Hemodynamic outcomes of adult patients on scalp block using ropivacaine and lidocaine: retrospective cohort study
Sheryl Lucille Alcibar-Abrenica,1 Eugene Lee Barinaga1
1Department of Anesthesiology, Southern Philippines Medical Center, JP Laurel Ave, Bajada, Davao City, Philippines
2Davao Medical School Foundation Hospital, Medical School Drive, Bajada, Davao City, Philippines
3Ricardo Limso Medical Center, Ilustre St, Poblacion District, Davao City, Philippines
4Brokenshire Integrated Health Ministries Inc, Brokenshire Heights, Madapo, Davao City, Philippines
5Metro Davao Medical & Research Center Inc, JP Laurel Ave, Davao City, Philippines
6Department of Anesthesiology, San Pedro Hospital of Davao City Inc, C Guzman St, Davao City, Philippines
7Community Health and Development Cooperative Hospital, Anda Riverside, Davao City, Philippines
8Department of Anesthesiology, Davao Doctors Hospital, E Quirino Avenue, Davao City, Philippines
9Tebow Cure Hospital, JP Laurel Ave, Davao City, Philippines
Correspondence Sheryl Lucille Alcibar-Abrenica, firstname.lastname@example.org
Article editors Dahlia Arancel, Jessy Mae Panggoy
Received 5 July 2017
Accepted 8 September 2017
Cite as Alcibar-Abrenica SL, Barinaga EL. Hemodynamic outcomes of adult patients on scalp block using ropivacaine and lidocaine: retrospective cohort study. SPMC J Health Care Serv. 2017;3(2):7. http://n2t.net/ark:/76951/jhcs9cce49
Background. Hemodynamic instability can occur with the pain from scalp incision to brain retraction during cranial neurosurgery.
Objective. To determine the hemodynamic outcomes of patients who received ropivacaine plus lidocaine scalp block.
Design. Retrospective cohort study.
Setting. Southern Philippines Medical Center, Davao City.
Participants. 44 patients given scalp block for cranial neurosurgery.
Main outcome measures. Heart rate (HR), mean arterial pressure (MAP), and frequencies of tachycardia, hypertension, bradycardia, and hypotension from the time of scalp block administration to 15 minutes after scalp incision (observation period).
Main results. There were 31 (70.45%) male and 13 (20.55%) female patients in this study. The patients’ mean age was 42.97 ± 17.33 years. Mean values of MAP from 5 minutes before incision to 15 minutes after incision all significantly differed from mean baseline MAP. There were no significant changes in mean HR within the observation period (p=0.2446). Among the patients, 3/44 (6.82%) had at least one episode of hypertension, 7/44 (15.91%) had at least one episode of tachycardia, 8/44 (18.18%) had at least one episode of bradycardia, and 27/44 (61.36%) had at least one episode of hypotension during the observation period.
Conclusion. The mean MAP of patients in this study significantly decreased from baseline starting from 5 minutes prior to scalp incision to 15 minutes after scalp incision. Many patients had at least one episode of hypotension, while fewer patients experienced at least one episode of hypertension, tachycardia or bradycardia.
Keywords. cranial neurosurgery, heart rate, mean arterial pressure, scalp incision
Table 1 Demographic and clinical profile of patients
|Mean age ± SD, years||42.97 ± 17.33|
|Indication for neurosurgery, frequency (%) n=43|
|Blunt head trauma||24 (55.81)|
|Brain tumor||9 (20.93)|
|Cerebrovascular accident||7 (16.28)|
|Gunshot wound||2 (4.65)|
|ASA classification, frequency(%)|
|ASA II||25 (56.82)|
|ASA III||13 (29.55)|
|ASA IV||5 (11.36)|
|ASA V||1 (2.27)|
|Mean GCS score ± SD||12 ± 3|
ASA—American Society of Anesthesiologists; GCS—Glasgow Coma Scale.
Table 2 Mean systolic blood pressure, diastolic blood pressure, mean arterial pressure, and heart rate across time
|Mean systolic blood pressure ± SD, mmHg||137.32 ± 26.45||113.30 ± 24.05||111.02 ± 21.82||110.07 ± 19.72||107.52 ± 20.29||104.07 ± 17.30||<0.0001|
|Mean diastolic blood pressure ± SD, mmHg||76.80 ± 16.06||62.86 ± 15.07||61.09 ± 14.80||61.18 ± 14.78||58.72 ± 12.76||57.36 ± 12.76||<0.0001|
|Mean mean arterial pressure ± SD, mmHg||96.97 ± 18.46||79.67 ± 17.26||77.73 ± 16.49||77.48 ± 15.57||74.99 ± 14.64||72.93 ± 13.37||<0.0001|
|Mean heart rate ± SD, beats per minute||89.07 ± 25.01||83.32 ± 21.58||82.05 ± 21.35||80.69 ± 21.34||78.68 ± 20.27||78.82 ± 22.45||0.2446|
Baseline—at the time of scalp block administration; 5BI—5 min before scalp incision; UI—upon scalp incision; 5AI—5 min after incision; 10AI—10 min after incision; 15AI—15 min after incision.
Figure 1 Systolic (A) and diastolic (B) blood pressures, mean arterial pressure (MAP; C), and heart rate (D) graphs of patients who underwent cranial neurosurgery at the time of scalp block administration (Baseline), 5 minutes before incision (5BI), upon incision (UI), 5 minutes after incision (5AI), 10 minutes after incision (10AI), and 15 minutes after incision (15AI).
Table 3 Demographic and clinical profile of patients
|Bradycardia, frequency(%)||8 (18.18)|
|Tachycardia, frequency(%)||7 (15.91)|
|Hypotension, frequency(%)||27 (61.36)|
|Hypertension, frequency(%)||3 (6.82)|
*At least one episode from scalp block administration to 15 minutes after scalp incision.
We would like to thank Dr Ana Maria Karla Datiles-Lei for sharing to us her expertise on the use of scalp block during cranial neurosurgery. We would also like to extend our gratitude to Dr Anna Lorraine Sison and Dr Manuel Gonzaga for their inputs during the writing of this report, and to Mr Jay Lord Canag for his assitance in preparing the statistics portion of this report.
This study was reviewed and approved by the Department of Health XI Cluster Ethics Review Committee (DOH XI CERC reference P16030901).
Reporting guideline used
Supported by personal funds of the authors
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1. Olsen KS, Pedersen CB, Madsen JB, Ravn LI, Schifter S. Vasoactive modulators during and after craniotomy: relation to postoperative hypertension. J Neurosurg Anesthesiol. 2002;14(3):171-9.
2. Geze S, Yilmaz AA, Tuzuner F. The effect of scalp block and local infiltration on the haemodynamic and stress response to skull-pin placement for craniotomy. Eur J Anaesthesiol. 2009;26(4):298-303.
3. Bala I, Gupta B, Bhardwaj N, Ghai B, Khosla VK. Effect of scalp block on postoperative pain relief in craniotomy patients. Australian Society of Anaesthetists. 2006;34(2).
4. Lee EJ, Lee MY, Shyr MH, Cheng JT, Toung TJ, Mirski MA, et al. Adjuvant bupivacaine scalp block facilitates stabilization of hemodynamics in patients undergoing craniotomy with general anesthesia: a preliminary report. J Clin Anesth. 2006;18(7):490-4.
5. Bloomfield EL, Schubert A, Secic M, Barnett G, Shutway F, Ebrahim ZY. The influence of scalp infiltration with bupivacaine on hemodynamics and postoperative pain in adult patients undergoing craniotomy. Anesth Analg. 1998;87(3):579-82.
6. Abbass O, Hussien G, Aboeldahab H, Othman S, Fareed M. Does scalp block with general anesthesia in craniotomy affect the intraoperative course and outcome in geriatric patients? Ain-Shams J Anesthesiol. 2015;8(1):25-30.
7. Sebeo J, Osborn I. The use of “scalp block& in pediatric patients. OJanes. 2012; 2:70-73.
8. Can BO, Bilgin H. Effects of scalp block with bupivacaine versus levobupivacaine on haemodynamic response to head pinning and comparative efficacies in postoperative analgesia: A randomized controlled trial. J Int Med Res. 2017;45(2):439-50.
9. Bala I, Gupta B, Bhardwaj N, Ghai B, Khosla VK. Effect of scalp block on postoperative pain relief in craniotomy patients. Anaesth Intensive Care. 2006;34(2):224-7.
10. Uchino H, Ushijima K, Ikeda Y, editors. Neuroanesthesia and cerebrospinal protection. Tokyo: Springer; 2015.
11. Clinicaltrials.gov [Internet]. Vancouver: University of British Columbia; c2015 [cited 2017 December 31]. Bupivacaine versus lidocaine local anesthesia. Available from: https://clinicaltrials.gov/ct2/show/NCT01751347
12. Gadsden J. Local anesthetics: clinical pharmacology and rational selection [Internet]. New York: The New York School of Regional Anesthesia; c2017 [cited 2017 December 31]. Available from: https://www.nysora.com/local-anesthetics-clinical-pharmacology-and-rational-selection.
13. BKoupparis, L. Pharmacology of regional anesthesia [Internet]. AnestheisaUK. 2007 [cited 2017 December 31]. Available from: http://www.frca.co.uk/article.aspx?articleid=100816 .
14. Kuthiala G, Chaudhary G. Ropivacaine: A review of its pharmacology and clinical use. Indian J Anaesth. 2011;55(2):104-10.
15. Singh G. Comparison of the effects of ropivacaine scalp block versus dexmedetomedine infusion on haemodynamic response to skull pin insertion in neurosurgical patients [dissertation]. Kerala, India: Sree Chitra Tirunal Institute for Medical Sciences and Technology. 2012. 81 p.
16. Kumar M, Levine J, Schuster J, Kofke WA, editors. Neurocritical Care Management of the Neurosurgical Patient. 1st ed. Philadelphia: Elsevier Saunders; 2017.
17. Manal el Gohary M, Gamil K, Nabil G, Nabil S. Scalp nerve block in children undergoing a supratentorial craniotomy; A randomized controlled study. Asian J Sci Res. 2009; 2:105-112.
18. Pinosky ML, Fishman RL, Reeves ST, Harvey SC, Patel S, Palesch Y, et al. The effect of bupivacaine skull block on the hemodynamic response to craniotomy. Anesth Analg. 1996;83(6):1256-61.
19. Mohammadi SS, Shahbazian E, Shoeibi G, Almassi F. Effect of scalp infiltration with Bupivacaine on early hemodynamic responses during craniotomy under general anesthesia. Pak J Biol Sci. 2009;12(7):603-6.
20. Albright GA. Cardiac arrest following regional anesthesia with etidocaine or bupivacaine. Anesthesiology. 1979;51(4):285-287.
21. Vijay BS, Mitra S, Jamil SN. Refractory cardiac arrest due to inadvertent intravenous injection of 0.25% bupivacaine used for local infiltration anesthesia. Anesth Essays Res. 2013;7(1):130-2.
22. Beilin Y, Halpern S. Focused review: ropivacaine versus bupivacaine for epidural labor analgesia. Anesth Analg. 2010; 111(2):482-7.
23. Levsky ME, Miller MA. Cardiovascular collapse from low dose bupivacaine. Can J Clin Pharmacol. 2005;12(3):e240-5.
24. Tonkovic D, Stambolija V, Lozic M, Martinovic P, Pavlovic DB, Sekulic A, et al. Scalp block for hemodynamic stability during neurosurgery. Period Biol. 2015;117(2):247-50..
25. Vacas S, Van de Wiele B. Designing a pain management protocol for craniotomy: A narrative review and consideration of promising practices. Surg Neurol Int. 2017;8:291.
26.Bryant H, Bromhead H. Intraoperative hypotension. Anaesthesia tutorial of the week 148. 2009 Aug.
27. Meuwly C, Golanov E, Chowdhury T, Erne P, Schaller B. Trigeminal cardiac reflex: new thinking model about the definition based on a literature review. Medicine (Baltimore). 2015;94(5).
28. Singh G, Chowdhury T. Brain and heart connections: The trigeminocardiac reflex! J Neuroanaesthesiol Crit Care. 2017;4(2):71-77.
29. Haldar R, Kaushal A, Gupta D, Srivastava S, Singh P. Pain following craniotomy: reassessment of the available options. Biomed Res Int. 2015 Apr;2015.
30. Nguyen A, Girard F, Boudreault D, Fugere F, Ruel M, Moumdjian R, et al. Scalp nerve blocks decrease the severity of pain after craniotomy. Anesth Analg. 2001;93(5):1272-76.
31. McNicholas E, Bilotta F, Titi L, Chandler J, Rosa G, Koht A. Transient facial nerve palsy after auriculotemporal nerve block in awake craniotomy patients. A A Case Rep. 2014;2(4):40-3.
32. Guilfoyle M, Helmy A, Duane D, Hutchinson A. Regional scalpblock for postcraniatomy analgesia: a systemic review and meta-analysis. Anesth Analg. 2013 May;116(5):1093-102.
33. Bebawy JF, Bilotta F, Koht A. A modified technique for auriculotemporal nevre blockade when performing selective scalp nerve block for craniotomy. J Neurosurg Anesthesiol 2014;26(3):271-2.
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