Anaesthetic techniques for carotid surgery.

In the GALA trial (Dec 20, p 2132), all types of regional anaesthesia were grouped as one: “local anaesthesia”. Yet clinical and anatomical studies confi rm important diff erences between simple subcutaneous infi ltration, formal “superfi cial” cervical plexus block, and a deep block. The last two are clinically equally eff ective, anatomical investigations showing that the so-called deep cervical fascia might not exist as a distinct or impermeable entity as previously supposed. Solutions freely enter the deep space: local anaesthetic placed relatively superfi cially in the neck will reach the same anatomical sites as that placed more deeply. However, the deep block results in a consistently higher rate of direct harm owing to the penetrating needle damaging or entering important vessels or even the cerebrospinal fl uid. We found this direct complication rate to be 0·25% (vs 0% for superfi cial cervical plexus block), and, further, a higher conversion rate to general anaesthesia of more than 2% (vs 0·4%). GALA fi nds an even higher rate of more than 4%. If these instances were confi ned to deep block, it suggests a perhaps prohibitive complication rate for this method. The GALA trial results failed to show diff erences between anaesthetic techniques in terms of cerebral or cardiac outcomes. However, by careful subgroup analysis, GALA might at least help establish which is the safer (and therefore more suitable) regional technique. With effi cacy equal, the safety profi le will help determine the anaesthetic choice.