Shorter acting Supra for avf pts

[turnupthevapor]

When I have an elderly patient that I don't want to send home with a numb arm what can I use for a shorter block than bupi for Supra on avf???

I was thinking mepi 2% but wondering what the hive does...I kind of remember using mepi 1.5% but my hospital stocks 2% now. Anyone use lido or anything else? Surgeon is pretty quick.

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[Maz777]

AVFs do not need a long-acting block. Unless they are doing a graft up to the axilla and filleting the arm open (which is rare), sending home with a dead arm for 12 hours makes no sense. This is commonly an antecubital 3-5cm traverse incision (for brachiocephalic and brachiobasilic AVFs) or even smaller incision near the wrist for radiocephalic AVFs. Even 2nd stage transpositions don't need bupi. These aren't distal radius ORIFs or humeral ORIFs that have a lot of postop pain.

2% lido or 2% mepi (doesn't matter). 20cc is more than sufficient of either for a dense 4-6 hour surgical block. These patients are higher risk for lido toxicity if you use higher volumes (have seen it twice; not truly LAST, just pre-excitation/change in mental status that will resolve with a benzo and time). I'd recommend adding epi 1:200k to your LA. Dorsal scapular artery can commonly run between the ST and MT/IT (yet look like a part of the brachial plexus) and if you inject into the sheath between the trunks you risk hitting it. Better to see a HR response with 2cc before you slam 5-10cc or more.

 

[turnupthevapor]

Thanks for the super thorough response. I agree although i do wonder if longer sympathectomy may protect the graft survival

referring to Comparison of regional and local anesthesia for arteriovenous fistula creation in end-stage renal disease: a systematic review and meta-analysis

Just a thought.

Back to the 2% wondering if that's just to much local as 30 ml (allowing a few cc for intercostobrachial) would be almost 9mg/kg. Thinking I would cut back to 1.5% or maybe even 1% but want to make sure I have a good enough motor block and duration. Based on the below article 1.5 maybe even 1% would work.

Effect of local anesthetic concentration, dose and volume on the duration of single-injection ultrasound-guided axillary brachial plexus block with mepivacaine: a randomized controlled trial

In what way volume, concentration and dose affect block duration is controversial. The purpose of the present study is to investigate the effect of dose, volume and concentration of mepivacaine on the duration of sensory and motor blockade in ultrasound-guided ...

www.ncbi.nlm.nih.gov

 

[Maz777]

I personally don't believe the suspect literature that regional anesthesia affects long-term fistula function or graft patency. It makes zero sense physiologically why short-term vasodilation gives the surgeon a magically improved anastomosis that will last months to years longer. I get that the anastomosis might be slightly easier to perform with a dilated brachial artery but a good anastomosis can be done with or without that vasodilation. Papaverine probably does the same thing. Studies that show any differences are poorly done. There are way more factors that affect long-term fistula function or graft patency.

30cc of 2% is a hefty amount but even with that amount lido toxicity would be quite rare. Unless you are watching trainees putz around and waste local anesthetic with every needle manipulation, it is an unnecessary amount to give. You only need to add on an ICB in select cases (and 3-5cc is plenty for that). Almost no AVFs require incisions up the medial upper arm into the axilla (mainly just some AV grafts do).

 

[Hoya11]

When I have an elderly patient that I don't want to send home with a numb arm what can I use for a shorter block than bupi for Supra on avf???

I was thinking mepi 2% but wondering what the hive does...I kind of remember using mepi 1.5% but my hospital stocks 2% now. Anyone use lido or anything else? Surgeon is pretty quick.

I don’t understand why it’s bad to have a 24 hr block and a numb arm that allows a more gentle anesthetic and predictable dense block for surgery without concern for LAST.

I wouldn’t be searching for alternatives to bupi or ropi.

 

[Urzuz]

The vast majority of AVFs/AVGs don’t need a PNB. Just have the surgeon inject local at incision site, run a little propofol, and sprinkle in homeopathic doses of fentanyl prn. These patients are so fragile that you can literally get away with running doses of propofol ~10 mcg/kg/min and they'll be konked out. Many of them are also very understanding to not being completely asleep for a procedure, and they are used to having their arms messed around with while they are completely awake during their dialysis sessions. No numb arm afterwards, no hemodynamic instability during the case.

In the last couple years we have had newer partners treat these cases like any other MAC case (i.e: trying to achieve GA without an airway), and we have had more than one intraoperative arrest. Err on the side of less anesthesia, talk them through it, they'll be fine.

 

[UscGhost]

I have done them all three ways. Mac plus local, general plus local, and general/Mac plus nerve block.

Smoothest cases are with my own blocks. Surgeons suck.

Ropiv 0.25% 20 ml. I don't need a dense block

Lido probably fine too

 

[Urzuz]

I have done them all three ways. Mac plus local, general plus local, and general/Mac plus nerve block.

Smoothest cases are with my own blocks. Surgeons suck.

Ropiv 0.25% 20 ml. I don't need a dense block

Lido probably fine too

I would change that say your surgeons suck. The surgeons who do vascular access with us are phenomenal…they give the local time to work, don’t have unrealistic expectations of zero movement during the case, etc.

In residency we did these cases with blocks and/or GA. When I first came to my current practice I was super skeptical of being able to do these under surgeon local, but now I’m a believer. We do local + moderate sedation for all these cases and they are smooth as butter. This includes tunneling for AV grafts, etc.

 

[vector2]

I would change that say your surgeons suck. The surgeons who do vascular access with us are phenomenal…they give the local time to work, don’t have unrealistic expectations of zero movement during the case, etc.

In residency we did these cases with blocks and/or GA. When I first came to my current practice I was super skeptical of being able to do these under surgeon local, but now I’m a believer. We do local + moderate sedation for all these cases and they are smooth as butter. This includes tunneling for AV grafts, etc.

If on any given day your vascular surgeons have an expectation of possible patient movement during a delicate anastomosis then it doesn't exactly sound "smooth as butter" to me...

 

[Arch Guillotti]

If on any given day your vascular surgeons have an expectation of possible patient movement during a delicate anastomosis then it doesn't exactly sound "smooth as butter" to me...

yeah our guys prefer them on bypass paralyzed

 

[Urzuz]

If on any given day your vascular surgeons have an expectation of possible patient movement during a delicate anastomosis then it doesn't exactly sound "smooth as butter" to me...

If anything the patient may move a little during the dissection and exposure. When they are creating the anastomosis, the painful portion of the procedure is over.

The surgeons have been doing it this way at our hospital for decades (one of them in particular has 30+ years of experience doing transplants etc) and that is their preferred anesthetic technique. If there was some major issue I’m sure they would have spoken up a long time ago.

 

[Urzuz]

yeah our guys prefer them on bypass paralyzed

That’s how our general surgeons who are doing inguinal hernias like their patients too.

 

[teacher2md]

If on any given day your vascular surgeons have an expectation of possible patient movement during a delicate anastomosis then it doesn't exactly sound "smooth as butter" to me...

Well, you know our private practice blocks don’t work as well as the fancy academic blocks, so we have to do the best we can 🤷‍♂️

 

[coffeebythelake]

Well, you know our private practice blocks don’t work as well as the fancy academic blocks, so we have to do the best we can 🤷‍♂️

The light GA helps

 

[vector2]

If anything the patient may move a little during the dissection and exposure. When they are creating the anastomosis, the painful portion of the procedure is over.

The surgeons have been doing it this way at our hospital for decades (one of them in particular has 30+ years of experience doing transplants etc) and that is their preferred anesthetic technique. If there was some major issue I’m sure they would have spoken up a long time ago.

I'm not saying local infiltration + light sedation isn't a viable option (especially in some pulmonary cripple), but given the fact that at worst surgical block is equivocal for outcomes and at best it really does help with long term patency, if me or a family member needed an AVF I would definitely elect for surgical block plus MAC.

Combine that with the fact that having to coach an awake-ish patient through the painful parts / reassure them while the surgeon infiltrates / suddenly have to snow them with prop, etc, sounds like generally a pain in the ass to me, imo block is a no brainer.

 

[Urzuz]

I'm not saying local infiltration + light sedation isn't a viable option (especially in some pulmonary cripple), but given the fact that at worst surgical block is equivocal for outcomes and at best it really does help with long term patency, if me or a family member needed an AVF I would definitely elect for surgical block plus MAC.

Combine that with the fact that having to coach an awake-ish patient through the painful parts / reassure them while the surgeon infiltrates / suddenly have to snow them with prop, etc, sounds like generally a pain in the ass to me, imo block is a no brainer.

It’s not a pain in the ass at all. As I said, I was skeptical at first, but after having it done it this way for a decade I can tell you a block is unnecessary if you have a competent surgeon on the other side of the drapes. Patients do great, the anesthetic is stable, and it’s overall easy for everyone involved. Don’t knock it until you try it.

 

[vector2]

It’s not a pain in the ass at all. As I said, I was skeptical at first, but after having it done it this way for a decade I can tell you a block is unnecessary if you have a competent surgeon on the other side of the drapes. Patients do great, the anesthetic is stable, and it’s overall easy for everyone involved. Don’t knock it until you try it.

I just did an emergent antecubital/low axilla region nec fasc vs cellulitis debridement on a cardiac cripple two days ago. Did a supra and ICB but my ICB was a bit patchy (or the tissue was too infected/acidic) so when they were in the axilla he required some surgeon infiltration, a bit of hand holding, 50mcg of fent and 20mg of ketamine.

I hated it, and I hate the possibility that AVFs could similarly require that much effort as opposed to a 5 minute (lol) block, low dose prop, and cruise control.

 

[anaesthetic]

It’s not a pain in the ass at all. As I said, I was skeptical at first, but after having it done it this way for a decade I can tell you a block is unnecessary if you have a competent surgeon on the other side of the drapes. Patients do great, the anesthetic is stable, and it’s overall easy for everyone involved. Don’t knock it until you try it.

The key to any anesthetic is to have a great surgeon. In vascular, those are few and far between, IMO.

 

[UscGhost]

Quit

I would change that say your surgeons suck. The surgeons who do vascular access with us are phenomenal…they give the local time to work, don’t have unrealistic expectations of zero movement during the case, etc.

In residency we did these cases with blocks and/or GA. When I first came to my current practice I was super skeptical of being able to do these under surgeon local, but now I’m a believer. We do local + moderate sedation for all these cases and they are smooth as butter. This includes tunneling for AV grafts, etc.

Quite true. You can do a lot of cases under local max if you have good surgeons who are gentle and patient.

In my scenario, I prefer to eliminate those variables whenever I can.

My surgeons inject and then cut 5 seconds later, and then I have to bolus propofol, etc.

 

[Urzuz]

I just did an emergent antecubital/low axilla region nec fasc vs cellulitis debridement on a cardiac cripple two days ago. Did a supra and ICB but my ICB was a bit patchy (or the tissue was too infected/acidic) so when they were in the axilla he required some surgeon infiltration, a bit of hand holding, 50mcg of fent and 20mg of ketamine.

I hated it, and I hate the possibility that AVFs could similarly require that much effort as opposed to a 5 minute (lol) block, low dose prop, and cruise control.

That does sound awful. I would hate it too.

Luckily AVFs under local are nothing like your experience.

 

[vector2]

That does sound awful. I would hate it too.

Luckily AVFs under local are nothing like your experience.

Except for the pt potentially "mov[ing] a little during the dissection and exposure" part, right?

Also, I don't know what your patient population is like but I glanced back at the last 5 AVFs we did and 3 of them were morbidly obese. I think that alters the local infiltration calculus as well when the upper arm incision is 5 inches deep before reaching a vessel.

 

[GassYous]

Except for the pt potentially "mov[ing] a little during the dissection and exposure" part, right?

Also, I don't know what your patient population is like but I glanced back at the last 5 AVFs we did and 3 of them were morbidly obese. I think that alters the local infiltration calculus as well when the upper arm incision is 5 inches deep before reaching a vessel.

Patients can move any time, including under general anesthesia

 

[Urzuz]

Except for the pt potentially "mov[ing] a little during the dissection and exposure" part, right?

Also, I don't know what your patient population is like but I glanced back at the last 5 AVFs we did and 3 of them were morbidly obese. I think that alters the local infiltration calculus as well when the upper arm incision is 5 inches deep before reaching a vessel.

Dude. You are arguing with me about something that you admittedly have no experience with. You can conjure up whatever image you want about the awfulness of doing an AVF under local MAC, but whatever it looks like in your head, it’s wrong. But as others have learned the hard way and I am learning again, you are completely unteachable and unwilling to admit when you’re wrong.

I also find it hilarious that you are pointing out the fact that I said a patient may move under local + MAC, yet you describe a scenario of yours where your patient moved after your block + MAC. It’s almost as if patients have the potential to move under any kind of anesthetic.

Anyway, I’m done trying to convince you of anything.

 

[vector2]

Dude. You are arguing with me about something that you admittedly have no experience with. You can conjure up whatever image you want about the awfulness of doing an AVF under local MAC, but whatever it looks like in your head, it’s wrong. But as others have learned the hard way and I am learning again, you are completely unteachable and unwilling to admit when you’re wrong.

It's ridiculous you'd phrase it as "unteachable" and "unwilling" when I literally just said a few posts ago:

I'm not saying local infiltration + light sedation isn't a viable option (especially in some pulmonary cripple)​

Clearly you're more interested in arguing against whatever strawmanned argument you've think I made instead of responding to exactly what I've been saying.

I also find it hilarious that you are pointing out the fact that I said a patient may move under local + MAC, yet you describe a scenario of yours where your patient moved after your block + MAC. It’s almost as if patients have the potential to move under any kind of anesthetic.

Anyway, I’m done trying to convince you of anything.

I'm not sure why you'd find it hilarious considering an emergent case for possible necrotizing fasciitis --- spanning from the antecubital fossa to low axilla where they're jamming probes along multiple subcutaneous and fascial planes up and down the arm to reach various pus pockets --- is not anywhere close to an apples to apples comparison to the average elective AVF surgery.

Also, I didn't say the patient moved. I said the ICB (a sensory block) set up patchy so I had to give him pain meds and do some hand holding, i.e. the figurative verbal reassurance kind. The SCB set up perfectly, so of course his arm was paralyzed and he couldn't move it and disrupt the surgery. Which is one of the many reasons why doing a block for AVF is superior imo.

 

[vector2]

Patients can move any time, including under general anesthesia

Sure.

But what's the incidence of the patient moving (or having significant discomfort as an impetus to move) with surgeon local infiltration vs. neuraxial/regional/GA? We do a few AVFs a week, and the last time I can remember a patient moving their arm during AVF placement was maybe two years ago (and that was possibly due to a bad batch of local).

So many people go on at length about how great it is to do an inguinal hernia or carotid or TCAR or AVF or whatever the f else under local with their wonderful surgeon, and sure, it may work for them, but my main point is that these experiences should not be broadly generalized to all surgeons and anesthesiologists. Especially not to the point of being a pompous prick and calling someone unteachable because they don't feel like putting in what's arguably more work for a possibly inferior outcome.

 

[anbuitachi]

i learned from plastic surgery that local anesthetic is not additive

 

[Urzuz]

So many people go on at length about how great it is to do an inguinal hernia or carotid or TCAR or AVF or whatever the f else under local with their wonderful surgeon, and sure, it may work for them, but my main point is that these experiences should not be broadly generalized to all surgeons and anesthesiologists. Especially not to the point of being a pompous prick and calling someone unteachable because they don't feel like putting in what's arguably more work for a possibly inferior outcome.

At least have the humility to go back and read the evolution of this post. The OP was saying he didn’t like send patients home with a numb arms following AVF creation. I suggested local from the surgeon as an alternative, and offered my experiences with the technique to support its use. You then interjected yourself into the middle of that discussion claiming that local doesn’t provide a smooth anesthetic, not believing me when I say it’s not as awful as you are suggesting, arguing with me about my own experiences (?!?!), and overall dismissing the technique as inferior to a peripheral nerve block and something you would never do, when I never suggested you do it to begin with. Who comes across as a pompous prick again in this scenario? Of course this kind of analysis requires the ability to self reflect…

 

[vector2]

At least have the humility to go back and read the evolution of this post. The OP was saying he didn’t like send patients home with a numb arms following AVF creation. I suggested local from the surgeon as an alternative, and offered my experiences with the technique to support its use. You then interjected yourself into the middle of that discussion claiming that local doesn’t provide a smooth anesthetic, not believing me when I say it’s not as awful as you are suggesting, arguing with me about my own experiences (?!?!), and overall dismissing the technique as inferior to a peripheral nerve block and something you would never do, when I never suggested you do it to begin with. Who comes across as a pompous prick again in this scenario? Of course this kind of analysis requires the ability to self reflect…

Yes, please, let's go look at the evolution. Because the very first thing you said in this thread was a broad, blanket statement that the "vast majority" of AVFs don't need a block, despite local infiltration being relatively niche and likely not the most common practice (for a reason).

Then @UscGhost shared his own experiences (?!?!) about having tried all the techniques and having found his blocks superior, and you dismissed it by saying:

I would change that say your surgeons suck. The surgeons who do vascular access with us are phenomenal…they give the local time to work, don’t have unrealistic expectations of zero movement during the case, etc.​

Maybe just a bit of a pompous declaration if I do say so.

As I said, you are taking your specific experience and erroneously trying to generalize its superiority to everyone else despite the fact that maybe, just maybe not everyone here works with "phenomenal" surgeons who have patience or phenomenal CRNAs who can manage a sick patient who still has full motor and sensory in their operative arm.

 

[turnupthevapor]

I have done them all three ways. Mac plus local, general plus local, and general/Mac plus nerve block.

Smoothest cases are with my own blocks. Surgeons suck.

Ropiv 0.25% 20 ml. I don't need a dense block

Lido probably fine too

Interesting, I never thought about using a lower concentration. I guess I was worried there I would be moving around.

 

[PpfSuxTube]

Well, you know our private practice blocks don’t work as well as the fancy academic blocks, so we have to do the best we can 🤷‍♂️

Its hard to move when you're on 100 propofol and remi.

Maybe the better patency of the AVF under regional is due to the venodilation from massive doses of propofol required to make blocks work?

I think everyone agrees the best dose of local for any block is 20mls of 1% propofol

 

[Dr. Rude]

Its hard to move when you're on 100 propofol and remi.

Maybe the better patency of the AVF under regional is due to the venodilation from massive doses of propofol required to make blocks work?

I think everyone agrees the best dose of local for any block is 20mls of 1% propofol

Corollary: All of my blocks work. Some just require more Propofol than others.

 

[Airway]

I don’t understand why it’s bad to have a 24 hr block and a numb arm that allows a more gentle anesthetic and predictable dense block for surgery without concern for LAST.

I wouldn’t be searching for alternatives to bupi or ropi.

I don't like doing long acting blocks because many of my 80 year old patients can barely get around with 2 hands and feet.

Take out an arm, put in a sling and they are a big fall risk.

Add on the aspirin and apixaban and they are a small fall away from death.

 

[Maz777]

I don't like doing long acting blocks because many of my 80 year old patients can barely get around with 2 hands and feet.

Take out an arm, put in a sling and they are a big fall risk.

Add on the aspirin and apixaban and they are a small fall away from death.

Totally agree. Some of our colleagues don't seem to understand what happens to the patients after leaving the PACU. I round on these patients POD1 if admitted and have never seen one of them in significant pain in which a long-acting block would have been useful. I have definitely seen the opposite though from blocks done by colleagues (dead arm, patient hates it, can't mobilize or get around, hoping the sensation will return soon).

 

[Hoya11]

I don't like doing long acting blocks because many of my 80 year old patients can barely get around with 2 hands and feet.

Take out an arm, put in a sling and they are a big fall risk.

Add on the aspirin and apixaban and they are a small fall away from death.

a numb arm is not a fall risk ime. is there data on that? i dont know of any..

we have had a few get dizzy and fall after oxycodone

never had a fall due a an upper extremity block

i actually found this that i thought was interesting: https://www.asra.com/docs/default-s...s/raapm22/abstract-3063.pdf?sfvrsn=b1b51bdc_2

 

[Hoya11]

Totally agree. Some of our colleagues don't seem to understand what happens to the patients after leaving the PACU. I round on these patients POD1 if admitted and have never seen one of them in significant pain in which a long-acting block would have been useful. I have definitely seen the opposite though from blocks done by colleagues (dead arm, patient hates it, can't mobilize or get around, hoping the sensation will return soon).

you have never seen a patient with a useful long acting block on POD 1? how about a total shoulder or distal radius fx?

the same guy telling you he "hates the way it feels" is going to tell you the agony they are in and how the pain meds dont work with no block..

for an older patient with a big painful surgery a brachial plexus block is a no brainer to minimize post op pain and anesthetic requirements intra-op

It might be a weird feeling , but its definitely the right thing to do even if the patient doesnt understand that..

one day we will have a sensory only local anesthetic! hopefully..

 

[Lookingforlolz]

c’mon people, this is a weird hill to die on. some of these responses are weirdly argumentative and defensive. there’s a million ways to skin a cat.

i’ve got vascular surgeons who want blocks, some who want GA, and some who only do local.

everyone does fine. there’s no obvious “right” way to do it.

 

[Maz777]

you have never seen a patient with a useful long acting block on POD 1? how about a total shoulder or distal radius fx?

the same guy telling you he "hates the way it feels" is going to tell you the agony they are in and how the pain meds dont work with no block..

for an older patient with a big painful surgery a brachial plexus block is a no brainer to minimize post op pain and anesthetic requirements intra-op

It might be a weird feeling , but its definitely the right thing to do even if the patient doesnt understand that..

one day we will have a sensory only local anesthetic! hopefully..

I forgot that TSAs and distal radiuses are just as painful as AVFs. Thank for the education.

Do you block someone's entire arm for a carpal tunnel? How about a trigger finger? How about a hangnail? I had one the other day. I think I need a long-acting block. It was super painful for like 2 hours. I want a noodle arm please for at least 24 hours.

Kidding aside. We do catheters for those for a reason. They are associated with significant postop pain. AVFs are not.

 

[Airway]

never had a fall due a an upper extremity block

i actually found this that i thought was interesting

In patient data. If they all stayed in the hospital I'd be more ok with it.


I work in a hospital where some of the patients don't have air-conditioning at home (it's 110f in the summer here), let alone someone to help them get around, cook food get to the toilet.

Your balance is absolutely altered by a UE block and this is a hill I'll die on

 

[Hoya11]

I forgot that TSAs and distal radiuses are just as painful as AVFs. Thank for the education.

Do you block someone's entire arm for a carpal tunnel? How about a trigger finger? How about a hangnail? I had one the other day. I think I need a long-acting block. It was super painful for like 2 hours. I want a noodle arm please for at least 24 hours.

Kidding aside. We do catheters for those for a reason. They are associated with significant postop pain. AVFs are not.

Right but AVFs are a population that benefits from a more minimal anesthetic and a block allows that.

I agree its not for post op pain control. Its for minimizing the anesthetic in a high risk population.

If I could do MAC and surgeon local obviously that would be plan A.

 

[Hoya11]

In patient data. If they all stayed in the hospital I'd be more ok with it.


I work in a hospital where some of the patients don't have air-conditioning at home (it's 110f in the summer here), let alone someone to help them get around, cook food get to the toilet.

Your balance is absolutely altered by a UE block and this is a hill I'll die

They are not going to be cooking with the new AVF arm on POD 1. Its going to be useless anyways.

And while you may have strong feelings about the balance issues, the evidence does not support it.

I agree with you that I would want it to wear off after surgery is over, I get that no one wants that limp noodle arm.

But I think thats a very minor inconvenience to an arm they arent going to be using anyways, if i believe the block and lighter anesthetic is the overall best thing for the patient.

 

[Airway]

And while you may have strong feelings about the balance issues, the evidence does not support it.

You only referenced in patient data. I'm not aware of any for outpatient, blocks and falls.

Going home is very different then staying in the hospital.

 

[Maz777]

They are not going to be cooking with the new AVF arm on POD 1. Its going to be useless anyways.

And while you may have strong feelings about the balance issues, the evidence does not support it.

I agree with you that I would want it to wear off after surgery is over, I get that no one wants that limp noodle arm.

But I think thats a very minor inconvenience to an arm they arent going to be using anyways, if i believe the block and lighter anesthetic is the overall best thing for the patient.

It's fine if you want to do a block as your primary anesthetic for these patients.

The original question from the thread is "what do I use that is shorter acting?" The point is that a long-acting block for extended postoperative analgesia is not necessary for >98% of these patients, and long-acting blocks for less than painful surgery have negative repercussions. We gave the OP options. 2% lidocaine or mepi will give you quick-onset, very dense surgical block that lasts an appropriate amount of time (4-6 hours).