Long-term functional patency and cost-effectiveness of arteriovenous fistula creation under regional anesthesia: a randomized controlled trial

BACKGROUND:Regional anesthesia improves short-term blood flow through arteriovenous fistulas (AVFs). We previously demonstrated that, compared with local anesthesia, regional anesthesia improves primary AVF patency at 3 months. METHODS:To study the effects of regional versus local anesthesia on longer-term AVF patency, we performed an observer-blinded randomized controlled trial at three university hospitals in Glasgow, United Kingdom. We randomly assigned 126 patients undergoing primary radiocephalic or brachiocephalic AVF creation to receive regional anesthesia (brachial plexus block; 0.5% L-bupivacaine and 1.5% lidocaine with epinephrine) or local anesthesia (0.5% L-bupivacaine and 1% lidocaine). This report includes findings on primary, functional, and secondary patency at 12 months; reinterventions; and additional access procedures (primary outcome measures were previously reported). We analyzed data by intention to treat, and also performed cost-effectiveness analyses. RESULTS:At 12 months, we found higher primary patency among patients receiving regional versus local anesthesia (50 of 63 [79%] versus 37 of 63 [59%] patients; odds ratio [OR], 2.7; 95% confidence interval [95% CI], 1.6 to 3.8; P=0.02) as well as higher functional patency (43 of 63 [68%] versus 31 of 63 [49%] patients; OR, 2.1; 95% CI, 1.5 to 2.7; P=0.008). In 12 months, 21 revisional procedures, 53 new AVFs, and 50 temporary dialysis catheters were required. Regional anesthesia resulted in net savings of £195.10 (US$237.36) per patient at 1 year, and an incremental cost-effectiveness ratio of approximately £12,900 (US$15,694.20) per quality-adjusted life years over a 5-year time horizon. Results were robust after extensive sensitivity and scenario analyses. CONCLUSIONS:Compared with local anesthesia, regional anesthesia significantly improved both primary and functional AVF patency at 1 year and is cost-effective. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER:Local Anaesthesia versus Regional Block for Arteriovenous Fistulae, NCT01706354

Regional anesthesia in children: indications and limitations

The goal of regional anesthesia in infants and children is perioperative and postoperative pain relief. The use of regional anesthesia and analgesia provide improvement in patient outcomes, and may be helpful in special situations, such as premature babies, patients with neuromuscular disorders or non-fasting children presenting for urgent surgery. Application of ilioinguinal and rectus sheath blocks, transverses abdominal plane blocks and wound infiltration with local anesthetics is commonly performed in combination with general anesthesia. Continuous central and perineural infusion of local anesthetics remains the technique of choice for prolonged major surgery or intense postoperative pain. Caudal block still remains the most important and safe technique. Introduction of nerve stimulators and lastly ultrasound guided regional anesthesia techniques reduced the risks and increase the benefits of this kind of anesthesia. The safety profile of regional anesthesia presented in surveys is superior with the very low incidence of serious complications. The aim is to find the safest technique for realizing the anesthesia and analgesia in children where a benefit overcomes the risk

Regional anesthesia in children: indications and limitations

The goal of regional anesthesia in infants and children is perioperative and postoperative pain relief. The use of regional anesthesia and analgesia provide improvement in patient outcomes, and may be helpful in special situations, such as premature babies, patients with neuromuscular disorders or non-fasting children presenting for urgent surgery. Application of ilioinguinal and rectus sheath blocks, transverses abdominal plane blocks and wound infiltration with local anesthetics is commonly performed in combination with general anesthesia. Continuous central and perineural infusion of local anesthetics remains the technique of choice for prolonged major surgery or intense postoperative pain. Caudal block still remains the most important and safe technique. Introduction of nerve stimulators and lastly ultrasound guided regional anesthesia techniques reduced the risks and increase the benefits of this kind of anesthesia. The safety profile of regional anesthesia presented in surveys is superior with the very low incidence of serious complications. The aim is to find the safest technique for realizing the anesthesia and analgesia in children where a benefit overcomes the risk

Barriers and facilitators to implementing a regional anesthesia service in a low-income country: a qualitative study

Introduction: regional anesthesia is a safe alternative to general anesthesia. Despite benefits for perioperative morbidity and mortality, this technique is underutilized in low-resource settings. In response to an identified need, a regional anesthesia service was established at the University Teaching Hospital of Kigali (CHUK), Rwanda. This qualitative study investigates the factors influencing implementation of this service in a low-resource tertiary-level teaching hospital. Methods: following service establishment, we recruited 18 local staff at CHUK for in-depth interviews informed by the “Consolidated Framework for Implementation Research” (CFIR). Data were coded using an inductive approach to discover emergent themes. Results: four themes emerged during data analysis. Patient experience and outcomes: where equipment failure is frequent and medications unavailable, regional anesthesia offered clear advantages including avoidance of airway intervention, improved analgesia and recovery and cost-effective care. Professional satisfaction: morale among healthcare providers suffers when outcomes are poor. Participants were motivated to learn techniques that they believe improve patient care. Human and material shortages: clinical services are challenged by high workload and human resource shortages. Advocacy is required to solve procurement issues for regional anesthesia equipment. Local engagement for sustainability: participants emphasized the need for a locally run, sustainable service. This requires broad engagement through education of staff and long-term strategic planning to expand regional anesthesia in Rwanda. Conclusion: while the establishment of regional anesthesia in Rwanda is challenged by human and resource shortages, collaboration with local stakeholders in an academic institution is pivotal to sustainability

Topics in Regional Anesthesia

Regional anesthesia has progressively evolved and currently occupies a predominant place in our daily practice. The development of skills for the safe practice of regional anesthesia requires in-depth knowledge of anatomy, physiology, pharmacology, and the pathology of each patient candidate to receive some type of regional block, as well as special and prolonged training beyond residence, particularly in this era of the COVID-19 pandemic, during which the training of thousands of anesthesiology residents has been impaired. Undoubtedly, the benefits of regional anesthesia techniques are enormous, as are their complications. Countless guidelines for regional anesthesia have been described based on the classic anatomical recommendations, the search for paresthesias, neurostimulation, and medical images. The introduction of ultrasound guidance and the rational use of local anesthetics and their adjuvants have favorably revolutionized regional anesthesia, making it safer and more effective. This book addresses several contemporary topics in regional anesthesia in a variety of interesting clinical settings with practical importance

Anesthesia Options and the Recurrence of Cancer: What We Know so Far?

Surgery is a critical period in the survival of patients with cancer. While resective surgery of primary tumors has shown to prolong the life of these patients, it can also promote mechanisms associated with metastatic progression. During surgery, patients require general and sometimes local anesthetics that also modulate mechanisms that can favor or reduce metastasis. In this narrative review, we summarized the evidence about the impact of local, regional and general anesthesia on metastatic mechanisms and the survival of patients. The available evidence suggests that cancer recurrence is not significantly impacted by neither regional anesthesia nor volatile or total intravenous anesthesia

Regional Anesthesia for Hand Surgeries

Anesthesia for hand surgeries is one of the domains of regional anesthesia, where it plays the role, not only as a viable alternative to GA but also as an adjunct to it. The efficacy and inherent advantages of regional anesthesia techniques are widely made use of by the hand and upper limb surgical centers across the world. There are a variety of established regional techniques ranging from major plexus blocks to local infiltration techniques and intra venous regional anesthesia for hand surgeries. The peripheral nerve blocks are recently being performed with ultrasound guidance which is undoubtedly the greatest influence till date in the practice of modern regional anesthesia. There is also a recent trend in the performance of certain minor hand surgeries (e.g., carpal tunnel release) under infiltrative techniques in office-like settings for rapid turnover. This chapter discusses concisely the selection and execution of such techniques in day-to-day practice

Reducing the incidence of adverse events in anesthesia practice

Background and purpose: adverse event during anesthesia is defined as an event that may result in the development of complications and is caused by human error, failure of the apparatus, the selected anesthetic techniques and individual reaction of the patient. Timely detection of adverse events prevents complications and their analysis through the register of the same to the adoption of preventive and remedial measures. Materials and methods:The Department of Anesthesiology in General Hospital Karlovac, in accordance with the accreditation standards of the Republic of Croatia monitors adverse events during anesthesia, the waking up period and the stay on the ward during the first 24 hours, and the type of anesthesia techniques applied. Results: During the 2012, a total of 4244 anesthesia with a 1.25% complications was done.We have been monitoring the number of anesthesia since 2011. when the percentage of complications was 5.4%. This is the basis to conclude that there is a tendency to reduce the number of complications. Anesthesia was classified as general and regional. The use of ultrasound contributes to safety of regional anesthesia, especially nerve conduction anesthesia of extremities and thus reducing the volume of local anesthetic administered and its toxicity. The incidence of complications of regional anesthesia among all regional anesthesias done during the 2012 was 0,31%. Conclusion: Keeping the register of complications during anesthesia has led to increased awareness of the need to record them and analyze the causes and consequences of complications at the department meetings. There is a trend of increased use of regional anesthesia techniques as indicated

Regional Anesthesia: Advantages of Combined Use with General Anesthesia and Useful Tips for Improving Nerve Block Technique with Ultrasound Technology

Regional anesthesia is not always performed independently, but rather is frequently employed as part of a general anesthesia technique. Thus, its procedures and usefulness should be considered in settings where general anesthesia is used. In this chapter, new perspectives regarding the interaction of regional and general anesthesia are presented, as well as novel tips for improving nerve block techniques during the course of general anesthesia, Regional anesthetics inhibit superoxide generation of neutrophils by inhibition of protein kinase C activity and also have potent antioxidant activities, while inhalation general anesthetics have contrasting effects. Therefore, it is considered that regional anesthetics are able to compensate for shortcomings of inhalation general anesthetics by reducing surgical oxidative stress. In clinical settings, combined use of regional with general anesthesia provides better intraoperative hemodynamics than general anesthesia alone, particularly in high‐risk patients affected by severe cardiovascular disease. To further improve the analgesic potency and duration of regional anesthesia, especially in cases in which a peripheral nerve block is performed, addition of low molecular weight dextran as an adjuvant to the local anesthetic solution is quite effective. Furthermore, recent advancements in ultrasound technology have made previously difficult regional anesthesia techniques easier and safer to achieve. A typical example is use of a caudal block in adults, which is quite difficult with a conventional method. Expanding its indication to adults is beneficial, especially for high‐risk patients undergoing surgery in the lower abdomen. Furthermore, proper in‐line positioning of ultrasound images is key for successful and easy completion of ultrasound‐guided procedures, such as needle insertion to the target. We have been able to establish such a positioning method by use of an iPad and the VT‐100 image transfer system (Scalar Co., Tokyo, Japan). Following consideration of the present findings and related experience, it is evident that performance of regional anesthesia under general anesthesia provides great advantages, including better and safe anesthesia management

Anesthesia in endovascular abdominal aortic aneurysm (AAA) repair

Introduction: endovascular AAA repair can be done using different anesthetic techniques, such as general anesthesia, regional block, and local anesthesia associated with sedation. For successful anesthetic management, it is important to select the best approach with an understanding of the patient's health status