Regional Anesthesia for AV fistula revision

Case info

Types of regional anesthesia for AV fistula

Regional anaesthesia practice for arteriovenous fistula formation surgery. Anaesthesia 2020, 75, 626–633.

Observational study of the efficacy of supraclavicular brachial plexus block for arteriovenous fistula creation. Indian J Anaesth. 2018 Aug; 62(8): 616–620.

NYSORA Ultrasound-guided Supraclavicular Block video

Ultrasound-guided supraclavicular versus infraclavicular brachial plexus nerve block in chronic renal failure patients undergoing arteriovenous fistula creation. Egyptian Journal of Anaesthesia. Volume 30, Issue 2, April 2014, Pages 161-167.

SonoSite Ultrasound-guided Supraclavicular Block video

Practical Anesthesia Techniques ultrasound-guided infraclavicular block video

From Doctorlib.info

A brachial plexus block technique for upper arm AV Fistula. BJA: British Journal of Anaesthesia, Volume 113, Issue eLetters Supplement, 29 December 2014.

Axillary Nerve Block for Upper Extremity Arteriovenous Fistula Creation. Proceedings of UCLA Healthcare. VOLUME 21 (2017).

Ultrasound-guided axillary brachial plexus block versus local infiltration anesthesia for arteriovenous fistula creation at the forearm for hemodialysis in patients with chronic renal failure. Saudi J Anaesth. 2017 Jan-Mar; 11(1): 77–82.

Long-Term Functional Patency and Cost-Effectiveness of Arteriovenous Fistula Creation under Regional Anesthesia: a Randomized Controlled Trial. JASN August 2020, 31 (8) 1871-1882.

Comparison of regional and local anesthesia for arteriovenous fistula creation in end-stage renal disease: a systematic review and meta-analysis. BMC Anesthesiology volume 20, Article number: 219 (2020).

From Doctorlib.info

Is it ok to do regional blocks in sepsis patients?

Neuraxial Regional Anaesthesia in Patients with Active Infection and Sepsis: A Clinical Narrative Review. Turk J Anaesthesiol Reanim. 2018 Feb; 46(1): 8–14.

Regional Anesthesia for Cardiac Surgery

Gathering data for Cardiac ERAS program for our hospital as well as the SCA. This page will be continuously updated as I find more information.

Resources:

• Regional Anesthesia in Cardiac Surgery: An Overview of Fascial Plane Chest Wall Blocks. Anesthesia & Analgesia: July 2020 – Volume 131 – Issue 1 – p 127-135.

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From Anesthesia & Analgesia131(1):127-135, July 2020.

• Regional anesthesia for cardiac surgery. Current Opinion in Anaesthesiology: October 2019 – Volume 32 – Issue 5 – p 674-682.
• Regional Analgesia in Cardiothoracic Surgery: A Changing Paradigm Toward Opioid-Free Anesthesia? Ann Card Anaesth. 2018 Jul-Sep; 21(3): 225–227.
• New approaches and old controversies to postoperative pain control following cardiac surgery. Eur J Anaesthesiol. 2006 Jul;23(7):539-50.
• Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence. Anesth Analg. 2007 Mar;104(3):689-702.
• Optimising pain management protocols following cardiac surgery: A protocol for a national quality improvement study. Int J Surg Protoc. 2019 Jan 11;14:1-8.
• Assessment and pathophysiology of pain in cardiac surgery. J Pain Res. 2018; 11: 1599–1611.
• The role of intraoperative interventions to minimise chronic postsurgical pain. Br J Pain. 2017 Nov;11(4):186-191.
• Impact of Enhanced Recovery After Surgery and Opioid-Free Anesthesia on Opioid Prescriptions at Discharge From the Hospital: A Historical-Prospective Study. Anesth Analg. 2017 Nov;125(5):1784-1792.
• Comparison of continuous thoracic epidural analgesia with bilateral erector spinae plane block for perioperative pain management in cardiac surgery. Ann Card Anaesth. Jul-Sep 2018;21(3):323-327.
• Erector spinae plane block as an alternative to epidural analgesia for post-operative analgesia following video-assisted thoracoscopic surgery: A case study and a literature review on the spread of local anaesthetic in the erector spinae plane. Indian J Anaesth. 2018 Jan;62(1):75-78.
• Efficacy of bilateral pectoralis nerve block for ultrafast tracking and postoperative pain management in cardiac surgery. Ann Card Anaesth. Jul-Sep 2018;21(3):333-338.
• Bilateral thoracic paravertebral block combined with general anesthesia vs. general anesthesia for patients undergoing off-pump coronary artery bypass grafting: a feasibility study. BMC Anesthesiology volume 19, Article number: 101 (2019).
• A novel approach for pain management in cardiac surgery via median sternotomy: bilateral single-shot paravertebral blocks. Heart Surg Forum. 2007;10(5):E357-62.
• Regional Anesthesia Cardiothoracic Enhanced Recovery (RACER): A New Era. ASRA News. August 2019 Issue
• Neuraxial Analgesia for Cardiac Surgery. ASRA News. November 2017 Issue
• Regional anesthesia considerations for cardiac surgery. Best Practice & Research Clinical Anaesthesiology. Volume 33, Issue 4, December 2019, Pages 387-406.

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• Thoracic
  • Ultrasound-Guided Serratus Anterior Plane Block Versus Thoracic Epidural Analgesia for Thoracotomy Pain. J Cardiothorac Vasc Anesth. 2017 Feb;31(1):152-158.
• Medical pumps for delivery of programmable intermittent bolus:
  • CADD medical Solis

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What I’m using these days:

• August 2020: None as we do not have programmable intermittent bolus pumps for regional.

Adjuvants to prolong regional anesthesia

For my single shot blocks, I’m always looking for ways to prolong my regional anesthetic effect.  For awhile, Exparel was the most talked about drug to have a 72 hour blockade.  We don’t have this medication available to us at the hospital.  Therefore, it’s time to get creative and hit the literature to see what has worked for prolonging our blocks.

Prolonging blockade with adjuvants:

• IOSR J of Dental and Medical Sci; Dec 2015. Comparative study of bupiv with dexamethasone and bupi with clonidine through single space PVB for post op analgesia in thoracic and abdominal surgeries.
  • 0.125% Bupiv + clonidine (1mcg/kg) vs 0.125% bupiv + dexamethasone (4mg): greater duration of analgesia in the dexamethasone group.

 

• Facilitatory effects of perineural dexmedetomidine on neuraxial and peripheral nerve block: a systematic review and meta-analysis. British Journal of Anaesthesia 110 (6): 915–25 (2013).
  • Sensory block duration was prolonged by 150 min [95% confidence interval (CI): 96, 205, P,0.00001] with intrathecal dexmedetomidine. Perineural dexmedetomidine used in brachial plexus (BP) block may prolong the mean duration of sensory block by 284 min (95% CI: 1, 566, P¼0.05), but this difference did not reach statistical significance. Motor block duration and time to first analgesic request were prolonged for both intrathecal and BP block. Dexmedetomidine produced reversible bradycardia in 7% of BP block patients, but no effect on the incidence of hypotension. No patients experienced respiratory depression.
  • Considerable differences existed in the doses of perineural dexmedetomidine; doses varied between 3, 5, 10, or 15 mcg for the intrathecal route, and 30, 100, 0.75, 1 mcg/kg for the peripheral route.

 

• Investigating the Efficacy of Dexmedetomidine as an Adjuvant to Local Anesthesia in Brachial Plexus Block: A Systematic Review and Meta-Analysis of 18 Randomized Controlled Trials. Regional Anesthesia and Pain Medicine: March/April 2017 – Volume 42 – Issue 2 – p 184–196.

 

• Effective Dose of Intravenous Dexmedetomidine to Prolong the Analgesic Duration of Interscalene Brachial Plexus Block: A Single-Center, Prospective, Double-Blind, Randomized Controlled Trial. Regional Anesthesia and Pain Medicine: July 2018 – Volume 43 – Issue 5 – p 488–495.
  • Intravenous DEX at a dose of 2.0 μg/kg significantly increased the duration of ISBPB analgesia without prolonging motor blockade and reduced the cumulative opioid consumption at the first 24 hours in patients undergoing arthroscopic shoulder surgery.

• Dexmedetomidine prolongs the effect of bupivacaine in supraclavicular brachial plexus block. J Anaesthesiol Clin Pharmacol. 2014 Jan-Mar; 30(1): 36–40.
  • 30 ml of 0.325% bupivacaine + 1 ml (100 μg) dexmedetomidine were given for supraclavicular brachial plexus block using the peripheral nerve stimulator.

 

• Effects of perineural administration of dexmedetomidine in combination with bupivacaine in a femoral-sciatic nerve block. Saudi J Anaesth. 2016 Jan-Mar; 10(1): 18–24.

  • Below knee surgery under combined femoral-sciatic nerve block were randomly allocated into two groups to have their block performed using bupivacaine 0.5% alone (group B) or bupivacaine 0.5% combined with 100 μg bupivacaine-dexmedetomidine

 

• IV and Perineural Dexmedetomidine Similarly Prolong the Duration of Analgesia after Interscalene Brachial Plexus Block: A Randomized, Three-arm, Triple-masked, Placebo-controlled Trial. Anesthesiology 3 2016, Vol.124, 683-695. 
  • Randomized to receive ISB using 15 ml ropivacaine, 0.5%, with 0.5 μg/kg dexmedetomidine administered perineurally (Dex_P group), intravenously (Dex_IV group), or none (control group). Dex_IV was noninferior to Dex_P for these outcomes. Both dexmedetomidine routes reduced the pain and opioid consumption up to 8 h postoperatively and did not prolong the duration of motor blockade.

 

• Evidence basis for using perineural dexmedetomidine to enhance the quality of brachial plexus nerve blocks: a systematic review and meta-analysis of randomized controlled trials. BJA: British Journal of Anaesthesia, Volume 118, Issue 2, 1 February 2017, Pages 167–181.

  • Upper limb block.  A 50-60µg dexmedetomidine dose maximized sensory block duration while minimizing haemodynamic side-effects.

 

• Review of Dexmedetomidine (Precedex) for Acute Pain and Analgesia. ASRA News, August 2018.

Other useful links:

• Erector Spinae Plane Block
• Suprascapular Blocks
• Enhanced Recovery After Surgery (ERAS)
• PEC 1 & 2 Blocks, Serratus Anterior Block

 

Suprascapular Blocks

Trends are evolving in decreasing intraoperative and postoperative opioid use.  Therefore, anesthesiologists are constantly learning new regional techniques to help with postoperative pain.  For shoulder surgeries, I’ve moved away from interscalene blocks toward supraclavicular blocks.  I think the interscalene block provides a better block of a total shoulder surgery, however, certain patient comorbidities often make the supraclavicular block a better choice.

Nice paper from Anesthesiology, Dec 2017: Suprascapular and Interscalene Nerve Block for Shoulder Surgery: A Systematic Review and Meta-analysis. Anesthesiology 12 2017, Vol.127, 998-1013.

Nowadays, it seems that suprascapular blocks are gaining in popularity (I’d probably use it to supplement the supraclavicular block.

Supplies and Technique (from USRA):

• After skin and transducer preparation, place a linear 38-mm high frequency 10-12 MHz transducer on the scapula to obtain a best possible transverse view of the suprascapular nerve (SSN) and suprascapular vessels.
• Ask the patient to place the hand over to the contralateral shoulder. This will move the scapula laterally to provide more space for SSN scanning. Also, this will move the target SSN injection site more laterally away from the thorax.
• Place one end of the transducer over the scapular spine and the other end directing towards the coracoid process.
• With the patient sitting up, a 22 G, 8 cm needle is advanced to penetrate the trapezius and supraspinatus muscles until the needle is positioned immediately next to the SSN and SSA.
• The optimal needle endpoint is reached when the needle tip is positioned underneath the fascia of the SSM.
• **CAUTION** : Avoid targeting the SSN in the suprascapular notch because accidental anterior needle advancement can puncture the pleura anteriorly. 
• The goal is to first inject local anesthetic deep to the fascia of the SSM. A total of 5-8 mL of local anesthetic is usually sufficient to block the SSN

Suprascapular Nerve

How to position the ultrasound probe:

From USRA

Ultrasound Image

From USRA.  SSM = supraspinatus muscle
SSA = suprascapular artery
SSN = suprascapular nerve
TZM = trapezius muscle
STSL = superior transverse scapular ligament

Useful Links

• ASRA: suprascapular and axillary combined block
• USRA
• James Cook Regional Anesthesia Course

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Update: June 19, 2018

Comparison of Anterior Suprascapular, Supraclavicular, and Interscalene Nerve Block Approaches for Major Outpatient Arthroscopic Shoulder Surgery: A Randomized, Double-blind, Noninferiority Trial. Anesthesiology 7 2018, Vol.129, 47-57.

From Anesthesiology, July 2018

• Conclusions: The anterior suprascapular block, but not the supraclavicular, provides noninferior analgesia compared to the interscalene approach for major arthroscopic shoulder surgery. Pulmonary function is best preserved with the anterior suprascapular nerve block.

Suprascapular blocks

Trends are evolving in decreasing intraoperative and postoperative opioid use.  Therefore, anesthesiologists are constantly learning new regional techniques to help with postoperative pain.  For shoulder surgeries, I’ve moved away from interscalene blocks toward supraclavicular blocks.  I think the interscalene block provides a better block of a total shoulder surgery, however, certain patient comorbidities often make the supraclavicular block a better choice.

Nice paper from Anesthesiology, Dec 2017: Suprascapular and Interscalene Nerve Block for Shoulder Surgery: A Systematic Review and Meta-analysis. Anesthesiology 12 2017, Vol.127, 998-1013.

Nowadays, it seems that suprascapular blocks are gaining in popularity (I’d probably use it to supplement the supraclavicular block.

Supplies and Technique (from USRA):

• After skin and transducer preparation, place a linear 38-mm high frequency 10-12 MHz transducer on the scapula to obtain a best possible transverse view of the suprascapular nerve (SSN) and suprascapular vessels.
• Ask the patient to place the hand over to the contralateral shoulder. This will move the scapula laterally to provide more space for SSN scanning. Also, this will move the target SSN injection site more laterally away from the thorax.
• Place one end of the transducer over the scapular spine and the other end directing towards the coracoid process.
• With the patient sitting up, a 22 G, 8 cm needle is advanced to penetrate the trapezius and supraspinatus muscles until the needle is positioned immediately next to the SSN and SSA.
• The optimal needle endpoint is reached when the needle tip is positioned underneath the fascia of the SSM.
• **CAUTION** : Avoid targeting the SSN in the suprascapular notch because accidental anterior needle advancement can puncture the pleura anteriorly. 
• The goal is to first inject local anesthetic deep to the fascia of the SSM. A total of 5-8 mL of local anesthetic is usually sufficient to block the SSN

Suprascapular Nerve

How to position the ultrasound probe:

From USRA

Ultrasound Image

From USRA.  SSM = supraspinatus muscle
SSA = suprascapular artery
SSN = suprascapular nerve
TZM = trapezius muscle
STSL = superior transverse scapular ligament

Useful Links

• ASRA: suprascapular and axillary combined block
• USRA
• James Cook Regional Anesthesia Course

Enhanced Recovery After Surgery (ERAS)

Enhanced recovery after surgery (ERAS) protocols: Time to change practice? Can Urol Assoc J. 2011 Oct; 5(5): 342–348.

Dario Bugada, Valentina Bellini, Andrea Fanelli, et al., “Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach,” Surgery Research and Practice, vol. 2016, Article ID 3561249, 6 pages, 2016. doi:10.1155/2016/3561249

Enhanced Recovery After Surgery: If You Are Not Implementing it, Why Not? PRACTICAL GASTROENTEROLOGY • APRIL 2016.

A Systematic Review of Enhanced Recovery After Surgery Pathways: How Are We Measuring ‘Recovery?’ Session: Poster Presentation. Program Number: P613

Sturm L and Cameron AL. Fast-track surgery and enhanced recovery after surgery (ERAS) programs. ASERNIP-S Report No. 74. Adelaide, South Australia: ASERNIP-S, March 2009.

Summary of Enhanced Recovery after Surgery Guideline Recommendations. Canada.

Patients Benefit From Enhanced Recovery Programs: Are Better Prepared for Surgery, Have Less Pain, Studies Show. Oct 2016. American Society of Anesthesiologists.

Enhanced Recovery after Surgery Guideline: Perioperative Pain Management in Patients Having Elective Colorectal Surgery: A Quality Initiative of the Best Practice in General Surgery Part of CAHO’s ARTIC program. April 2013.

Preserved Analgesia With Reduction in Opioids Through the Use of an Acute Pain Protocol in Enhanced Recovery After Surgery for Open Hepatectomy. Regional Anesthesia & Pain Medicine: July/August 2017 – Volume 42 – Issue 4 – p 451–457.

Regional Anesthesia for surgery and other comparative studies. Sweden.

ERAS: Role of Anesthesiologist. UTSW.

Stanford Anesthesia ERAS pathway website

Enhanced Recovery after Surgery Versus Perioperative Surgical Home: Is It All in the Name? Anesthesia & Analgesia: May 2014 – Volume 118 – Issue 5 – p 901–902

The Role of Regional Anesthesia in ERAS pathways. Sept 2015. UCSF.

ERAS Pathway Improves Analgesia, Opioid Use and PONV Following Total Mastectomy. Anesthesiology News. May 2016.

Anesthesia Practice and ERAS. Cooper University Hospital. 2017.

ERAS: Anesthesia Tutorial of the Week. Number 204. Nov 2010.

ERAS and Anesthesia. Anesthesia Business Consultants. May 2015.

All about ERAS: Why anesthesiologists need to understand this concept. Becker’s ASC Review. June 2015.

I’d love to incorporate my findings and use of lidocaine infusions and ketamine infusions on intraoperative and postoperative pain as a multimodal pain management pathway.

What we’re using:

• July 2020
  • Acetaminophen 1g PO (cardiac, gen surg)
  • Celebrex 400mg PO (gen surg)
  • Gabapentin 600mg PO (gen surg)
  • Lyrica 75mg PO (cardiac)
  • Entereg mg PO (gen surg)

How to deal with a regional block complication

Case_Scenario__Neurologic_Complication_after.37.pdf