Efficacy of Ultrasound-Guided Axillary Brachial Plexus Block for Analgesia During Percutaneous Transluminal Angioplasty for Dialysis Access

Anesthetic effect of ultrasound-guided block of the musculocutaneous nerve during endovascular treatment of dysfunctional radiocephalic arteriovenous fistulas

BACKGROUND

Delivering requisite and minimal anesthesia for endovascular treatment (EVT) of dysfunctional arteriovenous fistulas (AVFs) under the target nerve block can achieve reasonable analgesia. We evaluated the anesthetic efficacy of ultrasound (US)-guided selective block of the musculocutaneous nerve (MCN) during the EVT of runoff venous strictures in the forearm through the radiocephalic (RC)-AVF at the wrist or the anatomical snuff box and analyzed the factors inhibiting the analgesia achieved under the MCN block.

METHODS

We enrolled 30 adult patients undergoing hemodialysis who had received 78 EVT sessions in an outpatient clinic mainly for long and/or multiple outflow-venous strictures in the forearm under US-guided blocks of the MCN, which provides sensory innervation to the anterolateral forearm where the cephalic vein courses. We assessed patients' pain during balloon dilations using the Wong-Baker FACES® Pain Rating Scale (WBFRS) and evaluated the factors increasing the pain (WBFRS score ⩾4), including patient characteristics, dilated strictures, additional nerve blocks, and types of balloon catheters.

RESULTS

In 25 EVT sessions (32.1%) out of 78 sessions, patients complained of stronger pain (WBFRS score ⩾4), while in the other 53 sessions (67.9%), presented with no pain and slight pain (WBFRS score = 0 or 2). Univariate analysis clarified that dilation of the AVF anastomosis, presence of dilated stenosis >4 cm, and a single block of the MCN or its sensory terminal significantly triggered more pain (p < 0.05). Consequently, multivariate analysis of all the factors with p < 0.1 in the univariate analysis, including multiple dilated stenosis sites, demonstrated that dilation of the AVF anastomosis significantly caused severe pain despite the anesthesia of the MCN block (p < 0.05).

CONCLUSION

US-guided selective block of the MCN could be a leading anesthetic option for EVT for multiple long stenoses of the cephalic vein draining through the RC-AVF in the wrist or anatomical snuff box.

Brachial plexus block using only 1% lidocaine to reduce pain during the endovascular treatment of dysfunctional arteriovenous access

BACKGROUND

Interventional endovascular treatments of dysfunctional arteriovenous (AV) access for hemodialysis can cause pain and discomfort to the patients. Ultrasound-guided brachial plexus block (BPB) is an alternative regional anesthesia method, but conventional BPB using ropivacaine or bupivacaine may cause long-lasting motor power loss, significantly reducing patient satisfaction. This study aimed to introduce BPB using only 1% lidocaine, which induces sensory loss while minimizing motor block, and evaluate the efficacy and safety of this procedure.

METHODS

This retrospective study was conducted on 277 consecutive patients with dysfunctional AV access requiring percutaneous transluminal angioplasty (PTA). Of these, 174 patients underwent the BPB procedure using 1% lidocaine. Time data were recorded, and the motor strength grade (MRC scale, grade 0-5) was evaluated. Numeric rating pain score (NRPS, grade 0-10) was asked during every PTA, and overall NRPS and satisfaction scores (scale 1-3) were asked after the procedure was completed.

RESULTS

Of the 174 patients who received BPB, the success rate was 100%, and there were no significant complications related to BPB. The MRC scale measured at the time when the complete sensory loss was achieved was 1.99 ± 0.63, and that at the point of sensory recovery when the block effect expired was 3.93 ± 0.62, indicating a good grade of motor strength. The average NRPS during PTA in the BPB group was significantly lower than that of the control group without BPB (1.04 ± 2.04vs 6.30 ± 2.71, p < 0.001). The overall satisfaction score was significantly higher in the BPB group than in the control group (2.79 ± 0.50vs 2.00 ± 0.81, p < 0.001).

CONCLUSIONS

BPB using only 1% lidocaine can induce a sensory block while minimizing the effect on motor function. It can be applied safely in an outpatient clinic setting with relatively higher satisfaction.

Ultrasound-Guided Popliteal Sciatic Nerve Block: A Minimally Invasive Method for Pain Control During Endovascular Treatment of Critical Limb Ischemia

PURPOSE

To evaluate the safety and effectiveness of ultrasound-guided popliteal sciatic nerve block (PSNB) for pain control in endovascular treatment of critical limb ischemia (CLI).

MATERIALS AND METHODS

This retrospective study included 252 patients who underwent endovascular treatment for CLI between January 2020 and August 2022. Of these, 69 patients underwent PSNB, whereas moderate procedural sedation and analgesia was delivered in 183 patients. Pain scores were assessed using the visual analog scale (VAS) before and during the intervention. Technical and clinical success of PSNB, duration of the procedure, time to onset of nerve block, time for block resolution, and adverse events were recorded. Patient and operator satisfaction were assessed using the Likert scale.

RESULTS

All PSNB procedures were technically and clinically successful, and the mean procedural duration of PSNB was 5.0 minutes ± 0.8 (range, 4-7 minutes). Prolonged effect of PSNB was observed in 3 patients, which resolved within 24 hours. No adverse events were encountered. Median VAS score was significantly lower in the PSNB group than in the moderate procedural sedation and analgesia group during endovascular treatment (0 [range, 0-2] vs 3 [range, 0-7]; P < .001). Patient satisfaction was comparable ("very satisfied" in 66 [95.7%] vs 161 [88.0%]; P = .069). However, operator satisfaction was significantly higher in the PSNB group ("very satisfied" in 69 [100%] vs 161 [88.0%]; P = .003).

CONCLUSIONS

PSNB is safe and effective for pain control during endovascular treatment of CLI. Low adverse event rates with high patient and operator satisfaction make PSNB a reasonable alternative for high-risk patients.

Sedoanalgesia with intravenous midazolam and fentanyl for angioplasty of dysfunctional arteriovenous access: A retrospective single-center analysis

BACKGROUND

Endovascular therapy, such as percutaneous transluminal angioplasty (PTA), stenting, or embolization, is a well-established form of treatment to prolong the lifespan of arteriovenous access. These procedures, especially PTA, can be accompanied with severe pain. We reviewed and analyzed the efficacy, safety, and outcome of sedoanalgesia using intravenous midazolam and fentanyl, for pain relief during these procedures.

METHODS

Two hundred and two consecutive patients with dysfunctional dialysis access that had undergone endovascular procedure in our institute between July and November 2017 were included in this study. The dialysis access profile, procedure complication, and 10-point Visual Analog Scale (VAS) were collected. One-year clinical follow-up record was also collected to evaluate arteriovenous access patency and long-term complications.

RESULTS

Among the 202 patients, the mean age was (mean ± SD) 67.0 ± 12.08 years. Dialysis access profile of these patients were 119 (58.9%) native arteriovenous fistula and 162 (74.2%) forearm access. The number of lesions treated were 1.63 ± 0.802.Immediate complications included 11 (5.44%) nausea/vomiting, 24 (11.88%) desaturation (SpO2 < 90%, resolved after pillow removal or jaw trust), 16 (7.9%) hypotension (SBP < 90 mmHg, resolved without inotropic agents). There was a low average pain score (1.16 ± 1.594) during the procedure with 136 (67.3%) no pain (VAS 0-1) and 56 (27.7%) mild pain (VAS 2-4). Higher VAS score correlated with overweight patients, longer PTA time and pain after procedure. Six-month primary patency rate was 49.17% and primary assisted patency rate was 93.04%.

CONCLUSIONS

Sedoanalgesia with intravenous midazolam and fentanyl is an easy, safe, and effective method for surgeons.

Neurological pain relief interventional radiology procedures

Neurological interventions have taken on a significant role in interventional radiology (IR) practice. Indications fall under three main categories: (1) intraprocedural pain management, (2) cancer pain palliation, and (3) chronic non-cancer pain control. Short-term regional anaesthesia can be achieved with local anaesthetics, while longer-term pain control can be attained with radiofrequency neuromodulation (pulsed or otherwise) or thermal/chemical neurolysis. This review article summarises the therapeutic options, applications, and techniques of commonly used peripheral nerve and plexus interventions in IR.

A preliminary animal study on the prediction of nerve block success using ultrasonographic parameters

This study aimed to evaluate the diagnostic value of ultrasonographic parameters as an indicator for predicting regional nerve block success. Ultrasound-guided sciatic nerve block was performed in seven dogs using either 2% mepivacaine (nerve-block group) or saline (sham-block group). The cross-sectional area (CSA), nerve blood flow (NBF), and shear wave velocity (SWV) of the sciatic nerve (SWV_N), SWV of the biceps femoris muscle (SWV_M), and their ratio (SWV_NMR) were measured at 0, 30, 60, and 90 min after the nerve block as well as the change rate of each parameter from the baseline. A receiver operating characteristic (ROC) curve analysis was performed to determine the diagnostic value of each parameter in the prediction of nerve block success. No significant changes were observed in the CSA or NBF in association with the nerve block. The SWV_N and SWV_NMR in the nerve-block group were significantly higher than those in the sham-block group at 90 min and at 30, 60, and 90 min, respectively (p < 0.05). The change rates of SWV_N and SWV_NMR in the nerve-block group were significantly higher than those in the sham-block group at all time points (p < 0.05). The ROC curve analysis showed that SWV_N had a moderate diagnostic accuracy (area under the curve [AUC], 0.779), whereas SWV_NMR and change rates of SWV_N and SWV_NMR had a high diagnostic accuracy (AUC, 0.947, 0.998, and 1.000, respectively). Ultrasonographic evaluation of the SWV_N and SWV_NMR could be used as indicators for predicting nerve block success.

Application of Midazolam Injection in Patients with Intraoperative Nerve Block Anesthesia and Sedation Assisted by Imaging Guidance

OBJECTIVE

In the present study, we explored the clinical effect of midazolam as an adjuvant analgesic and tranquilizer after brachial plexus block anesthesia with the aid of imaging guidance.

METHODS

We selected 106 patients who had undergone elective unilateral upper extremity surgery from January 2017 to December 2019 and randomly divided them into groups A and B, with 53 cases in each group. All the patients had undergone brachial plexus block anesthesia. Group A received imidazole-assisted sedation, and group B received fentanyl plus midazolam-assisted sedation. Under ultrasound-guided intermuscular sulcus brachial plexus block, we observed and recorded the ultrasound anatomical images before injection, including the distance from the lower edge of the upper, middle, and lower trunk of the forearm brachial plexus to the skin. We also recorded the anesthesia and operation times, effects of the anesthetic block, and incidence of adverse reactions.

RESULTS

The distance from the lower edge of each nerve trunk to the skin averaged 1.002 cm for the upper stem, 1.598 cm for the middle stem, and 2.26 cm for the lower stem. The average anesthesia procedure time was 3 minutes, 56 seconds and was within 3-5 minutes for 92% of the procedures. The anesthesia effect was excellent, good, and poor in 81%, 11%, and 6%, respectively, and ineffective for 2% and effective for 92%.

CONCLUSIONS

The ultrasound-guided inferior intermuscular sulcus approach for brachial plexus block is suitable for unilateral upper extremity radial hand surgery. For surgery involving the upper extremity ulnar hand side, a larger dose (concentration) of local anesthetic should be used within a safe range and/or an additional ulnar nerve block might be necessary. Midazolam adjuvant medication can have a good sedative and amnestic effect in brachial plexus block anesthesia, helping to reduce pain and inhibit the increase in stress levels.

Efficacy and Safety of Ultrasound-Guided Supraclavicular Brachial Plexus Block during Angioplasty of Dysfunctional Arteriovenous Access: A Prospective, Randomized Single-Center Clinical Trial

PURPOSE

To evaluate the efficacy and safety of the ultrasound-guided supraclavicular brachial plexus block (BPB) during angioplasty of dysfunctional arteriovenous access.

MATERIALS AND METHODS

Eighty study participants with dysfunctional arteriovenous access were enrolled in this prospective, randomized clinical trial between November 2016 and February 2018. Eighty patients were randomized to either the ultrasound-guided supraclavicular BPB group (mean age ± standard deviation [SD], 65.1 ± 12.4; male:female = 17:23) or the no regional anesthesia group (mean age ± SD, 64.0 ± 11.7; male:female = 25:15). Pain was assessed on the 10-point Visual Analogue Scale. Participant satisfaction was examined. Six-month clinical follow-up was done to evaluate arteriovenous access patency and long-term complications.

RESULTS

The BPB group showed a lower average pain score than the control group (mean ± SD, 0.9 ± 1.9 vs 6.4 ± 2.5; P < .001). Participant satisfaction (mean ± SD, 2.8 ± 0.5 vs 2.1±0.8; P < .001) was also higher in the BPB group. Six-month patency was 65% (26/40) in the BPB group and 59% (23/39) in the control group, with no significant difference between the 2 groups (P = .59). No major immediate or delayed complications were observed.

CONCLUSIONS

Ultrasound-guided BPB is highly effective in reducing pain during angioplasty of dysfunctional arteriovenous access with an acceptable safety profile.