Q What are the best practices for monitoring and nursing care for a patient undergoing stellate ganglion block for refractory ventricular arrhythmias and electrical storm?A Anna Mall, MSN, APRN, ACCNS-AG, CCRN, CNL, replies:The stellate ganglion is a collection of nerves that are part of the sympathetic nervous system and that is located bilaterally at the level of the C7 vertebra. The stellate ganglion sends efferent sympathetic output to the myocardium, upper extremities, neck, and face. A stellate ganglion block is the injection of a local anesthetic agent into the ganglion to temporarily block nerve activity. Stellate ganglion block has recently been shown to be successful for temporarily reducing ventricular arrhythmias that are resistant to standard therapies.Ventricular arrhythmias are emergent situations that are associated with increased morbidity and mortality.1–3 Ventricular arrhythmias are often resistant to conventional treatments such as β-blockade, antiarrhythmic therapy, deep sedation, and mechanical circulatory support because of increased sympathetic tone.4,5 Additionally, treatment with catheter-based ablation may not be possible because of acute clinical instability. Recent case reports and multicenter studies have shown the promise of percutaneous stellate ganglion block for providing a short-term reduction (24-72 hours) in ventricular arrhythmia, allowing for stabilization of the patient and definitive therapy such as surgical sympathectomy, catheter ablation, ventricular assist device implantation, and heart transplant.4–9The left stellate ganglion is often the first target for therapy because of its increased sympathetic effects on the myocardium. Bilateral blockade can be performed if there is significant remodeling of the myocardium.10 A local anesthetic agent is injected into the ganglion either by direct access or a temporary infusion catheter. Both continuous infusion and daily bolus dosing have been shown to reduce ventricular arrhythmia.4,6,9 The choice of continuous or bolus dosing largely depends on patient presentation and provider preference.9 The local anesthetic agents ropivacaine, bupivacaine, and lidocaine are effective for decreasing myocardial sympathetic tone, resulting in temporary suppression of ventricular arrhythmia.4Owing to the risk for bilateral recurrent laryngeal nerve or phrenic nerve blockade, only patients who are intubated and receiving mechanical ventilation should be considered for bilateral blockade. Inadvertent bilateral blockade of these nerves increases the risk for acute respiratory decompensation via acute closure of the vocal cords or diaphragm paralysis. Additionally, a bilateral bolus should not be administered to the stellate ganglion within 8 hours before extubation.The use of mechanical circulatory support to reduce ventricular arrhythmias is common and frequently requires concomitant use of anticoagulation therapy. Although anticoagulation therapy is not an absolute contraindication to stellate ganglion block,4–6 the decision to temporarily withhold anticoagulation therapy should be informed by risk-benefit discussions among the primary and procedural providers.Antiarrhythmic medications (procainamide and lidocaine) are commonly given via continuous intravenous infusion to suppress ventricular arrhythmias in the intensive care unit. The concomitant intravenous infusion and local administration during stellate ganglion block increases the potential risk for local anesthesia systemic toxicity (LAST). Signs and symptoms of LAST primarily occur in the central nervous and cardiovascular systems and include seizures, altered mental status, hypotension, dysrhythmia, acute respiratory failure, and cardiac arrest. Management includes stopping the infusion, discontinuing the agents, and treating with lipid emulsion to lessen or reverse the toxicity.11To mitigate the risk of a patient’s developing LAST, it is recommended to stop any continuous intravenous infusion of procainamide or lidocaine for at least 2 hours before stellate ganglion block access.5,12 Because of the length of time required for therapeutic levels to be reestablished with both lidocaine and procainamide, it is recommended that the infusions be restarted without a bolus dose, approximately 1 hour after the stellate ganglion block procedure.5 Institutional protocols for therapeutic drug level monitoring should be followed. Additionally, patients who have received a liposomal bupivacaine injection should not undergo a stellate ganglion block for 96 hours.Nursing assessments and considerations are summarized in the Table. As discussed above, anticoagulation therapy may not be discontinued before the stellate ganglion block and thus minor or major bleeding may occur. Frequent site assessments including visualization and palpation over the area of injection or catheter insertion should be prioritized after the procedure. Escalation of abnormal findings is paramount for quick intervention for any procedural complications including hematoma, bleeding, infection, and pneumothorax. Unintended blockade of the recurrent laryngeal nerve, phrenic nerve, or brachial plexus is rare,5 and assessment findings of hoarseness, respiratory difficulty, or loss of sensation or movement in the arm should be escalated immediately.There are few specific and reliable objective measures of the technical success of stellate ganglion block. Horner syndrome is a common, usually transient effect of the sympathetic nerve block. A triad of symptoms, including ptosis (drooping eyelid), miosis (constricted pupil), and anhidrosis (loss of sweating) on the side of the block can be seen after injection. Horner syndrome is self-limiting and usually resolves within 4 to 6 hours. Thorough assessment and clinical escalation are needed if the patient’s symptoms persist or worsen. Additionally, Horner syndrome can be challenging to observe in patients in the intensive care unit who are intubated and sedated.Ipsilateral extremity temperature increases or an increase in pulse oximeter perfusion index can be interpreted as technical success. Vasodilation and reduced perspiration in the upper extremity causes the surface temperature of the skin to increase, but the utility of this measure remains unclear.13,14 An increase in the perfusion index on pulse oximetry may signify success via increased vasodilation, perfusion, and vessel relaxation.5,15Stellate ganglion block is an emerging therapy for ventricular arrhythmias that are resistant to traditional therapies. Although few safety events have been reported, nursing care following a stellate ganglion block must include vigilant monitoring to identify and manage potential complications, including bleeding, transient nerve blocks, and LAST. Indicators of technical success may include increased ipsilateral extremity temperature and perfusion index. Institutional protocols should guide ongoing monitoring and response to any adverse findings. Timely recognition and intervention are essential to ensure patient safety and optimize therapeutic outcomes.
Anna Mall (Wed,) studied this question.