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| Year : 2010 | Volume
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| Issue : 3 | Page : 494-500 |
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| The effect of low serum bicarbonate values on the onset of action of local anesthesia with vertical infraclavicular brachial plexus block in patients with End-stage renal failure |
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Mahmoud M Al-mustafa1, Islam Massad1, Moaath Alsmady2, Abdullah Al-qudah2, Subhi Alghanem1
1 Department of Anesthesia and Intensive Care, Jordan University Hospital, University of Jordan, Amman, Jordan
2 Department of Thoracic and Cardiovascular Surgery, Jordan University Hospital, University of Jordan, Amman, Jordan
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| Date of Web Publication | 26-Apr-2010 |
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 Abstract | | |
Vertical infraclavicular brachial plexus block is utilized in patients with chronic renal failure at the time of creation of an arterio-venous fistula (AVF). The aim of this study is to test the effect of impaired renal function, with the resulting deranged serum electrolytes and blood gases, on the success rate and the onset of action of the local anesthetics used. In this prospective clinical study, we investigated the effect of the serum levels of sodium, potassium, urea, creatinine, pH, and bicarbonate on the onset of action of a mixture of lidocaine and bupivacaine administered to create infraclavicular brachial plexus block. A total of 31 patients were studied. The success rate of the block was 93.5 % (29 patients). The mean onset time for impaired or reduced sensation was found to be 8.9 ± 4.7 mins and for complete loss of sensation, was 21.2 ± 6.7 mins. There was no significant association with serum sodium, potassium, urea, creatinine or the blood pH level (P> 0.05). The bivariate correlation between serum bicarbonate level and the partial and complete sensory loss was -0.714 and -0.433 respectively, with significant correlation (P= 0.00, 0.019). Our study suggests that infraclavicular block in patients with chronic renal failure carries a high success rate; the onset of the block is delayed in patients with low serum bicarbonate levels.
How to cite this article:
Al-mustafa MM, Massad I, Alsmady M, Al-qudah A, Alghanem S. The effect of low serum bicarbonate values on the onset of action of local anesthesia with vertical infraclavicular brachial plexus block in patients with End-stage renal failure. Saudi J Kidney Dis Transpl 2010;21:494-500 |
How to cite this URL:
Al-mustafa MM, Massad I, Alsmady M, Al-qudah A, Alghanem S. The effect of low serum bicarbonate values on the onset of action of local anesthesia with vertical infraclavicular brachial plexus block in patients with End-stage renal failure. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2022 Aug 10];21:494-500. Available from: https://www.sjkdt.org/text.asp?2010/21/3/494/62739 |
| Introduction | |  |
Patients with end-stage renal failure require anesthesia in order to create an arterio-venous fistula (AVF). Both general anesthesia and brachial plexus block are used and have been shown to improve the surgical outcome when compared with local anesthetic infiltration, by improving the blood flow through the vascular access. [1] On the other hand, patients with chronic renal failure (CRF) may have associated medical problems such as anemia, diabetes, hypertension, or cardiopulmonary disease; which may make general anesthesia undesirable. [2] Although the time taken for the onset and duration of anesthesia is a limiting factor, brachial plexus block is an ideal way to anesthetize patients with CRF to create an AVF. Many factors render the brachial plexus block a preferred option for anesthesia including: easy accessibility, simplicity of the technique, predictable landmarks, and the avoidance of the stress of the induction of general anesthesia. [3] Another important factor is the vasodilatation associated with sympathetic blockade, which facilitates successful surgical outcome for AVF, and causes minimal alteration in the homeostasis. [1]
Interscalene, supraclavicular, infraclavicular and axillary brachial plexus blocks are four different approaches in clinical practice. The vertical infraclavicular approach is a procedure, which has an advantage of blocking at the cord level of the brachial plexus; this is expected to result in a wider dermatomal distribution. [4]
Patients with CRF have metabolic acidosis which might affect the latency and the duration of action of local anesthesia. The nerves in such patients may be depolarized due to hyperkalemia, [5] and this may affect the nerve excitability and the nerve action potential refractory period. The aim of our study is to find if any relationship exists between the onset of sensory or motor block after brachial plexus block and the blood levels of potassium (K+), sodium (Na+), urea, creatinine, pH, and bicarbonate (HCO3 - ) as well as the effects of the potassium level on the ease of the technique.
| Methods | | |
This study was conducted at the Jordan University Hospital and funded by the University of Jordan. After obtaining approval for the study protocol from the medical ethics committee, an informed written consent was obtained from all the patients who were scheduled to undergo infraclavicular brachial plexus block anesthesia for the creation of an AVF in the antecubital region. Patients with a history of allergy to local anesthetic agents, liver disease, epilepsy, chest deformity, history of clavicular fracture at the block site, coagulopathy, infection at the site of the procedure, any neurological deficit (motor or sensory) in both upper extremities or, those who refused to accept to participate in the study, were excluded.
All involved patients had complete preoperative evaluation for blood count, serum electrolytes, urea, creatinine, and arterial blood gases. The blood sample was taken from the radial artery of the non-operation site, and the results were checked pre-operatively by an anesthesiologist who was not involved in either performing the block or assessing its onset and success rate. After the placement of a 20gauge intravenous (i.v.) cannula in the dorsum of the opposite hand, all the patients received a slow infusion of 0.9% saline solution. Standard monitoring was used, including non-invasive arterial blood pressure (BP), ECG, heart rate (HR) and arterial saturation by peripheral pulse oximetry. The motor power and sensation to pinprick of the patients were examined in both upper extremities. No sedation was given to any of the study patients.
The infraclavicular block was administered by a single anesthesiologist with the patient lying supine and the upper arm along the side, with the elbow flexed and the hand resting on the abdomen. The landmark identified was halfway between the jugular notch and the most anterior part of the acromion; the skin and subcutaneous tissue were infiltrated with 0.5-1.0 mL of 1% wt/vol of lidocaine. A 22 gauge 50-mm insulated stimulation short bevel (15°) needle (Stimuplex Kanula D, B/Braun Medical, Melsungen, Germany) was connected to a nerve stimulator (HNS 12, B/Braun Medical, Melsungen, Germany). The initial nerve stimulator setting was 0.8 mA and frequency 1 HZ. The anesthesiologist tried to find the maximum motor response and went down with the nerve stimulator current until the motor response disappeared, resulting in the remaining visible current to be less than 0.5 mA. Twenty ml of 1% wt/vol lidocaine (200 mg) and 20 mL of 0.5% wt/vol bupivacaine (100 mg) were intermittently injected over two minutes, with repeated aspiration. The anesthetist recorded the lowest current, the needle depth from the skin and the technique time.
Sensory and motor block were evaluated at two, five, 10, 15, 20, 25, and after 30 minutes, and time zero was designated the end of the local anesthesia injection. Sensory block was assessed by pinprick in the dermatomes over the area of the antecubital fossa (C5, C6, C8 and T1) using the sensory scale (0 normal sensation, 1 impaired or reduced sensation and 2 no sensation at all), and was compared with similar pinprick on the contralateral arm. Motor block was assessed by flexion of the forearm and the hand using the motor scale (0 normal motor movement, 1 no movement with slight resistance, and 2 no movement at all).
A blood sample was taken from the contralateral radial artery after completion of the block for arterial blood gas, electrolytes and kidney function analyses. During the surgery, the patients were supplied with 3-4 liters/min oxygen, using a simple facemask. The patients were observed for any complications that might occur, such as respiratory distress, cardiac arrhythmia or hypotension which was defined as a 30% decrease in the mean arterial blood pressure, or central nervous system (CNS) toxicity that was considered significant if it was associated with one or more of the following; circumoral numbness, tongue paresthesia, dizziness, tinnitus, blurred vision, agitation, slurred speech or drowsiness. [6] The block success rate was defined when no general anesthesia was needed to complete the surgery. A satisfaction score, regarding the anesthesia, was recorded by the surgeon after completing the procedure and from the patient after discharging him from the recovery room. This satisfaction score was done by using a 4-point scale (0 very unsatisfied, 1 unsatisfied, 2 satisfied, and 3 very satisfied). [4]
| Statistical analysis | | |
Descriptive statistics (mean, standard deviations, frequencies and percentages) were used to describe the characteristics of the sample such as age, gender, weight, height, body mass index (BMI) and the existence of some diseases [diabetes mellitus (DM), hypertension (HTN), ischemic heart disease (IHD), and respiratory problems]. Bivariate correlations were calculated between dependant and independent variables. Stepwise Multiple Regression analysis was used to test the relationship between the onset of sensory and motor block after the infraclavicular brachial plexus block as dependent variables, and electrolytes and arterial blood gases as independent variables, separately. In order to calculate the percent of variance (R square change) for each variable; 0.9 and 0.99 were used as the entry and removal points respectively. The analysis was performed on two separate groups of independent variables; the first group included urea, sodium, creatinine and potassium. The second group included pH, HCO3, Base Excess (BE), and pCO2. A P< 0.05 was considered statistically significant.
SPSS version 13.0 as a statistical package was used to perform all statistical analysis of the data.
| Results | | |
Between the period from April 2007 to October 2007, 42 patients who met our inclusion criteria were scheduled for creation of AVF. Of those 42, only 31 patients (25-70 years old) consented to participate in the study. The 31 patients were ASA II-IV, and underwent an elective infraclavicular brachial plexus block for the creation of an AVF. In two patients, the regional anesthesia failed and general anesthesia had to be employed to complete the surgery; they were excluded from the study. The overall success rate was 93.5%. Data from the remaining 29 patients were statistically analyzed. Demographic data was as follows: there were 18 males and 11 females with mean age of 51.3 ± 14.8 years, mean height of 170.1 ± 9.10 cm, mean weight of 78.8 ± 18.38 kg and mean body mass index (BMI) of 27.3 ± 6.69. There were 12 ASA II patients, 15 ASA III patients and two ASA IV patients [Table 1].
The pre-operative assessment showed that 86.2 % of these patients were hypertensive, 55.2% were diabetic, 37.9% were diagnosed to have ischemic heart disease and 30.7 % were having chronic respiratory problems. Two patients complained of nausea intra-operatively and were treated with anti-emetic agents; none of the patients had hypotension, arrhythmia, allergy, neurological deficit, respiratory distress or blood aspiration from the vessels during the block procedure.
The mean onset time for impaired or reduced sensation [sensory scale 1 (SS1)] was 8.9 ± 4.7 mins, and for complete loss of sensation [sensory scale 2 (SS2)], it was 21.2 ± 6.7 mins. The mean onset time for impaired movement (motor scale 1 (MS1)) was 8.93 ± 4.3 mins, and for complete loss of movement [motor scale 2 (MS2)], it was 23.96 ± 6.86 mins.
The SS1, SS2, MS1 and MS2 had no significant correlation with Na+, K+, urea and creatinine levels (P> 0.05) [Table 2]. However, SS1, SS2 and MS1 had a significant correlation with serum HCO3 levels (r = -0.714, -0.433, - 0.831). Correlation plot between HCO3 and onset time (SS1, SS2) are shown in [Figure 1] and [Figure 2] respectively. The P value for SS1, SS2 and MS1 were 0.00, 0.019 and 0.00 respectively [Table 3], while MS2 showed no significant correlation (r = -0.207, P> 0.05). The pCO2 showed a statistically significant effect on SS1 (r=-0.627, P= 0.001) and MS1 (r=0.677, P= 0.000). In addition, BE resulted in a statistically significant difference in all the parameters; SS1 (r=-.0.628, P= 0.009), SS2 (r=0.308, P= 0.010), MS1 (r=-.0750, P= 0.003) and MS2 (r=-0.131, P= 0.004). Diabetes and BMI did not have any effect on the time of onset of the sensory and motor block (P> 0.05).
The depth of the needle from the skin to the nerve where the local anesthesia was injected was 3.59 ± 0.743 cm, and the correlation with the BMI was significant (P= 0.02). The mean lowest current that was recorded when the muscle contraction disappeared was 0.341 ± 0.114 mA, and was not found to have any significant relationship with the onset of the sensory or motor block or the serum potassium level (P= > 0.05).
Three patients needed an adjuvant local anesthesia supplement with 3-6 mL of lidocaine 1%wt/vol. All three of them had minimal discom fort when the surgeon extended his incision medially, and with this adjuvant local anesthesia therapy, they felt more comfortable (patient satisfaction score was 2, for the 3 patients). Twenty-one patients were very satisfied and eight patients were satisfied, with an average patient satisfaction score of 2.72. In 16 patients, the surgeon was very satisfied, in 10 patients he was satisfied and in three patients, the surgeon was not satisfied and the average surgeon satisfaction score was 2.44.
All the patients were hemodynamically stable during the regional anesthesia procedure, during the surgery and in the recovery room.
| Discussion | | |
In the present study, vertical infraclavicular block provided highly consistent brachial plexus anesthesia of the upper extremity for the creation of an AVF in patients with CRF, with a success rate of 93.5%. An earlier study by Rittig et al, in non-renal failure patients, [4] compared vertical infraclavicular or axillary block in patients undergoing surgery of the elbow, forearm or hand. They showed superiority of the infraclavicular block with a successful complete block in 90% of the patients after 30 minutes and 97% of the patients after 60 minutes. Our results correlate well with these results.
Although patients with CRF may have impaired nerve excitability, [5] a prolonged axonal refractory period [7] and acidosis, which may result in a delayed onset of action of the local anesthetics or maybe a failure of a complete block, the high success rate in our study may be explained firstly by the drugs that we used (lidocaine and bupivacaine) instead of (ropivacaine) used in the Rittig study. Secondly, the hypothesis that the resulting depolarization in CRF patients, which may delay or impair the onset of the local anesthesia, is rapidly reduced by dialysis, a procedure that was done routinely through a pre-implanted central line in all our patients one day before surgery (18-24 hours); thus, the prolonged axonal refractory period of the nerves would have been normalized. [7] Thirdly, the success rate in our patients was determined by looking for the absence of sensation at the site of surgery (i.e. antecubital fossa), which was not the case in the Rittig study that considered a complete sensory block in all the dermatomal distributions as an indication for success in patients.
The primary aim of the study was to correlate the onset of action of the regional block with the serum electrolyte and blood gas levels. The onset of the block interestingly correlated with the serum level of bicarbonate but not with the arterial pH, serum potassium, sodium, urea or creatinine. In acidotic CRF patients, plasma pH is decreased and the fraction of ionized (lipid insoluble) lidocaine is thus increased.
Ionized (lipid insoluble) lidocaine penetrates the axonal membrane much less efficiently than the non-ionized (lipid soluble) form; [8] this is supposed to result in a slower onset and a shorter duration of action. The metabolic acidosis in all our patients was chronically compensated by the respiratory system. This compensation was evident by the values of the pCO2, which resulted in a statistically significant effect as our data showed [Table 3]. The relationship between the serum pH level of the patients and the onset of action of the sensory and motor block was not significant. The relationship between the low serum bicarbonate level and the delayed onset of action of the block (SS1, SS2, MS1) was significant with a P value of 0.00, 0.10, 0.00, respectively. This relationship was not significant (P> 0.05) when it was correlated to a complete motor block (MS2), a finding that can be explained as follows: Firstly, onset of the sensory block was our primary study aim, which allowed the surgeon to start his surgery, and secondly, the estimated time for the complete motor block in 10 patients in our study was more than 30 minutes (40 minutes), by which time surgery was already started and a proper assessment of the motor block was not feasible.
Alkalinization of the local anesthetics to hasten the onset of action was studied before and was not found to be effective in some studies. [9],[10] Other studies [11],[12] found that adding bicarbonate to the local anesthetics might reduce the onset of action of the drug by decreasing the ratio of the ionized and the non-ionized molecules, thereby permitting a more rapid penetration of the local anesthetics through the biological membrane. Chassard et al, [9] in their study on non-CRF patients, showed that routine alkalinization of the local anesthetics is not recommended and is clinically useless. The difference between their results and ours may be because adding bicarbonate to patients with already normal serum or tissue bicarbonate levels may be unjustified and not of clinical importance, but of great importance for patients with low bicarbonate levels. Nevertheless, this finding needs further evaluation.
Nerve excitability and the refractory period of the action potential are also affected by hyperkalemia. [5] One of our aims, in this study, was to study the relationship between potassium levels and the minimal stimulation current that can be achieved before injecting the local anesthetics, and whether high potassium level is associated with high nerve block failure rates. This could not be studied because all the study patients had a session of hemodialysis the day before surgery and had normal potassium levels on the day of surgery.
Three patients in our study had an incomplete sensory block at the ulnar nerve site of the anticubital fossa, and needed adjuvant local anesthesia infiltration. This was probably because, the block is done at the cord levels of the brachial plexus, the medial cutaneous nerve of the forearm, which supplies the medial (ulnar) aspect of the anticubital fossa, may not be adequately blocked since it comes from the medial cord, which lies medial to the puncture site.
In this study, we used a mixture of lidocaine and bupivacaine. These drugs, which are the only local anesthetics available in the market in our country, were used safely in CRF patients. [11],[13],[14] The maximum recommended adultsingle dose of lidocaine, without adrenaline, is between 300 and 500 mg. [15] Thus, patients with CRF underwent brachial plexus block at a dose that was just above the minimal toxic concentration despite high lidocaine levels. [13] Similarly, 100 mg of bupivacaine was used safely in adult CRF patients and was not associated with any significant pharmacokinetic problems. [3],[14]
In our study, all the patients were satisfied at the end of the surgery (very satisfied or satisfied), with an average satisfaction score of 2.72. However, surgeon satisfaction was lower. We attribute this to several factors: in most patients, surgery was started after the evaluation of sensory block by pinprick at the anticubital fossa, and had not been painful. In some patients, due to anatomical variability, the surgeons had to extend the incision medially for better exposure of the vessels. This resulted in extending the incision to an area that is not well blocked (ulnar side). Additionally, patients with end-stage renal failure are demanding and may have a problem in lying down in supine position. They also tend to have a low pain tolerance and may complain frequently. This makes a surgeon's concentration difficult and may disturb him.
In conclusion, infraclavicular brachial plexus block, in patients with end-stage renal failure, is a safe technique and the patient and surgeon satisfaction is very good. Renal failure patients have low serum bicarbonate level that was highly correlated with the onset of action of local anesthesia. The addition of HCO3 to local anesthesia in patients with CRF, who need peripheral nerve blocks, needs further studies.
| Acknowledgements | | |
This work was supported by the Deanship of Academic Research-University of Jordan. We thank Mr. Abbas Talfha and Dr. Hamdi AbuAli for their help with the statistical analysis.
| References | | |
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| 12. | Liepert DJ, Douglas MJ, McMorland GH, Gambling DR, Kim JH, Ross PL. Comparison of lidocaine CO2, two percent lidocaine hydrochloride and pH adjusted lidocaine hydrochloride for caesarean section anesthesia. Can J Anaesth 1990;37:333-6. [PUBMED] |
| 13. | McEllistrem RF, Schell J, O'Malley K, O'Toole D, Cunningham AJ. Interscalene brachial plexus blockade with Lidocaine in chronic renal failure: a pharmacokinetic study. Can J Anaesth 1989;36(1):59-63. |
| 14. | Rice AS, Pither CE, Tucker GT. Plasma concentrations of bupivacaine after supraclavicular brachial plexus blockade in patients with chronic renal failure. Anesthesia 1991;46(5):354-7. |
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Correspondence Address:
Islam Massad
Department of Anesthesia and Intensive Care, Jordan University Hospital, P.O. Box 13046, Amman - 11942
Jordan
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 20427875 
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3] |
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