Original Article

CME Article: Pain after Arteriovenous Access Creation

Authors: Amy Howk, MD, Callie McAdams, MD, Eric Heidel, PhD, Oscar Grandas, MD

Abstract

Objectives: Dialysis access creation is a common outpatient procedure that can be completed using general, regional, or local anesthetic techniques. There are few endorsed guidelines regarding opioid-based pain control following fistula creation. The purpose of this study was to determine whether utilization of regional anesthesia (RA) is associated with the decreased use of narcotics postoperatively.

Methods: We performed a prospective cohort study including all patients undergoing arteriovenous fistula creation with one vascular surgeon from August 2019 to February 2020. Patients were selected for regional versus general anesthesia. Selection for anesthesia type was determined by the primary anesthesiologist. Patients selected for RA underwent supraclavicular brachial plexus block with 30 cm3 of 0.5% ropivacaine. Patients were seen in clinic follow-up and completed a questionnaire regarding their postoperative opiate use and pain control.

Results: In the study period, 52 patients underwent arteriovenous fistula creation and completed the follow-up questionnaire. Forty patients received RA. Seventy-five percent of patients sent home with a narcotic prescription filled the prescription. There was a significant difference in postoperative opioid use between the two study groups. Patients who received regional block took on average 3.3 pills totaling 16.5 morphine milligram equivalents, whereas patients who received general anesthesia took on average 6.64 pills totaling 33.2 morphine milligram equivalents (P = 0.04).

Conclusions: Morbidity and mortality related to opiate use continues to be a public health issue in the United States. This study demonstrates that regional anesthetic techniques in comparison to general anesthesia can result in a significant decrease in postoperative opiate consumption.
Posted in: Nephrology and Urology21

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References

1. Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999–2018. https://www.cdc.gov/nchs/products/databriefs/db356. htm#:~:text=rate%20in%202017.-,In%202018%2C%20there%20were% 2067%2C367%20drug%20overdose%20deaths%20in%20the,1999%20to% 2021.7%20in%202017. Published January 2020. Accessed January 25, 2022.
 
2. Florence CS, Zhou C, Luo F, et al. The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013. Med Care 2016;54:901–906.
 
3. Andreae MH, Andreae DA. Regional anaesthesia to prevent chronic pain after surgery: a Cochrane systematic review and meta-analysis. Br J Anaesth 2013;111:711–720.
 
4. Burnett G, DeMaria S Jr, Levine AI. Regional anesthesia and acute pain management. Otolaryngol Clin North Am 2019;52:1065–1081.
 
5. Janek KC, Bennett KM, Imbus JR, et al. Patterns of opioid use in dialysis access procedures. J Vasc Surg 2020;72:1018–1024.
 
6. Kimmel PL, Fwu CW, Abbott KC, et al. Opioid prescription, morbidity, and mortality in United States dialysis patients. J Am Soc Nephrol 2017;28: 3658–3670.
 
7. Davison SN. The prevalence and management of chronic pain in end-stage renal disease. J Palliat Med 2007;10:1277–1287.
 
8. Lahori VU, Raina A, Gulati S, et al. A randomized comparative study of efficacy of axillary and infraclavicular approaches for brachial plexus block for upper limb surgery using peripheral nerve stimulator. Indian J Anaesth 2011;55:253–259.
 
9. Malinzak EB, Gan TJ. Regional anesthesia for vascular access surgery. Anesth Analg 2009;109:976–980.
 
10. Han Y, Balkrishnan R, Hirth RA, et al. Assessment of prescription analgesic use in older adults with and without chronic kidney disease and outcomes. JAMA Netw Open 2020;3:e2016839.
 
11. Nagar VR, Birthi P, Salles S, et al. Opioid use in chronic pain patients with chronic kidney disease: a systematic review. Pain Med 2017;18:1416–1449.
 
12. Lee SC, Quan C, Mun JH, et al. Efficacy of regional anesthesia in secondary procedures or revisions of arteriovenous fistula. Ann Vasc Surg 2021;71: 191–199.
 
13. You AS, Kalantar-Zadeh K, Streja E, et al. Mortality risk in chronic kidney disease patients transitioning to dialysis: impact of opiate and non-opiate use. Am J Nephrol 2020;51:715–725.
 
14. Santos-Parker JR, Yoshida M, Hallway AK, et al. Postoperative opioid prescription and use after outpatient vascular access surgery. J Surg Res 2021;264:173–178.
 
15. Phair J, Choinski K, Carnevale M, et al. Perioperative opioid and nonopioid prescribing patterns in AVF/AVG creation. Ann Vasc Surg 2021;72:290–298.
 
16. Shemesh D, Olsha O, Orkin D, et al. Sympathectomy-like effects of brachial plexus block in arteriovenous access surgery. Ultrasound Med Biol 2006;32: 817–822.
 
17. Mouquet C, Bitker MO, Bailliart O, et al. Anesthesia for creation of a forearm fistula in patients with endstage renal failure. Anesthesiology 1989;70:909–914.
 
18. Aitken E, Jackson A, Kearns R, et al. Effect of regional versus local anaesthesia on outcome after arteriovenous fistula creation: a randomised controlled trial. Lancet 2016;388:1067–1074.