data, it is impossible to associate low postoperative test scores to surgical, anesthetic, or illness variables with certainty. Subjective self-reported cognitive symptoms do not substitute for objective cognitive testing, because a poor relation between the two types of data has been demonstrated repeatedly.24There are a number of methodologic inconsistencies among studies that make the limited literature on POCD difficult to interpret. These include the selection of test instruments, timing of postoperative testing, inclusion and exclusion criteria, the inherent variability of cognitive testing, and most fundamentally, the operational definition of POCD.Mental status screening instruments such as the Mini-Mental State Examination are useful for detecting frank dementia but lack the sensitivity and specificity required to detect milder or more selective forms of cognitive impairment.23High-functioning patients who have experienced a mild decline in cognitive function and patients with "focal," as opposed to "diffuse," cognitive dysfunction may achieve high Mini-Mental State Examination scores. Cognition is not a unitary process, but rather is the result of activity in multiple complex, distributed, and interacting neuronal circuits that underlie specific information processing functions. There is no single measure of cognitive status; therefore, comprehensive neuropsychological assessment requires that a battery of tests assessing a variety of cognitive domains must be used. There are, however, a wide variety of tests available, which differ in their test–retest reliability, sensitivity, specificity, and the degree to which they are subject to practice effects.Another methodologic inconsistency among the studies is the timing of postoperative cognitive testing. In general, studies measuring cognitive function shortly after surgery find a much higher incidence of POCD than studies measuring cognitive function weeks to months after surgery. Longitudinal studies have the problem of attrition, which does not occur randomly but is influenced by the postoperative health status, functional status, and possibly the cognitive status of the patient. Patients who develop POCD may be more likely to drop out of the study, thus underestimating the true incidence of POCD.It is also important to consider the subject inclusion and exclusion criteria when interpreting study findings. Recently, the term mild cognitive impairment has come to represent a transitional zone in the spectrum of cognitive function from normal aging to progressive dementing conditions, such as Alzheimer and cerebrovascular diseases. Unfortunately, patients with preoperative mild cognitive impairment have not been differentiated in studies of POCD. Therefore, there is no information available concerning the impact of surgery and anesthesia on this subset of patients that may be at greatest risk for POCD. There is no evidence that anesthesia and surgery increase the incidence of Alzheimer disease.One of the greatest problems facing the investigation of postoperative cognitive function is the absence of a consensus regarding the operational definition of POCD. Variations in the methods that different groups have used to define deterioration in cognitive function in part underlie the difficulty in comparing studies. Furthermore, few studies use control groups and take practice effects into account.25The percent change method involves converting the preoperative to postoperative difference score into a percent of baseline score, i.e ., (postoperative score − preoperative score)/preoperative score. This method generates continuous data, which can then be averaged across patients for group comparisons. The use of group mean analyses, however, is discouraged, because a subset of subjects experiencing significant deterioration may be masked when other subjects exhibit improved performance over time. The SD method involves identifying patients who experience a postoperative decline of some criterion number of SD units (Z scores). The International Study of Postoperative Cognitive Dysfunction (ISPOCD) studies (see below) required a 2-SD decline to qualify as POCD. Limitations of the SD method include the following: (1) in patients with low baseline scores, it may not be possible to decline by more than 1 SD (i.e ., floor effect); and (2) the absolute magnitude of change in raw test scores required to meet the criterion differs between studies, because they are derived from the preoperative test scores of the baseline sample. A third strategy involves identifying patients who experience a specific percentage (e.g ., 20%) decline from baseline of at least a specific percentage (e.g ., 20%) of the tests administered. A limitation of this technique is that patients with lower preoperative test scores require a smaller decline in raw score to meet the 20% criterion. It should be noted that the methodology used by ISPOCD is a subset of the general assessment technique referred to as a reliable change index . Lewis has recently explored a number of issues related to the use of this technique.26In 1998, Möller et al .27presented the first of a series of multicenter studies from the ISPOCD that primarily included European centers. Information from the ISPOCD studies is available at the ISPOCD Web site.#The ISPOCD1 study tested the hypothesis that insufficient oxygen delivery to the brain, as assessed by the presence of hypotension and/or hypoxemia, is a causative factor for POCD. The study included 1,218 patients, aged 60 yr or older, who underwent major abdominal, noncardiac thoracic, or orthopedic surgery during general anesthesia. Patients were tested preoperatively and at 1 week and 3 months postoperatively. Test results were compared with a total of 321 controls recruited from the United Kingdom, 11 centers in and centers in Patients were classified as experiencing cognitive dysfunction when two scores in tests by or the average score greater than 1 week of patients experienced a decline in cognitive compared with of control 3 months of patients experienced a decline to preoperative of compared with of number of subsequent studies have described cognitive impairment within the first days after surgery and et al a rate of POCD of at months after surgery, although in the absence of a control the is to A study that patients at 1 and yr that the rate of POCD to which was not it seems that elderly patients deterioration shortly after surgery and anesthesia at 2–10 with such that the incidence at 3 at at 1 to from control subjects by 1 important are that (1) the of patients to drop out of such studies, the may the true incidence of and (2) the clinical course of an patient be clearly from this in that there is inconsistency between the In the ISPOCD studies, less than of the who were classified at POCD at 3 months decline at 1 week (i.e ., POCD at 1 week did not POCD at 3 a of the data from the ISPOCD studies, et al . to the impact of test–retest variability on the of that variability in cognitive results could after surgery would be as frequent as This that cognitive decline at 1 week but that there was no significant change at 3 months. study be required to impairment is an important clinical in cognitive is an important factor that to the low between that should be in studies of all of the studies to have that age is a risk factor for POCD. of patients aged yr undergoing major surgery a but significant decline in cognitive function at 1 week that was no at 3 months the ISPOCD that POCD is primarily a problem of elderly surgery seems to be the for POCD. A study comparing patients undergoing general anesthesia and surgery with at least a single hospital stay with patients who underwent general anesthesia for surgery that surgery was not associated with significant major surgery, postoperative cognitive dysfunction at 1 week was associated with increased age, increased duration of anesthesia, of postoperative and age was a significant risk factor for POCD at 3 postoperative pain has also been associated with postoperative cognitive function. In a study of patients aged who underwent surgery, greater pain on postoperative 1 was associated with performance on some neuropsychological degree of preoperative pain was not related to preoperative cognitive test date, the of POCD remains in neurotransmitter and system have all been but the has been general anesthesia. anesthesia is a with multiple medications, many of which are to cause delirium. The method of the potential of general anesthesia to POCD has been randomized trials of general regional anesthesia. studies that of anesthesia is not an important factor in the development of is in greater such different as regional and general anesthesia have impact on postoperative cognitive function in clinical studies, there are studies that general agents have effects on and of this to the clinical syndromes described require significant additional and are potential etiologies of POCD for which potential (e.g ., that were in the first ISPOCD study the role of hypotension and hypoxemia as potential was by continuous and blood was by the perioperative high of hypoxemia and condition was associated with POCD. may additional into this problem. research is to the role of in the of of the is associated with the development of Alzheimer but has not been to be an important of POCD in general for either a to POCD or a of POCD is but all such In studies of cardiac surgery patients, but not may be useful as a of research including that for different aspects of (in cardiac and require substantial additional research to establish clinical is that general anesthesia, which specifically the brain, as compared with regional anesthesia, which primarily the or would be associated with different of POCD. in a series of relatively studies that patients undergoing general anesthesia, but not anesthesia, were at greater risk for et al an randomized study of POCD that used neuropsychological This study compared the effect of general anesthesia on the incidence of POCD in patients undergoing total assessment was days preoperatively and 1 week and months postoperatively. mean scores for of the measures were compared between the two anesthesia groups, but no significant were observed postoperatively. In the of patients clinically important for test by were of patients a decline in cognitive function months after surgery, but no significant were between the anesthesia As this was a there was no control group for Recently, et al a comprehensive review of studies that the of anesthesia and that it does not the incidence of the of PD and it is important to consider that there may be an between Postoperative delirium may be a of POCD or an Patients who developed delirium in the ISPOCD1 study were not the patients who developed POCD. In ICU patients, delirium does seem to be of term cognitive majority of studies to have focused on either PD or POCD. In the studies that for PD and POCD should on this system dysfunction after anesthesia and surgery is primarily a problem of the elderly. The of an aging population and in anesthesia and surgery has led to in the number of elderly patients undergoing surgery. It is therefore, that postoperative dysfunction an common delirium is an diagnostic that requires research to as well as to effective and treatment There are available that seem to postoperative delirium. of these may be difficult limited however, assessment of patients for delirium has a of care in some European and should be with the and management of to PD, the that to define the presence or absence of POCD are The are not regarding the of cognitive that are associated with do they regarding the degree of dysfunction that is clinically illness requiring hospitalization may be associated with cognitive the that cognitive decline occurs as a of illness rather than it related to surgery and/or anesthesia. There are patients who significant after surgery and anesthesia. study, of clinical with mild cognitive impairment be for practitioners to the of cognitive dysfunction after noncardiac dysfunction is a health problem of study to the risk and and underlying should the current status of postoperative delirium and cognitive dysfunction and to prevent and delirium as studies to postoperative function.

To investigate the effects of ultrasound-guided stellate ganglion block (SGB) on sleep quality in elderly patients with lung cancer early after thoracoscopic surgery. A total of 86 patients with lung cancer (ASA class I-III, aged 60-80 years) undergoing elective thoracoscopic surgery were randomized into stellate ganglion block (SGB) group (n=43) and control group (n=43) to receive ultrasound-guided right SGB with 7 mL of 0.5% ropivacaine at the C6-7 level and injection of 7 mL saline at the same site 30 min before anesthesia induction, respectively. On the day before surgery and the first two days after the surgery, sleep duration, sleep efficiency index (SEI) and N3 sleep stage of the patients were monitored using a BIS-Vista monitor, and Athens Insomnia Scale (AIS) scores were recorded. The plasma levels of norepinephrine and cortisol of the patients were measured before SGB (T1), at 5 min after extubation (T2) and at 6:00 on the first morning after the surgery (T4). Urine levels of 6-hydroxysulfate melatonin (6-HMS) were measured at 6:00 in the morning for 3 consecutive days starting on the day of surgery (T3, T4 and T5, respectively). VAS score, incidences of postoperative delirium and depression, sufentanil consumption after surgery, and discharge time of the patients were recorded. Thirty-six patients in SGB group and 35 in the control group were analyzed. In both groups, most of the patients had insomnia after surgery, but compared with those in the control group, the patients in SGB group had significantly longer sleep duration (P < 0.05) with a higher sleep efficiency index (P < 0.05) and a longer sleep time in N3 stage (P < 0.05) on the first two nights after surgery. The mean postoperative AIS score and incidence of insomnia were significantly lower in SGB group than in the control group (P < 0.05). Compared with the control group, SGB group showed significantly lower plasma levels of norepinephrine and cortisol at T2 and T4 (P < 0.05), a higher urine level of 6-HMS at T5 (P < 0.05), and a shorter discharge time after the surgery (P < 0.05). The VAS scores, postoperative incidences of delirium and depression, or postoperative sufentanil consumption did not differ significantly between the two groups. Ultrasound-guided SGB improves objective and subjective sleep quality in elderly patients early after thoracoscopic surgery for lung cancer to alleviate stress responses and sleep disorders, reduce postoperative hospital stay, and accelerate postoperative recovery of the patients.

This study evaluates the impact of ultrasound-guided stellate ganglion block (SGB) on early postoperative cognitive dysfunction (POCD) in elderly patients who underwent laparoscopic gastrointestinal (GI) surgery, as well as its potential effect on oxidative stress and inflammatory responses. In this randomized controlled trial, 104 elderly patients scheduled for elective laparoscopic GI surgery were randomized to receive ultrasound-guided SGB before general anesthesia (SGB group) or general anesthesia alone (control group). A total of 98 patients completed the study. Cognitive function was assessed using the Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) preoperatively, and on postoperative days one and three. The perioperative recordings included mean arterial pressure, heart rate, and the bispectral index. Blood samples were analyzed for interleukin-6 (IL-6), superoxide dismutase (SOD), and malondialdehyde (MDA). The SGB group had a significantly lower incidence of POCD on postoperative day one (p < 0.05). IL-6 and MDA levels were significantly lower, while SOD levels were higher in the SGB group, when compared to the control group (p < 0.05). MDA levels were notably lower on postoperative day three in the SGB group (p < 0.05). Both groups showed significant changes in IL-6, SOD and MDA levels, when compared to preoperative values. The hemodynamic indicators showed a slight reduction in intraoperative blood pressure and decreased numerical rating scale scores on the first postoperative day without significant differences in other indicators. Preoperative SGB reduces early POCD in elderly patients who undergo laparoscopic GI surgery, possibly through the inhibition of oxidative stress and inflammatory responses.

To explore the potential effect of ultrasound-guided stellate ganglion block (SGB) on lung protection for patients undergoing one-lung ventilation (OLV). A total of 123 patients undergoing elective one-lung ventilation surgery were selected as research subjects in this prospective study. These patients were randomly divided into the SGB group, control group and blank group on average. Stellate ganglion block was carried out in the SGB and control groups. Patients in the SGB group were injected with 6 ml mixture of 0.25% ropivacaine hydrochloride and 1% lidocaine hydrochloride, while those in the control group were injected with 6 mL of 0.9% saline. Punctures weren't performed for patients in the blank group. The same induction and maintenance of general anesthesia was adopted for all three groups. Hemodynamics, respiratory parameters and arterial blood gas analysis were recorded after entering the operation room (T0), pre-OLV (T1), 30 min after OLV (T2), 60 min after OLV (T3), at the end of surgery (T4), and 30 min after extubation (T5). Oxygenation index (OI), pulmonary shunt fraction (Qs/Qt) and pH value were compared at different time points. Intravenous serum was collected at T0, T3 and T5 for the detection of surfactant proteins A (SP-A), superoxide dismutase (SOD), malondialdehyde (MDA), interleukin-6 (IL-6) and interleukin-10 (IL-10) levels, respectively. The complications related to SGB after surgery and the postoperative pulmonary complications within 72 h were recorded. At T1, T2, and T3, MAP level in SGB group was lower than that in blank and control groups (P<0.05). At T2, and T3, SGB group had lower hear rate (HR), peak airway pressure (Ppeak) and tidal volume (TV) than blank and control groups (all P<0.05). From T2 to T5, SGB group had higher OI but lower Qs/Qt than blank and control groups (both P<0.05). At T3 and T5, SGB group had lower SP-A, IL-6, and MDA levels but higher IL-10 and SOD levels than blank and control groups (all P<0.05). There was one case of hypoxemia in the blank group within 72 h after surgery. Ultrasound-guided SGB has lung-protective effects on patients undergoing OLV, which significantly improves patients' OI, reduces intrapulmonary shunts, declines ventilator-induced lung damage, and inhibits inflammatory response as well as oxidative stress (China Clinical Trial Registry, registration number ChiCTR2000033385, https://www.chictr.org.cn).

Surgery has been the primary treatment for breast cancer. However, instant postoperative complications, such as sleep disorder and pain, dramatically impair early postoperative quality of recovery, resulting in more extended hospital stays and higher costs. Recent clinical trials indicated that stellate ganglion block (SGB) could prolong sleep time and improve sleep quality in breast cancer survivors. Moreover, during the perioperative period, SGB enhanced the recovery of gastrointestinal functions in patients with laparoscopic colorectal cancer surgery and thoracolumbar spinal surgery. Furthermore, perioperative SGB decreased intraoperative requirements for anesthetics and analgesics in patients with complex regional pain syndrome. However, information is scarce regarding the effects of SGB on postoperative quality recovery in patients with breast cancer surgery. Therefore, we investigated the effects of SGB on the postoperative quality of recovery of patients undergoing breast cancer surgery. Sixty patients who underwent an elective unilateral modified radical mastectomy were randomized into two 30-patient groups that received either an ultrasound-guided right-sided SGB with 6 ml 0.25% ropivacaine (SGB group) or no block (control group). The primary outcome was the quality of postoperative recovery 24 hours after surgery, assessed with a Chinese version of the 40-item Quality of Recovery (QoR-40) questionnaire. Secondary outcomes were intraoperative requirements of propofol and opioids, rest pain at two, four, eight, and 24 hours after surgery, patient satisfaction score, and the incidence of postoperative abdominal distension. At 24 hours after surgery, global QoR-40 scores were higher in the SGB group than in the control group. Besides, in the SGB group, patients needed less propofol, had a lower incidence of postoperative abdominal bloating, and had higher satisfaction scores. Ultrasound-guided SGB could improve the quality of postoperative recovery in patients undergoing breast cancer surgery by less intraoperatively need for propofol and better postoperative recovery of sleep and gastrointestinal function.

IntroductionPostoperative impaired sleep quality and pain are associated with adverse outcomes. Stellate ganglion block (SGB) has shown promising results in enhancing sleep quality and alleviating neuropathic pain. This study aimed to investigate the effects of ultrasound-guided SGB on postoperative sleep quality and pain in patients undergoing breast cancer surgery.MethodsThis study is a parallel-group randomized controlled clinical trial with two groups: SGB and control. Fifty female patients undergoing breast cancer surgery were randomized in a 1:1 ratio to receive preoperative ultrasound-guided single-injection SGB (SGB group) or just an ultrasound scan (control group). All participants were blinded to the group assignment. The primary outcome was postoperative sleep quality, assessed by the St. Mary’s Hospital Sleep Questionnaire and actigraphy 2 days postoperatively. The secondary outcome was postoperative pain, measured by the visual analog scale.ResultsA total of 48 patients completed the study, with 23 patients in the control group and 25 in the SGB group. The postoperative St. Mary’s Hospital Sleep Questionnaire scores were significantly higher in the SGB group than in the control group on 1 day postoperative (30.88 ± 2.44 versus 27.35 ± 4.12 points, P = 0.001). The SGB also increased the total sleep time and sleep efficiency (main actigraphy indicators) during the first two postoperative nights. Compared with the control group, preoperative SGB reduced postoperative pain and the incidence of breast cancer-related lymphedema (20% versus 52.2%, P = 0.02, odds ratio 0.229, 95% confidence interval 0.064–0.821). There were no adverse events related to SGB.ConclusionPreoperative ultrasound-guided SGB improves postoperative sleep quality and analgesia in patients undergoing breast cancer surgery. SGB may be a safe and practical treatment to enhance the postoperative quality of life in patients with breast cancer.Trial RegistrationThe study was registered in the Chinese Clinical Trial Registry (ChiCTR2100046620, principal investigator: Kai Zeng, date of registration: 23 May 2021).

Objective To evaluate the effect of stellate ganglion block (SGB) on postoperative synaptic structure in hippocampal CA3 region in aged rats.Methods Seventy-two male Sprague-Dawley rats,aged 20-22 months,weighing 550-650 g,were randomly divided into 3 groups (n =24 each) using a random number table:control group (group C),operation group (group O) and SGB + operation group (group SGB).Group SGB received right SGB with 0.25％ bupivacaine 0.15 ml.Groups O and SGB underwent 30 min of exploratory laparotomy starting from 15 min after the end of administration.Y-maze test was performed on 1 day after operation in 6 rats chosen from each group for assessment of cognitive function.The frequency of standard training and standard time were recorded.Six rats were chosen from each group on 1,3 and 7 days after operation and sacrificed and the hippocampal CA3 region was isolated for microscopic examination and for measurement of synaptic structure.Results Compared with group C,the standard time was significantly prolonged,and the frequency of standard training was increased in groups O and SGB,the width of synaptic cleft was increased,the thickness of post-synaptic density was decreased,the length of active zones was shortened,and the curvature of the synaptic interface was decreased on 1,3 and 7 days after operation in group O (P ＜ 0.05),and no significant changes were found in each synaptic structure parameter in group SGB (P ＞ 0.05).Compared with group O,the standard time was significantly shortened,the frequency of standard training was decreased,the width of synaptic cleft was decreased,the thickness of the post-synaptic density was increased,the length of active zones was prolonged,and the curvature of the synaptic interface was increased on 1,3 and 7 days after operation in group SGB (P ＜ 0.05).Conclusion The mechanism by which SGB improves the postoperative cognitive dysfunction in aged rats may be related to inhibition of changes of synaptic structure in hippocampal CA3 region. Key words: Stellate ganglion; Nerve block; Aged; Hippocampus; Synapses

Lymphovenous anastomosis (LVA) and stellate ganglion block (SGB) have been reported as effective treatments for breast cancer-related lymphedema (BCRL). However, no studies have evaluated the efficacy of ultrasound-guided SGB in patients undergoing LVA. This study aimed to assess whether adding SGB to LVA improves outcomes in BCRL patients. Thirty BCRL patients were randomly assigned to either the control (LVA only, n = 15) or SGB group (n = 15). The SGB group received ultrasound-guided SGBs at 2 days, 2 weeks, and 4 weeks postoperatively. Arm circumferences were measured at four points (5 cm and 10 cm above and below the elbow) at baseline and at 1-, 3-, and 6-months post-surgery. Treatment-related variables were also analyzed to identify potential predictors of success. Repeated-measures analysis of variance showed no significant differences in circumferential changes between groups over time, although a decreasing trend was observed within groups. However, significant reductions in circumferential differences compared with baseline were observed at several measurement sites in the SGB group. Logistic regression analysis revealed no significant predictors of treatment success. In conclusion, ultrasound-guided SGB performed postoperatively may enhance the therapeutic effect of LVA in BCRL, further reducing arm circumferential differences.

Objective To examine the effect of ultrasound-guided stellate ganglion block (SGB) on the tourniquet reaction of the lower limbs. Methods A total of sixty patients undergoing unilateral knee replacement surgery under general anesthesia were divided into 2 groups (n=30): control group and group SGB. The age of patients was 18-75 years old with ASA gradeⅠ,Ⅱ. Before general anesthesia, 1% lidocaine (10 ml) was injected into the right deltoid muscle in control group, but in the right cervical stellate ganglion in group SGB. HR, SBP, BIS and drug doses were recorded at various time points: before induction of anesthesia (T0), before intubation (T1), 1 min after intubation (T2), before tourninquet inflated (T3), tourniquet inflatable 30 min (T4), tourniquet inflation 1 h (T5), tourniquet deflation(T6), tourniquet deflation 3 min (T7) and tourniquet deflation 30 min (T8) after discharge. Results Compared with control group, group SGB showed significantly lower SBP at T2, T5, T6 and T7 (P 0.05). There was no significant difference in the BIS, the doses of propofol, remifentanil, ephedrine and phenylephrine between the two groups, while the dose of urapidil in group SGB was significantly less than control group. Conclusions SGB can reduce the cardiovascular response to the tourniquet and maintain stable perioperative circulation. Key words: Stellate ganglion block; Tourniquet

Bulbar palsy typically causes severe dysphagia. Based on rehabilitation interventions, stellate ganglion block (SGB) might improve swallowing function by regulating sympathoexcitation and cerebral perfusion. This study explored the short- and long-term effects of SGB on swallowing function, anxiety, and cerebral blood flow in patients with bulbar palsy after ischemic stroke. This randomized double-blind placebo-controlled trial included 124 participants in rehabilitation departments from March 2024 to July 2025 in China. The participants were randomized 1:1 to SGB or placebo groups, and all received routine treatment for 10 consecutive days. The SGB group received SGB with lidocaine hydrochloride, whereas the placebo group received block with normal saline. The primary outcome was the clinical severity of dysphagia. The secondary outcomes were airway protection, forward and upward movement distances of the hyoid bone, accumulation of secretions, pharyngeal residue, anxiety, and mean blood flow velocity (Vm) and internal diameter of the vertebral artery. The Vm and internal diameter were additionally assessed one hour after the first SGB. Repeated measures ANOVA and generalized estimating equations were used to explore time, group, and their interaction effects. There were no significant baseline inter-group differences. After treatment, significant (P < 0.001) interaction effects were observed for dysphagia severity (η2 > 0.06), movement distances of the hyoid bone (η2 > 0.19), airway protection (β = - 0.774), pharyngeal residue (β < - 0.54), accumulation of secretions (β = - 0.371), and anxiety (η2 = 0.462). These effects remained significant at follow-up. After the first SGB, the Vm and internal diameter of the vertebral artery on the SGB side significantly increased (P < 0.001) in the SGB group, but the inter-group differences were non-significant after the intervention period. In patients with bulbar palsy after ischemic stroke who receive routine treatment, SGB is safe and can effectively improve swallowing function, airway protection, and anxiety. The effects of SGB on vertebral artery blood flow are temporary, but the functional impacts are long-term. ClinicalTrials.gov. (Unique identifier: NCT06319534, 20/03/2024).

IntroductionTo observe the clinical efficacy of ultrasound-guided stellate ganglion block (SGB) + extracorporeal shock wave therapy (ESWT) for limb spasticity in patients with ischemic stroke.MethodsA total of 60 patients with post-stroke limb spasticity in our hospital were selected and randomly divided into four groups (n = 15). In the control group, patients received routine rehabilitation training. Based on routine rehabilitation training, SGB group patients underwent ultrasound-guided SGB, ESWT group patients received ESWT, and SGB + ESWT group patients received ultrasound-guided SGB combined with ESWT. The total treatment course was one month. The Modified Barthel Index (MBI) score, Fugl-Meyer Assessment and upper limb rehabilitation training system were applied to evaluate the activities of daily living, upper limb motor function and upper limb performance before and after treatment. Finally, the improvement after treatment was compared among different groups.ResultsAfter treatment, compared with the control group, the MBI score and the upper limb score based on Fugl-Meyer Assessment in the SGB, ESWT, and SGB + ESWT groups were significantly increased (P < 0.05). Furthermore, compared with the SGB and ESWT groups, SGB + ESWT exhibited a higher upper limb function score (P < 0.05), while the MBI score was not significantly different (P > 0.05). In terms of upper limb performance ability, patients in the SGB, ESWT and SGB + ESWT groups had better fitting degree, participation and exertion of exercise than those in the control group, and the SGB + ESWT group patients had the same movement trajectory as robots.ConclusionUltrasound-guided SGB and ESWT can reduce the muscle tension of patients, alleviate spasticity, promote the motor function of the upper limb, and improve the working performance of patients. However, the effect of SGB combined with ESWT is better.

Objective To evaluate the effects of different depths of sedation on postoperative cognitive function in elderly patients with mild cognitive impairment. Methods A total of 100 patients with mild cognitive impairment before surgery, aged 65-75 yr, weighing 55-75 kg, of American Society of Anesthesiologists physical status Ⅱ or Ⅲ, scheduled for elective gynecological surgery under general anesthesia, were divided into Ⅰ and Ⅱ groups (n=50 each) using a random number table method.Propofol was given by closed-loop target-controlled infusion, and the target plasma concentration was automatically regulated.The bispectral index value was maintained at 40-50 in group Ⅰand at>50-60 in group Ⅱ.Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) were used to evaluate the cognitive function at 1 day before operation (T0) and 7 days after operation (T1), and the development of postoperative cognitive dysfunction (POCD) was recorded.Venous blood samples were collected at T0 and T1 for determination of the concentrations of serum interleukin-10 (IL-10) and tumor necrosis factor-alpha (TNF-α) by enzyme-linked immunosorbent assay. Results Compared with the baseline value at T0, MoCA and MMSE scores were significantly decreased at T1, and the serum concentrations of IL-10 and TNF-α were increased in both groups (P<0.05). Compared with group Ⅰ, MoCA and MMSE scores were significantly decreased at T1, and the incidence of POCD was increased, the serum concentration of TNF-α was increased, and the serum concentration of IL-10 was decreased in groupⅡ(P<0.05). Conclusion Maintaining BIS value at 40-50 during operation can decrease the development of POCD in elderly patients with mild cognitive impairment, which may be related to reduced systemic inflammatory responses. Key words: Electroencephalography; Cognition dissorders; Aged

Ultrasound-guided Stellate Ganglion Block Improves Gastrointestinal Function After Thoracolumbar Spinal Surgery

Preliminary Experience in the Use of Preoperative Echo-guided Left Stellate Ganglion Block in Patients Undergoing Cardiac Surgery

This randomized controlled trial aimed to evaluate the efficacy of preoperative ultrasound-guided left stellate ganglion block (SGB) on postoperative pain and opioid consumption in patients undergoing uvulopalatopharyngoplasty (UPPP) for obstructive sleep apnea-hypopnea syndrome (OSAHS). Sixty patients scheduled for UPPP were randomly assigned to receive either preoperative ultrasound-guided left SGB with 6 mL of 1% lidocaine (SGB group, n=30) or no block (Control group, n=30). The primary outcome was postoperative pain intensity measured by the visual analog scale (VAS) at extubation, 6h, 24h, and 48h after surgery. Secondary outcomes included intraoperative sufentanil consumption, number of patient-controlled analgesia (PCA) attempts, hemodynamic parameters, and incidence of postoperative complications. There was no significant difference in VAS scores and postoperative complications between the two groups at each time point after surgery, but compared with the control group, the intraoperative sufentanil dosage, postoperative PCA compression times in SGB group were significantly reduced (all p<0.05). Preoperative ultrasound-guided left SGB did not significantly reduce postoperative VAS scores in OSAHS patients undergoing UPPP, but it effectively decreased intraoperative opioid use, postoperative analgesic demand. SGB may serve as a valuable adjunct in multimodal analgesia to improve perioperative outcomes in this patient population.