Intra-arrest percutaneous stellate ganglion block: a scoping review

Introduction

Percutaneous stellate ganglion block (PSGB) has been widely described as an intervention for a variety of clinical conditions including complex regional pain syndrome, chronic post-surgical pain, phantom limb pain. Recently it has had increased interest in its role in treatment of ventricular arrhythmias (VA) (1). The objective of this study is to provide a scoping review of the reported literature regarding PSBG performed during cardiac arrest in order to describe the state of the literature. The recently published STAR study demonstrated that PSGB can be performed safely and reported effective VA suppression in 92% of patients with electrical storm (2). This procedure therefore represents a potential intervention for patients in refractory cardiac arrest in shockable arrhythmias.

Refractory shockable cardiac arrest is a pathology with increasing treatment complexity. The 2023 American Heart Association (AHA) focussed update on advanced cardiac life support (ACLS) gave extracorporeal cardiopulmonary resuscitation (ECPR) a grade 2A recommendation, a higher recommendation than amiodarone and adrenaline (3). However, ECPR is a cost and resource intensive intervention that is not universally available. Recent evidence suggests increased rates of return of spontaneous circulation (ROSC) with double sequential external defibrillation (DSED), a simple intervention which represents an opportunity to intervene earlier in the cardiac arrest (4). Likewise, PSGB conceivably represents a cost-effective and simple intervention that can be performed as an adjunct to ECPR, or when ECPR is unavailable.

Historical safety data assessing the anatomical approach to PSGB described no significant complications in approximately 2,000 patients receiving the block for analgesic purposes (5). PSGB has also been used for a wide variety of conditions including chronic post-surgical pain, herpes zoster pain and cardiac arrhythmias to name a few (5). Performance of the procedure mid-cardiac arrest represents suboptimal conditions, and it is important to determine the safety profile of the procedure in this context before widespread uptake can be recommended. The procedure also represents a potential distraction of proven resuscitation priorities. We present this article in accordance with the PRISMA-ScR reporting checklist (6) (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-95/rc).

Methods

We performed a scoping review of the use of intra-arrest PSGB to provide a narrative overview of the available literature. We did not seek to answer a single question, but instead to provide a description of the clinical context of published cases and their reported outcomes. The study was performed according to a pre-published protocol (7).

Database search

We performed a comprehensive electronic database search for articles using keywords, synonyms and subject headings that relate to VA, cardiac arrest and stellate ganglion block. We used controlled vocabulary specific to each database (see Appendix 1). Two review authors performed the search independently.

We searched the following databases for published studies:

• Cochrane Central Register of Controlled Trials (CENTRAL) (1996 to present);
• MEDLINE Ovid (1946 to present);
• Elsevier Embase (1947 to present);
• CINAHL EBSCO (1937 to present).

We performed a citation search of all included studies as well as any relevant studies and reviews on intra-arrest PSGB. We searched the grey literature search using Google Scholar.

Criteria for inclusion

Studies were included if they reported human cases of the use of PSGB in cardiac arrest. Case reports, case series, retrospective and prospective observational studies and randomised controlled trials (RCTs) were eligible. Conference abstracts were also considered eligible for inclusion. Animal studies, reports in healthy volunteers and studies reporting only on the use of PSGB in refractory VA not requiring active cardiopulmonary resuscitation (CPR) were excluded.

Data collection and analysis

All titles and abstracts of each reference identified by our search were independently screened by two reviewers (R.V., R.S., G.M., B.B.) and the full text of any potentially relevant studies were independently assessed for eligibility. Covidence software (8) was used to collate search results, remove duplicates, record screening decisions and exclusions at each stage. At each stage disagreements were resolved by discussion and consensus prior to proceeding.

Two review authors independently extracted information regarding study design, patient demographics, cardiac arrest characteristics, PSGB technique and outcomes. Where required, individual trial authors or organisations were contacted to obtain missing data or for clarification of unclear data. All studies were assessed for country of origin, authors, primary institution, and years of data collection to ensure outcomes were not collected from overlapping cohorts.

Details of collected data can be found in the appendix. We collected reported data regarding:

• Study characteristics;
• PSGB technique data;
• Patient demographics;
• Cardiac arrest-related data;
• Complication-related data.

Results

Included studies

Our scoping review identified 700 studies across four databases. Of these 23 were excluded as duplicates. One case was identified in the grey literature. Six hundred and two were excluded based on title and abstract review. A total of 77 full texts were reviewed, of which 65 were excluded (Figure 1) In total, 13 papers (2,9-20) were included in our final review. One trial registration was identified for an observational study that had not yet completed recruitment (21).

Figure 1 PRISMA study flow diagram.

Of the included studies, two were cohort studies (2,9), four were case series (10-12), and seven were case reports (13-20) (Table 1). Based on reported data collection time frames, four patients in three studies represent duplicates from patients included in Savastano et al. [2024] (11,19,20). However, outcomes of interest were reported for these four patients in these studies that were not included in Savastano et al. [2024], and as such they were included in our final review. In total, we identified 32 individual cases of PSGB being performed intra-arrest. Sex was reported in 23 cases, of which 15 (65%) were males.

PSGB procedural details

Only one case was performed as a bilateral PSGB (15). The rest were performed as single injection, unilateral block. In total, 20 patients had the LA formulation used for the block reported. Lignocaine was the most used agent and was the sole agent in 8 out of the 20 reported cases (40%). Two patients required a repeat block for recurrent VA, and in these instances, bupivacaine was utilised. Of the 32 reported cases, 23 (72%) cases were performed using a landmark technique and 7 (21.9%) were reported using the ultrasound (US) guidance. Only four cases commented on whether CPR was continued during the performance of the block. All four cases had CPR continued and were performed using US (Table 2). Of the 32 reported cases, seven were confirmed to have been performed in emergency department (ED) (22%). No prehospital cases were reported.

Cardiac arrest characteristics

In total, 22 (68.8%) cases reported an aetiology for cardiac arrest. In total 10 cases were the result of an acute myocardial infarction (AMI) (31.3%), all of which were successfully defibrillated following PSGB (Table 2). One case occurred 3 days post-AMI. Two cases were the result of chronic ischaemic heart disease (IHD) (6.3%). A wide spectrum of duration of cardiac arrest prior PSGB attempt was reported. Amino et al. (9) reported a mean duration of 36±75.4 electrical defibrillation attempts for successfully defibrillated cases and 7±3.8 electrical defibrillation attempts for unsuccessful cases. Successfully defibrillated cases were reported at up to 120 min of cardiac arrest, however this patient did not survive to hospital discharge (10). Given the protracted nature of these cardiac arrests, several concomitant interventions were trialled. In total, six patients were reported to have received DSED prior to PSGB (Table 2). Two patients underwent ECPR, one prior to PSGB (20) and one post-PSGB (10). Neither of these patients survived to hospital discharge. One 17-year-old patient underwent zone 1 resuscitative endovascular balloon occlusion of the aorta (REBOA) to augment cerebral perfusion then underwent PSGB at between 90 and 100 min to facilitate successful defibrillation (13). This patient was discharged neurologically intact. One patient received thrombolysis (10). Anti-arrhythmic drugs (AADs) were reported for 20 patients. Generally, routine AAD options were exhausted prior to attempting PSGB (Table 2). Four patients received beta-blockers (20%). Of the 20 patients with AAD reported, 19 received intravenous (IV) lignocaine prior to PSGB (95%).

Outcomes and PSGB-related complications

Of the 32 individual cases reported, only 23 cases reported ROSC as an outcome. A temporal relationship between performing the block and achieving ROSC was reported in 19 cases (82.6%) (Table 2). Savastano et al. reported 11 cases of intra-arrest PSGB but did not report whether ROSC was achieved for these cases. However, individual reports of 2 of these cases reported progression to ROSC post-PSGB. One of these patients underwent ECPR, with a PSGB being performed shortly after due to ongoing cardiac arrest post-cannulation. Of the 19 patients confirmed to have achieved ROSC, 15 survived to admission from the ED to hospital (78.9%) and 12 survived to hospital discharge (63.2%). Data was unavailable for 2 of these 19 patients. Data was unavailable for seven patients in the Italian cohort (2). One instance of ROSC post-PSGB was reported without apparent need for defibrillation (10). Where details were available, the rest reported a temporal relationship between PSGB and subsequent successful electrical defibrillation.

Three complications potentially attributable to PSGB were described in two identified cases. Rushatamukayanunt et al. described a patient experiencing a partial seizure following a PSGB using 10 mL of 2% lignocaine after multiple doses of IV lignocaine (18). It is possible that this seizure may have been caused by injection of lignocaine into the vertebral or thyroid artery in addition lignocaine toxicity cannot be excluded as a differential diagnosis.

Marcellino et al. described a case of lacosamide overdose with refractory cardiac arrest treated with bilateral PSGB (15). In this case, the patient was noted to experience sinus bradycardia following the arrest. Bradycardia is a recognised complication of lacosamide overdose. In addition, this patient experienced a left middle cerebral artery stroke. The authors report suspicion that the stroke was the result of cardioembolic phenomena in the setting of prolonged arrest. No haematomas were reported, including in the patients who underwent thrombolysis and extracorporeal membrane oxygenation (ECMO).

Discussion

What can we learn from the reported cases of intra-arrest PSGB?

Performing a PSGB during cardiac arrest is technically feasible

This review identified 32 cases of PSGB being performed intra-arrest, by a variety of proceduralists, in a variety of locations using both landmark and US techniques. In four cases that specifically commented, CPR did not have to be discontinued to facilitate the block (10,13,14). No visceral or vascular injuries were reported.

Intra-arrest PSGB had a temporal relationship with achieving successful defibrillation in prolonged cardiac arrest in patients with a variety of arrest aetiologies

In 19 of 23 cases (82.6%), a temporal relationship was described between PSGB and subsequently achieving ROSC occurred. This was despite prolonged refractory arrest prior to the PSGB in many cases. This relationship ranged from successful defibrillation on the next attempt to defibrillation within 10 minutes of the PSGB. No randomised data exists to confirm whether this association is real, and in most cases exhaustive AADs and other confounding interventions such as DSED where employed. However, given the likelihood of achieving ROSC rapidly decreases with time, this temporal relationship following prolonged cardiac arrest suggests that PSGB may be effective to some degree. All patients presenting with cardiac arrest due to AMI were able to successfully be resuscitated, although other aetiologies including toxicologic and primary arrhythmogenic arrests were successfully resuscitated as well.

Based on the described cases, PSGB may lower the threshold for successful electrical defibrillation rather than induce spontaneous reversion to sinus rhythm. Only one case reported spontaneous reversion to sinus rhythm post-PSGB in this review (10). The other cases in this review either do not report the circumstances surrounding achieving ROSC or report successful electrical defibrillation post-PSGB. If this procedure were to be pursued, it is essential all causes of failure to defibrillate are optimised prior to attempting the procedure, including pad contact and pad positioning, and that resuscitation is not ceased until electrical defibrillation is attempted again. If a previously shockable rhythm amenable to PSGB deteriorates to pulseless electrical activity (PEA) prior to performance of block, it is unclear if the PSGB should go ahead but it is reasonable to now omit this procedure as further sympathetic outflow blockade in conjunction with PEA is likely to be deleterious.

The risk: benefit analysis of PSGB in cardiac arrest differs when compared to refractory VA or outpatient settings

No complications were reported that could be definitively attributed to PSGB in this cohort. The risks described with PSGB include intravascular injection, vascular injury, haematoma, oesophageal or thyroid injury, upper limb palsy, pneumothorax, phrenic nerve block and laryngeal nerve palsy. In the context of a prolonged cardiac arrest, phrenic and laryngeal nerve block are of limited acute consequence given the patients generally undergo endotracheal intubation. Although it is not possible to confirm from this data whether Rushatamukayanunt et al.’s described seizure was the result of lignocaine toxicity, it does highlight the importance of maintaining awareness of the cumulative dose of administered local anaesthetic (18). In the reported literature of PSGB in ES, the risk of permanent upper limb palsy is extremely low (2). Inadvertent pneumothorax can easily be identified by assessing for lung sliding at the conclusion of the block by any critical care clinician with US skills, and this can be readily rectified if needed. The concern for vascular injury and haematoma is legitimate, particularly if the patient requires thrombolysis, anticoagulation, or ECMO. However, no cases included in this review described haematoma, and experience now exists with performing PSGB in therapeutically anticoagulated patients which has shown a low risk (2). In the event of a refractory cardiac arrest with no other interventions available to achieve ROSC, a skilled proceduralist that feels that they may be able to perform with block safely should perform their own risk-benefit analysis to determine whether to pursue PSGB and should be mindful of the cumulative dose of local anaesthetic administered.

Intra-arrest PSGB has been performed in a variety of locations by emergency physicians, critical care physicians, and cardiologists

This review identified PSGB being performed by proceduralists from emergency medicine, critical care and cardiology backgrounds. As with most invasive interventions employed in critically ill patients, it is reasonable that any appropriately trained clinician that regularly treats this condition may utilise this technique if it is likely to benefit the patient. If further data demonstrated high-level evidence that PSGB increases the likelihood of ROSC without an undue risk of complications, it may be possible for prehospital teams with a medical lead to perform this block in instances where prolonged hospital transfer are expected or where ECPR is not available, given the required equipment is highly mobile and affordable.

What questions does this review raise?

Is PSGB truly effective in achieving ROSC?

No randomised data exists regarding PSGB for the treatment of VA. In the 32 cases of PSGB used intra-arrest, data on defibrillation outcome was only available on 23 patients and out of this successful defibrillation was described in 19 patients and failure to achieve ROSC was described in 4 patients. In these patients, numerous other interventions were employed simultaneously that may confound the likelihood of achieving ROSC. Despite this, the temporal relationship of ROSC with the PSGB is compelling. This literature is at risk of a publication bias, as unsuccessful intra-arrest PSGB is unlikely to be reported in case reports. As a result, randomised data is required to determine whether PSGB is truly effective. Of note, the LIVE study is currently recruiting refractory cardiac arrest patients in Italy (21). This study will aim to recruit 53 arrested patients to be treated in the prehospital or ED setting with US-guided PSGB using 10 mL of 2% lignocaine. The primary outcomes of this study will include complication rates, feasibility and survival compared to historical controls. In addition, it will allow clinicians to choose whether the block is performed with US guidance or with landmark technique an important distinction, especially considering block performance in the pre-hospital setting. The study is currently powered to detect an increase in ROSC from 40% in historical controls to 70% in the trial participants.

Where does PSGB fit in the armamentarium of interventions for refractory shockable cardiac arrest without interfering with evidence-based interventions?

If this procedure were to be employed in a refractory cardiac arrest patient, it is essential that guideline and evidence-based interventions take priority in the first instance, and that the PSGB does not interfere with normal team workflow. However, given the rapid decline in the likelihood of achieving ROSC in prolonged cardiac arrest, it may be reasonable to employ PSGB if it is felt that it can be performed safely. If PSGB is felt to be feasible and potentially beneficial by the treating team, it should not be delayed until the likelihood of good neurological recovery is negligible. The LIVE study protocol intends to implement PSGB following the third unsuccessful defibrillation attempt. A proposed approach to incorporating the procedure in the workflow of a cardiac arrest is outlined in Figures 2,3. This proposed approach should not be considered a recommendation, but instead represents variables that may need to be considered if this intervention is pursued based on the limited available literature described. In the event of a shockable cardiac arrest, standard ACLS should be prioritised, with a focus on detecting and treating reversible causes. If ECPR is available, this should be considered. Following three shocks, consideration can be given to DSED or performing a vector change (22). These conceivably represent lower risk interventions than a PSGB and have RCT level evidence suggesting a benefit (4). The team should agree on whether appropriate doses of anti-arrhythmics have been administered, including whether the administered doses of lignocaine risks local anaesthetic toxicity. Before proceeding to the block, a final check should be conducted to confirm defibrillation cannot be further optimised, and to confirm the block is indicated. If the block is to be pursued, consideration should be given to whether the patient is likely to benefit. It may be reasonable to consider similar criteria to ECPR, including an end-tidal carbon dioxide (EtCO₂) >10, witnessed arrest with early bystander CPR, age, and time to block <60 min (23), although no evidence exists to determine if this is translatable to PSGB. Mechanical CPR may allow for a more predictable compression rhythm whilst performing the block, as well as potentially providing improved access to the patient.

Figure 2 Proposed approach to implementing PSGB in cardiac arrest. ACLS, advanced cardiac life support; ECPR, extracorporeal cardiopulmonary resuscitation; DSED, double sequential external defibrillation; AAD, anti-arrhythmic drug; PSGB, percutaneous stellate ganglion blockade; CPR, cardiopulmonary resuscitation.

Figure 3 Proposed resuscitation team roles for implementing PSGB without impeding ongoing resuscitation. PSGB, percutaneous stellate ganglion blockade; US, ultrasound; CPR, cardiopulmonary resuscitation; DSED, double sequential external defibrillation.

Is US guidance superior to a landmark technique?

The evidence available is insufficient to suggest superiority of US guidance in this context. The STAR study reported training in both techniques and a preference by the proceduralists was demonstrated for the landmark technique during cardiac arrest. The LIVE study will allow clinicians to choose the technique that they are comfortable with.

What is the ideal formulation for the local anaesthetic in this population?

Given lignocaine’s pharmacokinetics, it likely represents the favourable choice of local anaesthetic (24). Lignocaine was used as a sole agent in 42.1% of included cases that reported their formulation. A low volume, high concentration block, such as 2% lignocaine, may potentially improve efficacy whilst avoiding potentially hazardous spread of the agent. It is however well recognised that lignocaine’s efficacy is impaired in acidic tissue, as may be encountered in prolonged arrest. Although the ideal formulation would need to be easily accessible, affordable and able to be safely drawn up in a crisis, consideration may need to be given to adjuncts such as alkalinisation with sodium bicarbonate (24) in future research.

What training is necessary to be able to reliably perform a PSGB intra-arrest with minimal risk of complications?

The only study that described the clinicians’ specific training in PSGB was the STAR study. This study described an 8-hour course for proceduralists that included learning on both landmark and US techniques, specific training on utilisation in cardiac arrest and 4 hours of hands-on workshops and specific simulation-based training in cardiac arrest PSGB. Given the low rates of complications in the STAR study, it is our opinion that this process should be considered the safe and appropriate standard of training. The LIVE study protocol describes a similar training process that in addition includes training on volunteers.

Strengths and weaknesses

This review represents the most comprehensive review of the literature on this topic. A pre-published protocol was followed, and it was reported in line with the PRISMA-ScR checklist. However, the available literature is extremely limited, is likely to suffer from significant confounding and publication bias. The depth of description of the included cases varied widely and as such we are hesitant drawing firm conclusions at this stage.

Conclusions

Intra-cardiac arrest PSGB is technically feasible and may increase the possibility of successful defibrillation in cases of refractory VA. It has been described in a variety of aetiologies of refractory cardiac arrest. The optimal technique, type of local anaesthetic, dose and whether the use of US is superior is not currently known. Further data in these areas will provide a standardised approach to the procedure.

The LIVE study currently underway will aim to examine the feasibility and practicability of performing a PSGB in the pre-hospital setting and will importantly also allow clinicians to choose how the block is performed and whether the rate of ROSC is higher in those treated with PSGB as compared to historical controls. The results of this study are eagerly awaited.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA-ScR reporting checklist. Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-95/rc

Peer Review File: Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-95/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-24-95/coif). R.S. is employed by CareFlight in the capacity of prehospital doctor and has no financial disclosures. The opinions expressed in this manuscript don’t reflect necessarily those of the employer. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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