|Year : 2017 | Volume
| Issue : 2 | Page : 80-85
A systematic approach to give bedside ultrasound-guided celiac plexus block
Ekta Dhamija1, Indermohan Khandelwal1, Sushma Bhatnagar2, Sanjay Thulkar1
1 Department of Radiodiagnosis, Dr. B.R.A Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
2 Department of Onco-Anaesthesia and Palliative Care, Dr. B.R.A Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||6-Sep-2017|
Room No. 242, 2nd Floor, Department of Onco-Anaesthesia and Palliative Care, Dr. B.R.A Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi 600 029
Source of Support: None, Conflict of Interest: None
Celiac plexus neurolysis (CPN) is an established modality of choice for the management of pain due to advanced upper abdominal malignancies. The procedure is usually performed under imaging guidance, traditionally, using fluoroscopy. Numerous techniques and approaches have been described in literature for conducting CPN with fluoroscopy and computed tomography guidance. Ultrasound (USG) has gained popularity recently for performing the procedure with added advantage of being radiation free, enabling real-time visualization of the needle tract, and possibility of performing CPN in bedside setting. This article describes the technique of USG-guided CPN using percutaneous anterior approach and discusses the dos and don'ts associated with it.
Keywords: Celiac plexus neurolysis, pain management, ultrasound guidance
|How to cite this article:|
Dhamija E, Khandelwal I, Bhatnagar S, Thulkar S. A systematic approach to give bedside ultrasound-guided celiac plexus block. Indian J Pain 2017;31:80-5
|How to cite this URL:|
Dhamija E, Khandelwal I, Bhatnagar S, Thulkar S. A systematic approach to give bedside ultrasound-guided celiac plexus block. Indian J Pain [serial online] 2017 [cited 2017 Sep 26];31:80-5. Available from: http://www.indianjpain.org/text.asp?2017/31/2/80/214119
| Introduction|| |
Pain is one of the most common distressing symptoms in patients with advanced malignancies. In inoperable upper abdominal cancer patients, it is known to cause significant impairment of the quality of life and these patients need high doses of analgesics and opioids for pain relief. Celiac plexus neurolysis (CPN) has been widely accepted as the modality of choice for symptomatic pain relief in these patients and is associated with reduction in opioid dose. Moreover, it is a safe and minimally invasive procedure with <2% incidence of major complications.
CPN is basically chemical splanchicectomy of the efferent nerve fibers using chemical agents such as alcohol or phenol. Image guidance has become an imperative part of the procedure to ensure proper needle localization and drug spread. Various techniques of performing CPN have been described in literature using fluoroscopy and computed tomography (CT) guidance.,,,,,,, Ultrasound (USG) is the imaging modality which is cheap, readily available and is associated with no risk of radiation exposure to patient or operator. In addition, the development of portable USG machines has revolutionized the role of imaging in evaluation of patients in bedside setting and performing various procedures without having patient shifted to the different room. Working in the same line, USG-guided CPN is being performed and is being accepted as a boon in palliative care practice for advanced cancer patients. At authors' institute, this is the preferred modality for conducting CPN in oncology setting. This article describes the technique and limitations of USG-guided CPN.
| Planning and Technique|| |
The USG-guided CPN is performed using percutaneous anterior approach with patient lying in supine position; after taking written informed consent by the patient. The patient needs to be evaluated for feasibility of the procedure and investigated to rule out any contraindications for the procedure. The entire workup includes teamwork of palliative care physician, oncologist, and interventional radiologist at authors' institute.
The initial presentation of the patient is usually to an oncology clinic where he/she is evaluated in terms of demographic, clinical, and laboratory details followed by evaluation with cross-sectional imaging, either CT or magnetic resonance imaging. The operability is assessed based on these parameters. The patient who complaints of severe abdominal pain due to primary advanced malignancy or secondary metastases is referred to pain/palliative care clinic for further management. The pain physician reevaluates and records baseline visual analog scale (VAS) score for pain in the patient and manages it with oral analgesics and opioids.
Patients who have no or mild relief with opioids or those who experience severe side effects with opioids intake are considered for CPN. The cross-sectional imaging is then interpreted by the radiologist to assess amenability of CPN. The following features are particularly looked for -extent of primary or secondary disease, preservation of retroperitoneal fat in pre-/para-aortic location, presence of any other associated pathology such as ascites, aortic aneurysm, abdominal wall, or intra-abdominal infection which can defer the procedure.
A collaborative effort and discussion is mandatory to ascertain that pain is due to infiltration of nerve fibers and whether CPN will actually benefit the patient or not. After this detailed evaluation, if it is established that the pain is due to upper abdominal malignancy and the fat around celiac axis is preserved with no encasement of celiac trunk by primary tumor or lymphadenopathy; then the patient is considered for CPN.
Preprocedure work up
The patient and family as a unit, undergoes comprehensive counseling about what is being done, why and how. The role of interventional radiologist and pain physician is to inform the patient about the outcome and potential complications of the procedure; and to obtain written informed consent from the patient. After taking patient's consent, complete blood count and coagulation profile of patient are obtained to rule out possible contraindications, such as coagulopathy and thrombocytopenia.
The patient is kept overnight fasting so as to decrease bowel gas that may hinder visualization of the retroperitoneal structures. Procedure is done early morning and half dose of analgesics given through intravenous (IV) route prior to the procedure. The other drugs such as antihypertensives and chemotherapeutic agents are administered as indicated. Oral anticoagulants are stopped the night before and coagulation profile is assessed before conducting the procedure.
The baseline pain scale (VAS score) is recorded and approach for needle insertion is planned on preprocedure imaging.
[Table 1] enumerates the equipments required for USG-guided CPN.
The basic hardware includes USG machine, tray with necessary containers, Chiba needle, and the diluted drug in glass syringes. The most common neurolytic agents available are ethanol and phenol. Where ethanol causes damage to nerve fibers by causing precipitation of endoneural lipoproteins and mucoproteins with resultant extraction of cholesterol, phospholipid, and cerebroside from the neurilemma; phenol causes protein coagulation and necrosis of the neural tissue. Concentration of 50%–100% of ethanol or 5%–10% of phenol is recommended for CPN. Long-acting anesthetic agent such as bupivacaine is added with ethanol as latter is known to cause local transient severe pain on injection. On the other hand, phenol is more viscous than ethanol which limits its utilization in higher concentration and makes it unsuitable for mixing with iodinated contrast material, in case fluoroscopic or CT guidance is being used.
At authors' institute, 50% ethanol with bupivacaine is used as standard drug for CPN.
Steps of the procedure
The patient lies in supine position with hands preferably by the side of head or far from the area of interest. Access to IV line is established and one pint of normal saline infusion is started to prevent postprocedure dehydration. The abdomen is exposed and preliminary USG is performed to assess the needle track and to depict expected site of injection. The settings are adjusted on USG machine for adequate visualization throughout the procedure. If the visualization is grossly limited due to bowel gas, the procedure should be deferred and an alternate imaging modality should be used. For the beginners and in some patients where bowel gas is not hampering visualization a lot, the procedure may be conducted in radiology department with additional CT guidance and in the presence of interventional radiologist.
After preliminary USG, the exposed region of interest is cleaned and draped. The convex transducer is cleaned and covered with tegaderm or sterile camera cover. Using sterile jelly, probe is put in the region of epigastrium and the anatomy is identified: vertebral body is seen posteriorly, aorta and IVC anterior to the vertebra, celiac artery arising from the anterior part of abdominal aorta, and bifurcating into common hepatic artery and splenic artery. The fat around celiac artery is seen as echogenic area in the paraaortic region.
Skin entry site is instilled with local anesthetic agent (2–3 ml of 1% lignocaine) till the level of peritoneum, under sonographic guidance. The Chiba needle is then inserted as planned through right- or left-sided approach. In right-sided (corresponds to patient's right side) approach, the needle traverses through liver parenchyma (transhepatic route) and in left-sided approach, it traverses through stomach wall (transgastric route) to reach up to paraaortic location with continuous real-time visualization of the celiac artery, hepatic artery, and needle tip. This passage through liver, stomach, and sometimes pancreas do not cause any significant complications in the patient and are usually uneventful. However, care should be taken while injecting alcohol that it should not enter pancreatic parenchyma as it can induce pancreatitis.
Once the needle tip is in pre-/para-aortic location, suction is applied to confirm negative aspirate. If suction leads to aspiration of blood, it indicates that needle tip is in some blood vessel and requires careful repositioning. If negative, diluted drug is injected. In authors' institute, 30 ml of diluted drug containing 50% ethanol and 0.25% bupivacaine is injected. Some authors have recommended performing a diagnostic block first by injecting local anesthetic agent followed by injection of absolute alcohol, if diagnostic block is positive (patient has relief in pain). The injected drug is seen as increased echogenicity in vicinity of aorta and celiac artery referred to as “echogenic cloud” which confirms adequate deposition and spread of drug on USG. The needle is removed while injecting normal saline along the path of needle to prevent tracking of neurolytic agent along it [Figure 1].
|Figure 1: Steps of ultrasound-guided celiac plexus neurolysis: (a) patient lies in supine position and the epigastric area is cleaned and draped; (b) local anesthestic agent is injected into the skin, subcutaneous tissue up to the level of peritoneum along the planned needle track; (c) ultrasound image showing the anatomical structures – celiac artery arising from aorta and bifurcating into hepatic and splenic artery. The echogenic area on both sides of celiac artery is the target location for celiac plexus neurolysis; (d) 22G Chiba needle is inserted under real-time ultrasound guidance through right transhepatic route (arrow in e) or left transhepatic (arrow in f) or transgastric route. The injected drug is seen as echogenic cloud around the celiac artery (asterisk in e and f); Ao: Aorta, CA: Celiac axis, HA: Hepatic artery, SA: Splenic artery|
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Continuous monitoring of pulse, blood pressure, electrocardiogram, and respiration is done throughout the procedure. Note should be made of pre- and post-procedure pain scale to assess the effect of CPN.
Postprocedure work up and follow-up
The patient is admitted in palliative care ward and observed for 24 h for any possible minor or major complications. VAS score is calculated in postprocedure period immediately after CPN and at the time of discharge. Modified analgesic regimen based on the World Health Organization guidelines is administered to the patient. Follow-up is advised routinely at 1st and 4th week after conducting CPN and immediately, in case of increased pain or any other complaint. Routine follow-up in oncology clinic to be done as suggested by the clinician.
If the patient cannot come to the OPD, telephonic contact is made with him/her to assess for performance status of patient.
[Table 2] illustrates the basic key points of the technique.
| Efficacy|| |
The efficacy of CPN has been studied by various authors though the technique varies in each setting/institution. In a meta-analysis, Eisenberg et al. reported 89% pain relief during first 2 weeks post-CPN with long-lasting benefit in 90% of the patients till the time of follow-up or survival. In a prospective randomized controlled trial, efficacy and morbidity associated with three different techniques of CPN were evaluated and no statistical difference was observed in pain relief postprocedure using different techniques. It was also documented that neurolytic celiac plexus block was effective in more number of patients if carried out early during the disease process. Patients with unresectable pancreatic cancer who underwent CPN experienced larger decrease in pain intensity as compared to patients receiving systemic oral analgesic therapy alone.
However, in these studies, CPN was conducted either without radiological guidance or with fluoroscopy or CT guidance. Limited literature is available on USG-guided CPN. In 1989, Montero Matamala et al. performed CPN under USG guidance using percutaneous anterior approach in nine patients by injecting 35 ml of 50% alcohol and achieved good pain relief in 78% of patients during 6-month follow-up period. Das and Chapman used sonographic guidance in conducting CPN for hepatobiliary interventions in nine patients and observed good pain relief in 88% patients. Various authors have subsequently performed USG-guided CPN in an attempt to assess its efficacy and safety, as tabulated in [Table 3].,,,,,,
|Table 3: Results of various studies demonstrating ultrasound-guided celiac plexus neurolysis|
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| Complications|| |
CPN is a safe procedure, associated with minor complications. Anterior approach is further associated with lower rate of complications as there is no risk of traversing needle close to the spinal canal or through the vital retroperitoneal structures such as kidney. Hence, there is less chance of injuring somatic nerve roots minimizing risk of neurological complications. Although in anterior percutaneous approach, needle does pass through liver, pancreas, and stomach; no significant complication has been reported with 22G needle. USG also enables us to visualize the major vessels; hence inadvertent injury to them can also be avoided.
Minor complications related to drug injection and neurolysis include pain at puncture site, transient epigastric pain due to injected drug, transient diarrhea, and hypotension., Local site pain and epigastric pain last for up to 30 min and can be managed with oral or IV analgesics/opioids. Use of anesthetic agent along with neurolytic agent also reduces incidence and severity of pain due to nerve damage caused by the latter. Hypotension and diarrhea are transient side effects of CPN which occur due to unopposed parasympathetic activity following destruction of sympathetic fibers. These complications are usually self-limiting and have been reported in 10%–52% of the patients. Perioperative and postprocedural administration of IV fluids, bed rest, and continuous monitoring of patients help in managing them. Symptomatic treatment can be given in moderate-to-severe cases.
Rare complications documented in literature are hematoma formation, chemical peritonitis, abscess formation, visceral injury, and fistula formation. The most serious complication reported due to CPN is paraplegia (0.15% of patients) occurring due to spasm or injury to artery of Adamkiewicz supplying the spinal cord., However, this complication has not been reported with anterior percutaneous approach as the needle is far from these structures and injection of alcohol is performed under observation, especially using USG guidance.
Although USG guidance for conducting CPN is gaining acceptance, it is majorly limited by lack of skill and expertise. There is no doubt that it needs practice to perform and manipulate needle and USG probe at same time and that is why authors' recommend team effort and learning with radiologists, especially for beginners.
Other limitations are inherent limitations of USG as a modality (a) poor bowel preparation leads to excessive bowel gas causing impaired visualization of anatomical structures; (b) markedly obese patients, in whom penetration of the USG waves itself is limited; and (c) uncooperative patients who are either not willing for any sort of intervention or are physically/mentally challenged to cooperate.
| Summary|| |
In brief, USG is the imaging modality which is readily available, cheap, radiation free, and enables real-time visualization of needle. All these qualities make it the modality of choice for carrying out interventional procedures. With the use of USG guidance, CPN can be performed in bedside setting without the need of shifting the patient, using anterior percutaneous approach which is comfortable for the patients in pain. There is need of gaining expertise on the part of physician which seems to be one of the major obstacles in its acceptance on large scale.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]