Continuous stellate ganglion block for ventricular arrhythmias: case series, systematic review, and differences from thoracic epidural anaesthesia

Background: Percutaneous stellate ganglion block (PSGB) through single bolus injection and thoracic epidural anaesthesia (TEA) have been proposed for the acute management of refractory ventricular arrhythmias (VAs). However, data on continuous PSGB (C-PSGB) are scant. Aims: To report our dual-center experience with C-PSGB and to perform a systematic review on C-PSGB and TEA. Methods: Consecutive patients receiving C-PSGB at 2 centers were enrolled. The systematic literature review follows the latest PRISMA criteria. Results: Our case series (26 patients, 88% male, 60±16 years, all with advanced structural heart disease, LVEF 23±11%, 32 C-PSGB performed, median duration 3 days) shows that C-PSGB is feasible and safe and leads to complete VAs suppression in 59% and to overall clinical benefit in 94% of cases. Overall, 61 patients received 68 C-PSGB and 22 TEA, with complete VAs suppression in 63% of C-PSGBs (61% of patients). Most TEA procedures (55%) were performed on intubated patients, as opposed to 28% C-PSGBs (p=0.02); 52% of patients were on full anticoagulation at C-PSGB, none at TEA (p<0.001). Ropivacaine and lidocaine were the most used drugs for C-PSGB, and the available data support a starting dose of 12 mg/h and 100 mg/h, respectively. No major complications occurred, yet TEA discontinuation rate due to side-effects was higher than C-PSGB (18% versus 1%, p=0.01). Conclusions: C-PSGB seems feasible, safe, and effective for the acute management of refractory VAs. The antiarrhythmic effect may be accomplished with less concerns for concomitant anticoagulation compared to TEA, and with a lower side-effects related discontinuation rate.