Regional anaesthesia practice for arteriovenous fistula formation surgery

The upper extremity regional anaesthesia trifecta: three upper extremity nerve blocks for awake upper-limb surgery in a patient with a history of contralateral pneumonectomy

While regional anaesthesia plays a pivotal role in the perioperative management of patients undergoing upper extremity surgery, its utility can be limited by the risk of hemi-diaphragmatic paresis. Furthermore, each approach to blocking the brachial plexus has associated limitations that may result in incomplete upper extremity anaesthesia. We describe the combination of three upper extremity nerve blocks to achieve surgical anaesthesia of the whole arm for a patient who had previously undergone a contralateral pneumonectomy. On this occasion, she required upper arm lipectomy and arteriovenous fistula formation. Adequate blockade was achieved with no significant perioperative complications. This case demonstrates the potential of this approach for patients with respiratory compromise undergoing upper limb procedures.

Effects of double vs triple injection on block dynamics for ultrasound-guided intertruncal approach to the supraclavicular brachial plexus block in patients undergoing upper limb arteriovenous access surgery: study protocol for a double-blinded, randomized controlled trial

Background

Ultrasound-guided intertruncal approach (IA) has been proposed to be an alternative and promising approach to the supraclavicular block (SCB), in which double injection (DI) of local anesthetics (LA) is sequentially administered between intertruncal planes. We would like to apply a refined injection technique, named triple injection (TI) technique, based on the 3 separate compartments visualized by ultrasound. The aim of this study is to compare the percentage of patients with complete sensory blockade at 20 min of DI vs TI technique, when they are applied in patients undergoing upper limb arteriovenous access surgery.

Methods

This study is a prospective parallel-group randomized controlled trial. A total of 86 end-stage renal disease patients will be randomly allocated to receive IA-SCB using either DI or TI technique with identical LA (0.5% ropivacaine 24 mL). The primary outcome is the percentage of patients with complete sensory blockade of all 4 terminal nerves (median, ulnar, radial, and musculocutaneous nerves) of the brachial plexus measured at 20 min after injection. The secondary outcomes will consist of the sensory or motor blockade of all individual nerves, onset times, performance time, diaphragmatic paralysis, surgical anesthesia, and adverse events.

Discussion

It is expected that ultrasound-guided IA-SCB with the TI technique results in better block dynamic in patients undergoing upper limb arteriovenous access surgery.

Trial registration

Chinese Clinical Trial Registry ChiCTR2100045075.

Supraclavicular brachial plexus and paravertebral blocks: novel regional anaesthetic technique for brachioaxillary fistula formation with a synthetic graft

Vascular access formation surgery for renal replacement therapy can be performed under local, regional or general anaesthesia. Regional anaesthesia may offer several advantages, however the sensory innervation to the upper medial arm can be difficult to adequately block. We describe a novel regional anaesthetic technique using both supraclavicular brachial plexus and paravertebral blocks for a multimorbid 73-year-old woman undergoing brachioaxillary fistula formation with a synthetic graft. An ultrasound-guided supraclavicular brachial plexus block was performed, followed by an ultrasound-guided T2/3 level paravertebral block. Adequate sensory blockade for surgery was achieved. Supplemental local anaesthetic infiltration was not required, and the operation was well tolerated by the patient. We consider this to be a valuable regional anaesthetic technique for vascular access formation surgery involving the upper arm.

Individualised care or anaesthetist preference: an uncomfortable question

There is widespread variation in how anaesthesia is provided to individual patients even for the same types of surgery. This variation exists within departments, between hospitals, and between countries. Patient and surgical factors are often cited as a justification for variation. Local and national norms, guidance, and standards, and the positive or negative roles of key opinion leaders likely all play a part. Although clinicians may disagree where the line falls between warranted and unwarranted variations, at least some of this variation is down to anaesthetist preference, not individualised patient care.

Anaesthesia Choice for Creation of Arteriovenous Fistula (ACCess) study protocol : a randomised controlled trial comparing primary unassisted patency at 1 year of primary arteriovenous fistulae created under regional compared to local anaesthesia

INTRODUCTION

Arteriovenous fistulae (AVF) are the 'gold standard' vascular access for haemodialysis. Universal usage is limited, however, by a high early failure rate. Several small, single-centre studies have demonstrated better early patency rates for AVF created under regional anaesthesia (RA) compared with local anaesthesia (LA). The mechanistic hypothesis is that the sympathetic blockade associated with RA causes vasodilatation and increased blood flow through the new AVF. Despite this, considerable variation in practice exists in the UK. A high-quality, adequately powered, multicentre randomised controlled trial (RCT) is required to definitively inform practice.

METHODS AND ANALYSIS

The Anaesthesia Choice for Creation of Arteriovenous Fistula (ACCess) study is a multicentre, observer-blinded RCT comparing primary radiocephalic/brachiocephalic AVF created under regional versus LA. The primary outcome is primary unassisted AVF patency at 1 year. Access-specific (eg, stenosis/thrombosis), patient-specific (including health-related quality of life) and safety secondary outcomes will be evaluated. Health economic analysis will also be undertaken.

ETHICS AND DISSEMINATION

The ACCess study has been approved by the West of Scotland Research and ethics committee number 3 (20/WS/0178). Results will be published in open-access peer-reviewed journals within 12 months of completion of the trial. We will also present our findings at key national and international renal and anaesthetic meetings, and support dissemination of trial outcomes via renal patient groups.

TRIAL REGISTRATION NUMBER

ISRCTN14153938.

SPONSOR

NHS Greater Glasgow and Clyde GN19RE456, Protocol V.1.3 (8 May 2021), REC/IRAS ID: 290482.

Practice Variation in Regional Anesthesia Utilization by Current and Former U.S. Military Anesthesiology Residents

Introduction

Per Joint Trauma System guidelines, military anesthesiologists are expected to be ready to lead an Acute Pain Service with regional anesthesia in combat casualty care. However, regional anesthesia practice volume has not been assessed in the military. The objective of this study was to assess regional anesthesia utilization among current residents and graduates of U.S. military anesthesiology residency programs.

Materials and Methods

All current and former active duty military anesthesiology program residents, trained at any of the four military anesthesiology residency programs between 2013 and 2019, were anonymously surveyed about their regional anesthesia practice. Bivariate statistics described the total single-injection and catheter block techniques utilized in the last month. Cluster analysis assessed for the presence of distinct practice groups within the sample. Follow-up analyses explored potential associations between cluster membership and other variables (e.g., residency training site, residency graduation year, overall confidence in performing regional anesthesia, etc.). This protocol received exemption determination separately from each site’s institutional review board.

Results

Current and former residents reported broad variation in regional anesthesia practice and clustered into four distinct practice groups. Less than half of respondents utilized a moderate to high number of different single-injection and catheter blocks.

Conclusions

These findings highlight the need for creative solutions to increase regional anesthesia training in military anesthesiology programs and continued ability to implement skills, such that all military anesthesiologists have adequate practice for deployed responsibilities.