CLINICAL STUDY
Ultrasound-Guided Supraclavicular Brachial Plexus Block for Analgesia during Endovascular Treatment of Dysfunctional Hemodialysis Fistulas Murat Gedikoglu, MD, Cagatay Andic, MD, Hatice Evren Eker, MD, Ismail Guzelmansur, MD, and Levent Oguzkurt, MD
ABSTRACT Purpose: To evaluate prospectively the efficacy and safety of ultrasound (US)-guided supraclavicular brachial plexus block (BPB) for analgesia during endovascular treatment of dysfunctional hemodialysis fistulas. Materials and Methods: US-guided supraclavicular BPB was performed before endovascular treatment of dysfunctional hemodialysis fistulas in 40 consecutive patients. After BPB, standard interventional procedures were performed for treatment of dysfunctional hemodialysis fistulas. A visual analog scale (0–10) was used to assess pain related to performance of BPB immediately after the endovascular procedure. Patient satisfaction and operator satisfaction during the procedure were also assessed after the procedure. Results: Satisfactory regional anesthesia and analgesia were achieved in all patients without a need for supplemental intravenous analgesia. The mean onset time for complete block was 5.4 minutes ⫾ 2.6. Pain scores were 0 (no pain) in 26 patients and 1–3 (mild, annoying pain) in 14 patients. The patient’s satisfaction with pain control was recorded as satisfied (very well) in all cases. The operator’s satisfaction with this anesthetic technique was also recorded as satisfied (very well) in all cases. Complications related to the block procedure did not occur in any patient. Conclusions: US-guided supraclavicular BPB can be used safely to provide analgesia during endovascular treatment of dysfunctional hemodialysis fistulas in adult patients.
ABBREVIATION BPB = brachial plexus block
Hemodialysis patients are usually poor surgical and anesthetic candidates. Various sedation and anesthesia techniques are used to provide anesthesia during surgical creation or revision of fistulas or prosthetic access grafts. The use of brachial plexus block (BPB) for these procedures results in analgesia and sympathetic block that achieves desired surgical conditions. BPB reduces
From the Departments of Radiology (M.G., C.A., L.O.) and Anaesthesiology (H.E.E.), Baskent University School of Medicine, Dadaloglu Mah. 39. sok. No: 4/A, 01250 Yuregir/Adana, Turkey; and Department of Radiology (I.G.), Mozaik Hospital, Hatay, Turkey. Received February 3, 2014; final revision received and accepted May 6, 2014. Address correspondence to M.G.; E-mail: [email protected] None of the authors have identified a conflict of interest. Video 1 is available online at www.jvir.org. & SIR, 2014 J Vasc Interv Radiol 2014; 25:1427–1432 http://dx.doi.org/10.1016/j.jvir.2014.05.007
morbidity, mortality, postoperative complications, length of hospital stay, and costs after surgery compared with general anesthesia. Simplicity and reliability of BPB anesthesia has made it particularly desirable for outpatient upper limb surgery (1–8). Most hemodialysis fistula problems can be treated by percutaneous endovascular methods in an outpatient setting. Although less invasive than surgery, percutaneous endovascular procedures are still stressful and painful and usually require sedation and analgesia during the procedure. The most commonly used drugs for this purpose are midazolam and fentanyl, which should be used carefully in hemodialysis patients because of increased risk of respiratory depression (9–12). Many studies demonstrate the safety and efficacy of BPB in hemodialysis patients who require surgical creation or revision of an arteriovenous fistula. However, there is no information on efficacy of BPB during percutaneous endovascular treatment of dysfunctional hemodialysis fistulas. Ultrasound (US)-guided BPB can
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offer analgesia without the adverse respiratory side effect of intravenous sedation and analgesia in hemodialysis patients. We designed a prospective study to investigate the safety and efficacy of US-guided supraclavicular BPB for analgesia during endovascular treatment of dysfunctional hemodialysis fistulas in adult patients.
MATERIALS AND METHODS Patients The study was approved by the institutional review board. This prospective single-arm study included 40 consecutive adult patients (21 women; age range, 19–81 y; mean age, 56.7 y ⫾ 15.6) referred to our interventional radiology department for evaluation and treatment of a dysfunctional hemodialysis fistula. An interventional radiologist and an anesthesiologist assessed patients for inclusion in the study, risk of complications of the block and contraindications, and alternative anesthesia methods when required. Potential risks and benefits of the procedures for BPB and endovascular treatment of the dysfunctional hemodialysis fistula were explained in detail, and written informed consent was obtained from each patient. Patient exclusion criteria are listed in the Table. The definition of criteria and complications were based on reporting standards of the Society of Interventional Radiology (SIR) (13). Two patients were excluded from the study because they had a history of neurologic deficit in the ipsilateral upper limb.
Patient Preparation and Block Procedure All patients were monitored with blood pressure measurement and pulse oximetry throughout the procedure. Diagnostic fistulography was obtained in each patient to determine any vascular problems. The entire route of the hemodialysis fistula was evaluated, including the afferent artery, anastomosis, and efferent vein to the level of the superior vena cava. All patients were informed about the signs of local anesthetic toxicity, such as circumoral numbness and lightheadedness. Premedication was not administered during the BPB procedure because cooperation from an alert patient was required. In all patients, supraclavicular
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BPB were performed under US guidance by the same interventional radiologist (M.G.) to provide uniformity to the procedure. This operator also participated to the fistula treatment together with four other interventional radiologists or interventional radiology fellows. All blocks were performed under aseptic conditions. The patients were positioned supine on the operating table with the head turned to the opposite side. A linear 9- to 13-MHz transducer (Antares; Siemens AG, Erlangen, Germany) was placed transversally on the supraclavicular fossa to locate the brachial plexus. The brachial plexus, as a cluster of hypoechoic nodules, was found posterolateral to the subclavian artery (Fig 1). After skin anesthesia with local prilocaine, a 21-gauge needle with a cutting tip was advanced longitudinally to the transducer (in-plane) under real-time US guidance (Fig 2). Once the needle tip cut through the capsule and entered the brachial plexus, a mixture of 5 mL of bupivacaine 0.5%, and 5 mL normal saline was injected into the sheath (Fig 3, Video 1: The video shows US-guided puncture of the brachial plexus sheath and infiltration of the brachial plexus with anesthetic agent. [available online at www.jvir.org]). The needle tip was repositioned if spread of the local anesthetic was not appropriate. If the patients complained of paresthesia, the needle was withdrawn and repositioned until the patients did not complain. All patients were checked for respiratory discomfort, Horner syndrome, and voice changes throughout the procedure. Side effects and complications, including blood vessel puncture, intravascular injection, overdose, dyspnea, and Horner syndrome, were noted after the procedure. If the patient was not symptomatic for pneumothorax, a chest radiograph was not obtained routinely (Fig 4).
Table . Patient Exclusion Criteria Inability to understand nature of study History of neurologic deficit in ipsilateral upper limb Respiratory diseases such as chronic obstructive lung disease or asthma Abnormal coagulation parameters (INR 4 1.3 and platelet count o 50,000/mL) Allergy to local anesthetics or contrast media Pregnancy INR ¼ international normalized ratio.
Figure 1. US image of right supraclavicular region with color Doppler. Thin arrows indicate brachial plexus, and thick arrow indicates subclavian artery.
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Figure 4. Drawing shows the anatomic relationship of the left brachial plexus and percutaneous needle approach to the brachial plexus at the supraclavicular level. Arrows point the brachial plexus. LAT ¼ lateral; m ¼ muscle; SCM ¼ sternocleidomastoid muscle. Figure 2. Advancement of the needle (thick arrow) toward the brachial plexus (thin arrows).
pain was tested initially during puncture of the access vein. If a patient felt pain during puncture of the skin to place a vascular sheath, local anesthesia was infiltrated and recorded. If the patient felt pain during the endovascular procedure (eg, during balloon dilation) intravenous sedoanalgesia with midazolam and fentanyl was administered to supplement the anesthesia. A combination of fentanyl (50 μg) and midazolam (1 mg) was routinely given incrementally to relieve pain.
Treatment Procedure
Figure 3. US image of the supraclavicular brachial plexus after local anesthetic injection (arrows).
Assessment of Block Performance and Related Pain The onset and extent of the motor and sensory block were tested by the same operator each minute for 30 minutes immediately after the BPB procedure. A successful block was defined as complete motor block and achievement of a pain-free state without supplemental medications. Motor block was assessed complete when the patient could not lift or abduct the arm. Successful analgesia and anesthesia were evaluated as indicative of adequate sensory block. If the patient could still lift or abduct the arm after 3 minutes, BPB was repeated by injecting the same dose of bupivacaine and normal saline mixture. After achieving the complete motor block, the
Standard interventional procedures were performed by using our criteria for treatment of dysfunctional hemodialysis fistulas. Local anesthesia was administered for BPB puncture site in all patients but not administered for vascular access site puncture to be able to evaluate the effectiveness of BPB. Access to the fistula was achieved initially with a 21-gauge needle. US guidance was used to puncture the vein per our routine. A vascular sheath ranging from 5-F to 8-F depending on the requirement of treatment procedures was inserted into the vein over a guide wire. Occluded or stenotic segments were treated with percutaneous transluminal angioplasty by using balloon catheters, high-pressure balloon catheters, or peripheral cutting balloon catheters. If follow-up angiograms revealed residual stenosis 4 30%, long-duration balloon inflation (3–5 min) was applied using conventional balloons with the same size or a larger balloon. Thrombectomy procedures were performed by manual aspiration thrombectomy, with or without previous thrombolysis. Stent placement after balloon dilation was usually avoided. A stent was placed when the stenosis did not respond to repeated long-duration balloon dilation. Covered stent placement was reserved for acute ruptures not controlled by balloon tamponade.
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Procedural Parameters
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(very well) in all cases. No patients experienced dyspnea or any other respiratory side effects after the BPB. Systematic chest radiography after BPB was not obtained; subclinical pneumothoraces may have occurred. No additional serious side effects or complications were observed during and after the procedure.
All data were collected prospectively. Technical details, including block execution time (from probe positioning to the end of local anesthetic injection), number of needle attempts, amount of local anesthetic, onset of complete block (from the end of the local anesthetic injection to the onset of complete motor loss), duration of the treatment (from initial puncture of the fistula to completion of the treatment), requirements for additional local anesthetic infiltration, and need for intravenous sedative or analgesic medication, were registered immediately after the procedure. Pain related to performance of BPB was recorded using a visual analog scale that was graded from 0 (no pain) to 10 (agonizing pain). We asked patients to quantify their feelings of pain during the whole procedure. Patients subjectively assessed their feelings of procedural pain and marked this accordingly on the visual analog scale. Patient satisfaction and operator satisfaction were graded from 0–3: 0, not satisfied (poor); 1, partially satisfied (slightly well); 2, satisfied (very well). The visual analog scale score and patient satisfaction and operator satisfaction with the anesthetic technique were asked and measured immediately after the procedure and not during the procedure. Statistical analysis was performed using SPSS software (version 17.0; SPSS, Chicago, Illinois). All numerical data are expressed as mean ⫾ SD or as proportions.
In 40 consecutive patients, dysfunctional hemodialysis fistulas were treated successfully. Of the 40 dysfunctional fistulas, 39 were native, and 1 was a graft fistula; 27 were in the forearm (67.5%), and 13 were in the upper arm (32.5%). Occlusions or significant stenoses or both were identified in the afferent arteries (n ¼ 1), anastomoses (n ¼ 28), efferent veins (n ¼ 37), and central veins (n ¼ 5). Conventional balloon angioplasty for occlusion or stenosis was performed in each patient (range, 3–14 mm). In 10 patients, cutting balloons (with 5–8 mm diameter) were used for tight stenoses resistant to conventional balloon catheters. A technically successful result (a stenosis o 30% residual diameter) was achieved in all patients. There were 10 thrombosed hemodialysis fistulas that were declotted by manual aspiration thrombectomy alone or in combination with catheter-directed thrombolysis. Two of the fistulas required stent placement. In one patient, distal arterial emboli occurred during declotting procedures and were immediately managed using manual aspiration thrombectomy.
RESULTS
DISCUSSION
Pain Control and Procedural Parameters
US-guided supraclavicular BPB allowed pain-free endovascular treatment of dysfunctional hemodialysis fistulas without supplemental analgesia. Only two patients required intravenous sedation for procedure-related anxiety. Patient satisfaction and physician satisfaction from the procedure were excellent. No complications secondary to BPB or the endovascular procedure itself were encountered. Significant pain may be experienced by hemodialysis patients during treatment of dysfunctional hemodialysis fistulas by endovascular techniques. Such procedures are also stressful and performed under sedation and analgesia. The combination of benzodiazepines and opioid analgesics has been widely used to relieve pain especially secondary to balloon dilation during endovascular procedures (9–12,14,15). The construction and intraoperative balloon angioplasty for dysfunctional fistulas were also performed under local anesthesia with intravenous sedation, regional block, or general anesthesia (16). The synergistic effect of midazolam and fentanyl increases their effectiveness but also increases the adverse effects, such as respiratory depression. Hemodialysis patients are usually more susceptible to these adverse effects than healthy volunteers (9–12). Relative risk of cardiopulmonary arrest in patients undergoing interventional radiology procedures was
BPB was technically successful in all patients. Satisfactory procedural anesthesia and analgesia were achieved in all patients. Five patients (12.5%) in whom puncture sites were anesthetized locally with prilocaine complained of slight pain during needle insertion initially or placement of the vascular sheath to the fistula. A single intravenous dose of 1 mg midazolam was required in two patients to relieve anxiety before the BPB procedure and subsequent treatment. Analgesia with intravenous fentanyl was not required in any patients. The mean time necessary to perform the block was 3.8 minutes ⫾ 1.8. The median number of needle attempts was 3 (range, 1–5). The mean amount of local anesthetic was 7.8 mL ⫾ 3.4. Adequate anesthesia and analgesia were achieved with 5 mL in 21 patients (52.5%), with 10 mL in 15 patients (37.5%), and with 15 mL in 4 patients (10%). The mean onset time for complete block was 5.4 minutes ⫾ 2.6. The mean treatment time was 65.2 minutes ⫾ 36.7. After the treatments, pain scores were 0 (no pain) in 26 patients and 1–3 (mild, annoying pain) in 14 patients. The patient’s satisfaction with pain control was recorded as satisfied (very well) in all cases. The operator’s satisfaction during treatment was recorded as satisfied
Treatment Procedure
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significantly higher in procedures related to dialysis access (17,18). In this setting, US-guided supraclavicular BPB can offer opportunities for relieving pain without adverse effects of intravenous sedation and analgesia. US-guided BPB was performed rapidly and did not require any additional equipment and staff. Brachial plexus can be blocked through interscalene, supraclavicular, infraclavicular, or axillary approaches. Each of these approaches has its own particular advantages, disadvantages, and complication rate. For shoulder surgery, the interscalene approach is more appropriate. For procedures of the arm, the supraclavicular or infraclavicular approach produces adequate anesthesia and analgesia. Compared with the supraclavicular block, infraclavicular block has less impact on pulmonary function but is more likely to spare the radial nerve distribution if a single injection is used. For forearm and hand surgery, the axillary approach is associated with less risk of adverse effects than other approaches (8,19,20). In the present study, US-guided supraclavicular BPB was preferred to other approaches because it was considered to be technically easy, was associated with fewer complications, and provided regional anesthesia and analgesia suitable for endovascular procedures at the level of the arm, forearm, and hand. US guidance was reported to decrease the risk of pneumothorax and to increase the accuracy of the block (6,7,20–24). In our study, no patients developed clinically apparent pneumothorax, Horner syndrome, or recurrent laryngeal nerve block. US guidance also helped to lower the local anesthetic volume needed to perform the blocks (22,23). We were able to use less local anesthetic to achieve acceptable results, which is important in terms of the risk of Horner syndrome and phrenic nerve palsy. In the literature, we could find only a few studies on use of nerve blocks during interventional radiology procedures. Yilmaz et al (25 reported that femoral or sciatic nerve blocks could provide considerable reduction of pain during endovenous laser ablation of the saphenous vein insufficiency. They reported that femoral or sciatic nerve blocks made these procedures more comfortable for the patient and easier for the operator. These authors suggested that prolonged procedure time or the use of foam sclerotherapy could potentially increase the risk of deep vein thrombosis. For this reason, patients were requested to walk for about 15 minutes immediately after the treatment. To achieve this goal, the nerve blocks performed need to provide analgesia with minimal or no motor block. In contrast, when BPB was performed for treatment of fistula dysfunction, the sensory block was more desirable than the motor block. However, motor block was not always considered a disadvantage for these procedures because control of unwanted movement of the upper limb could be an important advantage to obtain roadmap images,
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which are used while traversing the occluded venous segments with a guide wire. The present study has some limitations that might have weakened the conclusions. First, the success rate of this study was not compared in a randomized manner with other options, such as the use of sedoanalgesia. With such a comparison, a more solid conclusion would have been provided regarding the efficacy of BPB. Second, authors who collected the data were not blinded because most of the measurements had to be taken during and immediately after BPB. Third, the type and volume or concentration of local anesthetics were arbitrarily chosen. It might be possible that a lower volume or concentration could be sufficient for a successful nerve block. Another significant limitation was that we did not measure the length of anesthesia and recovery time from the motor block. This could have been one of the major components of the study. However, we sent the patients home after recovery of the block and did not measure the exact time it took. In conclusion, US-guided supraclavicular BPB can be used safely to provide analgesia during endovascular treatment of dysfunctional hemodialysis fistulas. It provides good procedural satisfaction in adult hemodialysis patients. Studies directly comparing BPB with intravenous sedation and analgesia in the same patient population are needed.
REFERENCES 1. Neuman MD, Silber JH, Elkassabany NM, Ludwig JM, Fleisher LA. Comparative effectiveness of regional versus general anesthesia for hip fracture surgery in adults. Anesthesiology 2012; 117:72–92. 2. Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg 2005; 101:1634–1642. 3. Mouquet C, Bitker MO, Bailliart O, et al. Anesthesia for creation of a forearm fistula in patients with end stage renal failure. Anesthesiology 1989; 70:909–914. 4. Malinzak EB, Gan TJ. Regional anesthesia for vascular access surgery. Anesth Analg 2009; 109:976–980. 5. Laskowski IA, Muhs B, Rockman CR, et al. Regional nerve block allows for optimization of planning in the creation of arteriovenous access for hemodialysis by improving superficial venous dilatation. Ann Vasc Surg 2007; 21:730–733. 6. Liu SS, Gordon MA, Shaw PM, Wilfred S, Shetty T, YaDeau JT. A prospective clinical registry of ultrasound-guided regional anesthesia for ambulatory shoulder surgery. Anesth Analg 2010; 111:617–623. 7. Tsui BCH, Doyle K, Chu K, Pillay J, Dillane D. Case series: ultrasoundguided supraclavicular block using a curvilinear probe in 104 day-case hand surgery patients. Can J Anesth 2009; 56:46–51. 8. Mulroy MF, McDonald SB. Regional anesthesia for outpatient surgery. Anesthesiol Clin N Am 2003; 21:289–303. 9. Skehan SJ, Malone DE, Buckley N, et al. Sedation and analgesia in adult patients: evaluation of a staged-dose system based on body weight for use in abdominal interventional radiology. Radiology 2000; 216: 653–659. 10. Martin ML, Lennox PH. Sedation and analgesia in the interventional radiology department. J Vasc Interv Radiol 2003; 14:1119–1128. 11. Johnson S. Sedation and analgesia in the performance of interventional procedures. Semin Intervent Radiol 2010; 27:368–373. 12. Beathard GA, Urbanes A, Litchfield T, Weinstein A. The risk of sedation/ analgesia in hemodialysis patients undergoing interventional procedures. Semin Dial 2011; 24:97–103.
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13. Gray RJ, Sacks D, Martin LG, Trerotola SO. Reporting standards for percutaneous interventions in dialysis access. J Vasc Interv Radiol 2003; 14:S433–S442. 14. Manninen HI, Kaukanen ET, Ikäheimo R, et al. Brachial arterial access: endovascular treatment of failing Brescia-Cimino hemodialysis fistulas— initial success and long-term results. Radiology 2001; 218:711–718. 15. Rajan DK, Bunston S, Misra S, Pinto R, Lok CE. Dysfunctional autogenous hemodialysis fistulas: outcomes after angioplasty—are there clinical predictors of patency? Radiology 2004; 232:508–515. 16. Hingorani A, Ascher E, Kallakuri S, Greenberg S, Khanimov Y. Impact of reintervention for failing upper-extremity arteriovenous autogenous access for hemodialysis. J Vasc Surg 2001; 34:1004–1009. 17. Rueb GR, Brady WJ, Gilliland CA, et al. Characterizing cardiopulmonary arrest during interventional radiology procedures. J Vasc Interv Radiol 2013; 24:1774–1778. 18. Nadolski G, Praestgaard A, Shlansky-Goldberg RD, et al. Medical emergencies and cardiopulmonary arrests in interventional radiology. J Vasc Interv Radiol 2013; 24:1779–1785.
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19. Lanz E, Theiss D, Jankovic D. The extent of blockade following various techniques of brachial plexus block. Anesth Analg 1983; 62:55–58. 20. Neal JM, Gerancher JC, Hebl JR, et al. Upper extremity regional anesthesia: essentials of our current understanding, 2008. Reg Anesth Pain Med 2009; 34:134–170. 21. Chan VWS, Perlas A, Rawson R, Odukoya O. Ultrasound-guided supraclavicular brachial plexus block. Anesth Analg 2003; 97:1514–1517. 22. Kapral S, Krafft P, Eibenberger K, Fitzgerald R, Gosch M, Weinstabl C. Ultrasound-guided supraclavicular approach for regional anesthesia of the brachial plexus. Anesth Analg 1994; 78:507–513. 23. Williams SR, Chouinard P, Arcand G, et al. Ultrasound guidance speeds execution and improves the quality of supraclavicular block. Anesth Analg 2003; 97:1518–1523. 24. Jeon DG, Kim WI. Cases series: ultrasound-guided supraclavicular block in 105 patients. Korean J Anesthesiol 2010; 58:267–271. 25. Yilmaz S, Ceken K, Alimoglu E, Sindel T. US-guided femoral and sciatic nerve blocks for analgesia during endovenous laser ablation. Cardiovasc Intervent Radiol 2013; 36:150–157.
Ultrasound-Guided Supraclavicular Brachial Plexus Block for Analgesia during Endovascular Treatment of Dysfunctional Hemodialysis Fistulas Murat Gedikoglu, MD, Cagatay Andic, MD, Hatice Evren Eker, MD, Ismail Guzelmansur, MD, and Levent Oguzkurt, MD
ABSTRACT Purpose: To evaluate prospectively the efficacy and safety of ultrasound (US)-guided supraclavicular brachial plexus block (BPB) for analgesia during endovascular treatment of dysfunctional hemodialysis fistulas. Materials and Methods: US-guided supraclavicular BPB was performed before endovascular treatment of dysfunctional hemodialysis fistulas in 40 consecutive patients. After BPB, standard interventional procedures were performed for treatment of dysfunctional hemodialysis fistulas. A visual analog scale (0–10) was used to assess pain related to performance of BPB immediately after the endovascular procedure. Patient satisfaction and operator satisfaction during the procedure were also assessed after the procedure. Results: Satisfactory regional anesthesia and analgesia were achieved in all patients without a need for supplemental intravenous analgesia. The mean onset time for complete block was 5.4 minutes ⫾ 2.6. Pain scores were 0 (no pain) in 26 patients and 1–3 (mild, annoying pain) in 14 patients. The patient’s satisfaction with pain control was recorded as satisfied (very well) in all cases. The operator’s satisfaction with this anesthetic technique was also recorded as satisfied (very well) in all cases. Complications related to the block procedure did not occur in any patient. Conclusions: US-guided supraclavicular BPB can be used safely to provide analgesia during endovascular treatment of dysfunctional hemodialysis fistulas in adult patients.
ABBREVIATION BPB = brachial plexus block
Hemodialysis patients are usually poor surgical and anesthetic candidates. Various sedation and anesthesia techniques are used to provide anesthesia during surgical creation or revision of fistulas or prosthetic access grafts. The use of brachial plexus block (BPB) for these procedures results in analgesia and sympathetic block that achieves desired surgical conditions. BPB reduces
From the Departments of Radiology (M.G., C.A., L.O.) and Anaesthesiology (H.E.E.), Baskent University School of Medicine, Dadaloglu Mah. 39. sok. No: 4/A, 01250 Yuregir/Adana, Turkey; and Department of Radiology (I.G.), Mozaik Hospital, Hatay, Turkey. Received February 3, 2014; final revision received and accepted May 6, 2014. Address correspondence to M.G.; E-mail: [email protected] None of the authors have identified a conflict of interest. Video 1 is available online at www.jvir.org. & SIR, 2014 J Vasc Interv Radiol 2014; 25:1427–1432 http://dx.doi.org/10.1016/j.jvir.2014.05.007
morbidity, mortality, postoperative complications, length of hospital stay, and costs after surgery compared with general anesthesia. Simplicity and reliability of BPB anesthesia has made it particularly desirable for outpatient upper limb surgery (1–8). Most hemodialysis fistula problems can be treated by percutaneous endovascular methods in an outpatient setting. Although less invasive than surgery, percutaneous endovascular procedures are still stressful and painful and usually require sedation and analgesia during the procedure. The most commonly used drugs for this purpose are midazolam and fentanyl, which should be used carefully in hemodialysis patients because of increased risk of respiratory depression (9–12). Many studies demonstrate the safety and efficacy of BPB in hemodialysis patients who require surgical creation or revision of an arteriovenous fistula. However, there is no information on efficacy of BPB during percutaneous endovascular treatment of dysfunctional hemodialysis fistulas. Ultrasound (US)-guided BPB can
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offer analgesia without the adverse respiratory side effect of intravenous sedation and analgesia in hemodialysis patients. We designed a prospective study to investigate the safety and efficacy of US-guided supraclavicular BPB for analgesia during endovascular treatment of dysfunctional hemodialysis fistulas in adult patients.
MATERIALS AND METHODS Patients The study was approved by the institutional review board. This prospective single-arm study included 40 consecutive adult patients (21 women; age range, 19–81 y; mean age, 56.7 y ⫾ 15.6) referred to our interventional radiology department for evaluation and treatment of a dysfunctional hemodialysis fistula. An interventional radiologist and an anesthesiologist assessed patients for inclusion in the study, risk of complications of the block and contraindications, and alternative anesthesia methods when required. Potential risks and benefits of the procedures for BPB and endovascular treatment of the dysfunctional hemodialysis fistula were explained in detail, and written informed consent was obtained from each patient. Patient exclusion criteria are listed in the Table. The definition of criteria and complications were based on reporting standards of the Society of Interventional Radiology (SIR) (13). Two patients were excluded from the study because they had a history of neurologic deficit in the ipsilateral upper limb.
Patient Preparation and Block Procedure All patients were monitored with blood pressure measurement and pulse oximetry throughout the procedure. Diagnostic fistulography was obtained in each patient to determine any vascular problems. The entire route of the hemodialysis fistula was evaluated, including the afferent artery, anastomosis, and efferent vein to the level of the superior vena cava. All patients were informed about the signs of local anesthetic toxicity, such as circumoral numbness and lightheadedness. Premedication was not administered during the BPB procedure because cooperation from an alert patient was required. In all patients, supraclavicular
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BPB were performed under US guidance by the same interventional radiologist (M.G.) to provide uniformity to the procedure. This operator also participated to the fistula treatment together with four other interventional radiologists or interventional radiology fellows. All blocks were performed under aseptic conditions. The patients were positioned supine on the operating table with the head turned to the opposite side. A linear 9- to 13-MHz transducer (Antares; Siemens AG, Erlangen, Germany) was placed transversally on the supraclavicular fossa to locate the brachial plexus. The brachial plexus, as a cluster of hypoechoic nodules, was found posterolateral to the subclavian artery (Fig 1). After skin anesthesia with local prilocaine, a 21-gauge needle with a cutting tip was advanced longitudinally to the transducer (in-plane) under real-time US guidance (Fig 2). Once the needle tip cut through the capsule and entered the brachial plexus, a mixture of 5 mL of bupivacaine 0.5%, and 5 mL normal saline was injected into the sheath (Fig 3, Video 1: The video shows US-guided puncture of the brachial plexus sheath and infiltration of the brachial plexus with anesthetic agent. [available online at www.jvir.org]). The needle tip was repositioned if spread of the local anesthetic was not appropriate. If the patients complained of paresthesia, the needle was withdrawn and repositioned until the patients did not complain. All patients were checked for respiratory discomfort, Horner syndrome, and voice changes throughout the procedure. Side effects and complications, including blood vessel puncture, intravascular injection, overdose, dyspnea, and Horner syndrome, were noted after the procedure. If the patient was not symptomatic for pneumothorax, a chest radiograph was not obtained routinely (Fig 4).
Table . Patient Exclusion Criteria Inability to understand nature of study History of neurologic deficit in ipsilateral upper limb Respiratory diseases such as chronic obstructive lung disease or asthma Abnormal coagulation parameters (INR 4 1.3 and platelet count o 50,000/mL) Allergy to local anesthetics or contrast media Pregnancy INR ¼ international normalized ratio.
Figure 1. US image of right supraclavicular region with color Doppler. Thin arrows indicate brachial plexus, and thick arrow indicates subclavian artery.
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Figure 4. Drawing shows the anatomic relationship of the left brachial plexus and percutaneous needle approach to the brachial plexus at the supraclavicular level. Arrows point the brachial plexus. LAT ¼ lateral; m ¼ muscle; SCM ¼ sternocleidomastoid muscle. Figure 2. Advancement of the needle (thick arrow) toward the brachial plexus (thin arrows).
pain was tested initially during puncture of the access vein. If a patient felt pain during puncture of the skin to place a vascular sheath, local anesthesia was infiltrated and recorded. If the patient felt pain during the endovascular procedure (eg, during balloon dilation) intravenous sedoanalgesia with midazolam and fentanyl was administered to supplement the anesthesia. A combination of fentanyl (50 μg) and midazolam (1 mg) was routinely given incrementally to relieve pain.
Treatment Procedure
Figure 3. US image of the supraclavicular brachial plexus after local anesthetic injection (arrows).
Assessment of Block Performance and Related Pain The onset and extent of the motor and sensory block were tested by the same operator each minute for 30 minutes immediately after the BPB procedure. A successful block was defined as complete motor block and achievement of a pain-free state without supplemental medications. Motor block was assessed complete when the patient could not lift or abduct the arm. Successful analgesia and anesthesia were evaluated as indicative of adequate sensory block. If the patient could still lift or abduct the arm after 3 minutes, BPB was repeated by injecting the same dose of bupivacaine and normal saline mixture. After achieving the complete motor block, the
Standard interventional procedures were performed by using our criteria for treatment of dysfunctional hemodialysis fistulas. Local anesthesia was administered for BPB puncture site in all patients but not administered for vascular access site puncture to be able to evaluate the effectiveness of BPB. Access to the fistula was achieved initially with a 21-gauge needle. US guidance was used to puncture the vein per our routine. A vascular sheath ranging from 5-F to 8-F depending on the requirement of treatment procedures was inserted into the vein over a guide wire. Occluded or stenotic segments were treated with percutaneous transluminal angioplasty by using balloon catheters, high-pressure balloon catheters, or peripheral cutting balloon catheters. If follow-up angiograms revealed residual stenosis 4 30%, long-duration balloon inflation (3–5 min) was applied using conventional balloons with the same size or a larger balloon. Thrombectomy procedures were performed by manual aspiration thrombectomy, with or without previous thrombolysis. Stent placement after balloon dilation was usually avoided. A stent was placed when the stenosis did not respond to repeated long-duration balloon dilation. Covered stent placement was reserved for acute ruptures not controlled by balloon tamponade.
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Procedural Parameters
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(very well) in all cases. No patients experienced dyspnea or any other respiratory side effects after the BPB. Systematic chest radiography after BPB was not obtained; subclinical pneumothoraces may have occurred. No additional serious side effects or complications were observed during and after the procedure.
All data were collected prospectively. Technical details, including block execution time (from probe positioning to the end of local anesthetic injection), number of needle attempts, amount of local anesthetic, onset of complete block (from the end of the local anesthetic injection to the onset of complete motor loss), duration of the treatment (from initial puncture of the fistula to completion of the treatment), requirements for additional local anesthetic infiltration, and need for intravenous sedative or analgesic medication, were registered immediately after the procedure. Pain related to performance of BPB was recorded using a visual analog scale that was graded from 0 (no pain) to 10 (agonizing pain). We asked patients to quantify their feelings of pain during the whole procedure. Patients subjectively assessed their feelings of procedural pain and marked this accordingly on the visual analog scale. Patient satisfaction and operator satisfaction were graded from 0–3: 0, not satisfied (poor); 1, partially satisfied (slightly well); 2, satisfied (very well). The visual analog scale score and patient satisfaction and operator satisfaction with the anesthetic technique were asked and measured immediately after the procedure and not during the procedure. Statistical analysis was performed using SPSS software (version 17.0; SPSS, Chicago, Illinois). All numerical data are expressed as mean ⫾ SD or as proportions.
In 40 consecutive patients, dysfunctional hemodialysis fistulas were treated successfully. Of the 40 dysfunctional fistulas, 39 were native, and 1 was a graft fistula; 27 were in the forearm (67.5%), and 13 were in the upper arm (32.5%). Occlusions or significant stenoses or both were identified in the afferent arteries (n ¼ 1), anastomoses (n ¼ 28), efferent veins (n ¼ 37), and central veins (n ¼ 5). Conventional balloon angioplasty for occlusion or stenosis was performed in each patient (range, 3–14 mm). In 10 patients, cutting balloons (with 5–8 mm diameter) were used for tight stenoses resistant to conventional balloon catheters. A technically successful result (a stenosis o 30% residual diameter) was achieved in all patients. There were 10 thrombosed hemodialysis fistulas that were declotted by manual aspiration thrombectomy alone or in combination with catheter-directed thrombolysis. Two of the fistulas required stent placement. In one patient, distal arterial emboli occurred during declotting procedures and were immediately managed using manual aspiration thrombectomy.
RESULTS
DISCUSSION
Pain Control and Procedural Parameters
US-guided supraclavicular BPB allowed pain-free endovascular treatment of dysfunctional hemodialysis fistulas without supplemental analgesia. Only two patients required intravenous sedation for procedure-related anxiety. Patient satisfaction and physician satisfaction from the procedure were excellent. No complications secondary to BPB or the endovascular procedure itself were encountered. Significant pain may be experienced by hemodialysis patients during treatment of dysfunctional hemodialysis fistulas by endovascular techniques. Such procedures are also stressful and performed under sedation and analgesia. The combination of benzodiazepines and opioid analgesics has been widely used to relieve pain especially secondary to balloon dilation during endovascular procedures (9–12,14,15). The construction and intraoperative balloon angioplasty for dysfunctional fistulas were also performed under local anesthesia with intravenous sedation, regional block, or general anesthesia (16). The synergistic effect of midazolam and fentanyl increases their effectiveness but also increases the adverse effects, such as respiratory depression. Hemodialysis patients are usually more susceptible to these adverse effects than healthy volunteers (9–12). Relative risk of cardiopulmonary arrest in patients undergoing interventional radiology procedures was
BPB was technically successful in all patients. Satisfactory procedural anesthesia and analgesia were achieved in all patients. Five patients (12.5%) in whom puncture sites were anesthetized locally with prilocaine complained of slight pain during needle insertion initially or placement of the vascular sheath to the fistula. A single intravenous dose of 1 mg midazolam was required in two patients to relieve anxiety before the BPB procedure and subsequent treatment. Analgesia with intravenous fentanyl was not required in any patients. The mean time necessary to perform the block was 3.8 minutes ⫾ 1.8. The median number of needle attempts was 3 (range, 1–5). The mean amount of local anesthetic was 7.8 mL ⫾ 3.4. Adequate anesthesia and analgesia were achieved with 5 mL in 21 patients (52.5%), with 10 mL in 15 patients (37.5%), and with 15 mL in 4 patients (10%). The mean onset time for complete block was 5.4 minutes ⫾ 2.6. The mean treatment time was 65.2 minutes ⫾ 36.7. After the treatments, pain scores were 0 (no pain) in 26 patients and 1–3 (mild, annoying pain) in 14 patients. The patient’s satisfaction with pain control was recorded as satisfied (very well) in all cases. The operator’s satisfaction during treatment was recorded as satisfied
Treatment Procedure
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Number 9
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significantly higher in procedures related to dialysis access (17,18). In this setting, US-guided supraclavicular BPB can offer opportunities for relieving pain without adverse effects of intravenous sedation and analgesia. US-guided BPB was performed rapidly and did not require any additional equipment and staff. Brachial plexus can be blocked through interscalene, supraclavicular, infraclavicular, or axillary approaches. Each of these approaches has its own particular advantages, disadvantages, and complication rate. For shoulder surgery, the interscalene approach is more appropriate. For procedures of the arm, the supraclavicular or infraclavicular approach produces adequate anesthesia and analgesia. Compared with the supraclavicular block, infraclavicular block has less impact on pulmonary function but is more likely to spare the radial nerve distribution if a single injection is used. For forearm and hand surgery, the axillary approach is associated with less risk of adverse effects than other approaches (8,19,20). In the present study, US-guided supraclavicular BPB was preferred to other approaches because it was considered to be technically easy, was associated with fewer complications, and provided regional anesthesia and analgesia suitable for endovascular procedures at the level of the arm, forearm, and hand. US guidance was reported to decrease the risk of pneumothorax and to increase the accuracy of the block (6,7,20–24). In our study, no patients developed clinically apparent pneumothorax, Horner syndrome, or recurrent laryngeal nerve block. US guidance also helped to lower the local anesthetic volume needed to perform the blocks (22,23). We were able to use less local anesthetic to achieve acceptable results, which is important in terms of the risk of Horner syndrome and phrenic nerve palsy. In the literature, we could find only a few studies on use of nerve blocks during interventional radiology procedures. Yilmaz et al (25 reported that femoral or sciatic nerve blocks could provide considerable reduction of pain during endovenous laser ablation of the saphenous vein insufficiency. They reported that femoral or sciatic nerve blocks made these procedures more comfortable for the patient and easier for the operator. These authors suggested that prolonged procedure time or the use of foam sclerotherapy could potentially increase the risk of deep vein thrombosis. For this reason, patients were requested to walk for about 15 minutes immediately after the treatment. To achieve this goal, the nerve blocks performed need to provide analgesia with minimal or no motor block. In contrast, when BPB was performed for treatment of fistula dysfunction, the sensory block was more desirable than the motor block. However, motor block was not always considered a disadvantage for these procedures because control of unwanted movement of the upper limb could be an important advantage to obtain roadmap images,
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which are used while traversing the occluded venous segments with a guide wire. The present study has some limitations that might have weakened the conclusions. First, the success rate of this study was not compared in a randomized manner with other options, such as the use of sedoanalgesia. With such a comparison, a more solid conclusion would have been provided regarding the efficacy of BPB. Second, authors who collected the data were not blinded because most of the measurements had to be taken during and immediately after BPB. Third, the type and volume or concentration of local anesthetics were arbitrarily chosen. It might be possible that a lower volume or concentration could be sufficient for a successful nerve block. Another significant limitation was that we did not measure the length of anesthesia and recovery time from the motor block. This could have been one of the major components of the study. However, we sent the patients home after recovery of the block and did not measure the exact time it took. In conclusion, US-guided supraclavicular BPB can be used safely to provide analgesia during endovascular treatment of dysfunctional hemodialysis fistulas. It provides good procedural satisfaction in adult hemodialysis patients. Studies directly comparing BPB with intravenous sedation and analgesia in the same patient population are needed.
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