Intractable arteriovenous access-related pain relieved after a single, pain-free hemodialysis session under selective block of the sensory nerves in the upper limb: A psychosocial factorial case.

Intractable arteriovenous access (AVA)-related pain can not only lead to abandonment of a well-functioning AVA, but can also cause hemodialysis (HD) patients to be unwilling to accept, interrupt, or withdraw from HD. Such pain primarily derives from nociceptive and neuropathic factors caused by mechanical stimulation of needle cannulation; however, this might be related to psychosocial factors making it difficult for patients to accept their dependency on HD. Furthermore, the pain can be complicated by the interaction of biological and psychosocial factors, which hampers appropriate pain management and treatment. However, there have been few investigations pertaining to this matter. Herein, we describe the case of an HD patient who experienced chronic refractory AVA-related pain during a 32-month period of HD sessions, which occasionally caused treatment interruption. After clinical inquiry, physical evaluation, and ultrasonographic assessment of the blood circulation and cutaneous nerves in the ipsilateral upper limb to the radiocephalic arteriovenous fistula in the anatomical snuffbox, we diagnosed the patient with primarily psychosocially driven pain in consultation with an experienced pain clinician. A single, pain-free HD session under ultrasound-guided sensory nerve blocks in the upper limb markedly relieved her pain, followed by HD sessions with subtle but acceptable pain. This report provides insights into the mechanism underlying the vicious cycle of AVA-related pain, including the psychosocial aspects that might trigger such pain, as well as into the importance of treating such pain to improve the patient's quality of life, and underscores the need for cooperation of experts engaged in HD and pain management.

Anesthetic effect of ultrasound-guided block of the musculocutaneous nerve during endovascular treatment of dysfunctional radiocephalic arteriovenous fistulas.

BACKGROUND: Delivering requisite and minimal anesthesia for endovascular treatment (EVT) of dysfunctional arteriovenous fistulas (AVFs) under the target nerve block can achieve reasonable analgesia. We evaluated the anesthetic efficacy of ultrasound (US)-guided selective block of the musculocutaneous nerve (MCN) during the EVT of runoff venous strictures in the forearm through the radiocephalic (RC)-AVF at the wrist or the anatomical snuff box and analyzed the factors inhibiting the analgesia achieved under the MCN block. METHODS: We enrolled 30 adult patients undergoing hemodialysis who had received 78 EVT sessions in an outpatient clinic mainly for long and/or multiple outflow-venous strictures in the forearm under US-guided blocks of the MCN, which provides sensory innervation to the anterolateral forearm where the cephalic vein courses. We assessed patients' pain during balloon dilations using the Wong-Baker FACES® Pain Rating Scale (WBFRS) and evaluated the factors increasing the pain (WBFRS score ⩾4), including patient characteristics, dilated strictures, additional nerve blocks, and types of balloon catheters. RESULTS: In 25 EVT sessions (32.1%) out of 78 sessions, patients complained of stronger pain (WBFRS score ⩾4), while in the other 53 sessions (67.9%), presented with no pain and slight pain (WBFRS score = 0 or 2). Univariate analysis clarified that dilation of the AVF anastomosis, presence of dilated stenosis >4 cm, and a single block of the MCN or its sensory terminal significantly triggered more pain (p < 0.05). Consequently, multivariate analysis of all the factors with p < 0.1 in the univariate analysis, including multiple dilated stenosis sites, demonstrated that dilation of the AVF anastomosis significantly caused severe pain despite the anesthesia of the MCN block (p < 0.05). CONCLUSION: US-guided selective block of the MCN could be a leading anesthetic option for EVT for multiple long stenoses of the cephalic vein draining through the RC-AVF in the wrist or anatomical snuff box.

Transposition of the superficial femoral artery combined with ultrasound-guided returning-venous cannulation as a last resort for vascular access in a multi-complicated hemodialysis patient.

A superficialized artery as a blood-drawing route could be an option for vascular access (VA) in hemodialysis patients with cardiac failure, vessel damage, steal syndrome, and venous hypertension, and it could be a secondary VA option in those with repetitive vascular access troubles, routinely requiring a blood-returning venous route. The brachial artery is preferably used for superficialization due to the benefit of its appropriate diameter for cannulation, procedural ease of surgery under local anesthesia, and usable subcutaneous vein for blood-returning route in the upper limb. The superficial femoral artery (SFA) has also been reported as a candidate for arterial transposition; however, its subcutaneous transposition could have difficulties in requiring general anesthesia and securing blood-inflow-venous routes. We experienced a multi-complicated hemodialysis patient who had intractable tunneled-cuffed catheter-related bacteremia and right atrial thrombosis, low cardiac function with bilateral proximal bifurcation of the brachial artery at the axilla, and damaged cutaneous veins in the upper limb. Herein, we report a case of successful superficialization of the SFA under ultrasound-guided regional anesthesia combined with local anesthesia and intravenous sedation, which could be feasible as a blood-drawing route with ultrasound-guided ipsilateral greater saphenous vein cannulation during chronic hemodialysis. Assisted by ultrasound-guided venous cannulation in the ipsilateral lower limb, cutaneous repositioning of the SFA could be a viable and acceptable option for VA in hemodialysis patients with a multitude of complications, wherein the possibilities of VAs of arteriovenous access, arterial superficialization using vessels in the upper extremity, or artificial devices should be eliminated.

Cutaneous nerve-conscious surgical repair of vascular access-related aneurysm assisted by anatomical ultrasonography in hemodialysis patients.

BACKGROUND: The superficial runoff veins anatomically run alongside the cutaneous nerves in the volar forearm. Consequently, the surgical repair of vascular access (VA)-associated venous aneurysms attached to the cutaneous nerves could cause intraoperative nerve injury. Therefore, we proposed a cutaneous nerve-conscious VA-related aneurysmal repair assisted by nerve ultrasonography. This ultrasonography aids in the preoperative examination of the courses of the nerves neighboring the aneurysm. METHODS: Sixteen consecutive patients who underwent surgical revisions of VA-related aneurysms (14 venous aneurysms and two arterial pseudoaneurysms) were enrolled. The locations of aneurysms derived from preexisting arteriovenous fistulas included 11 radiocephalic arteriovenous fistulas in the wrist or distally, three radiocephalic arteriovenous fistulas at the antecubital fossa, and two brachiocephalic arteriovenous fistulas at the antecubital fossa or in the distal upper arm. A preoperative ultrasonographic scan of the cutaneous nerve trunks that ran peripherally toward and along the aneurysms was attempted to avoid nerve injuries during operations. Basically, the aneurysms were resected from the proximal to the distal ends after being separated from the preserved adjacent nerves. RESULTS: The cutaneous nerve trunks that coursed toward and along the aneurysm could be identified by preoperative ultrasonography and could be preserved intraoperatively based on ultrasonographic findings in all patients. In four patients, the cutaneous nerve branch was unexpectedly or intentionally severed for a seamless surgical process because the nerve branch that divided from the cutaneous nerve trunk was strongly attached to the aneurysm. They subsequently suffered from hypoesthesia, but did not experience neuropathic pain. CONCLUSION: Preoperative ultrasonographic examination of the cutaneous nerve facilitated the intraoperative prevention of cutaneous nerve injury in VA-related aneurysmectomy. Nerve-sparing VA surgery assisted by preoperative nerve ultrasonography based on the understanding of topological anatomy might contribute to the reduction in postoperative neuropathy and enhance comfort in the daily life of hemodialysis patients.

Preoperative ultrasound for runoff-venous decompression of peripheral nerves for arteriovenous access-related pain in the upper limb.

INTRODUCTION: Arteriovenous access (AVA)-related pain treated successfully with runoff-venous decompression of the causative nerve, following ultrasound (US)-assisted preoperative evaluation, has never been reported. CASE PRESENTATION: A 57-year-old man suffering from constant exhausting pains along the outflow cephalic vein of the radiocephalic arteriovenous fistula at the wrist and the antecubital fossa, was treated surgically after the diagnosis of AVA-related pain derived from cephalic vein compression on two peripheral cutaneous nerves, the superficial radial nerve (SRN) and the lateral antebrachial cutaneous nerve (LACN). TECHNIQUE: The SRN and LACN, which ran along and/or provided sensory innervation to the painful regions in the upper limb, were traced using ultrasonography in the short axis and proved to be compressed by and in contact with veins where the pain existed, at the wrist and the antecubital fossa. Once diagnostic US-guided blocks of both were performed and pain disappeared, they were identified as the causative nerves. The cephalic venous decompression surgeries that separated and transposed the veins away from the SRN and the LACN were performed sequentially under pneumatic tourniquet inflation to improve nerve visualization. RESULTS: The pains disappeared after the operations. An adequate length of the runoff cephalic vein was maintained for needle cannulations during hemodialysis. CONCLUSIONS: Outflow venous compression to the peripheral nerves may be a cause of AVA-related pain. US-guided assessments of the nerves may improve the safety and efficiency of venous decompression surgeries to treat AVA-related pains.

Arterial Access Port: A Shunt-Less Vascular Access Using a Blind-Ending Artificial Graft Anastomosed to the Brachial Artery.

We retrospectively investigated the usability of arterial access ports (AAPs), which are blind-ending short prosthetic grafts anastomosed to the brachial artery (BA) and implanted subcutaneously, via which cannulation and blood-drawing from the BA was performed. Nineteen AAPs in 16 patients were evaluated. The AAP cumulative functional usage rate tended to drop within a year after its implantation because of infection and inappropriate positioning; however, its usability was extended for a maximum of 97 months after re-implantation. The operative modification of minimal superficial repositioning of the BA anastomosed with the graft significantly improved its usage rate by easing the cannulation via the graft and eliminated usage withdrawal caused by infection and dislocation. Occlusion, thrombus, and ligation of the BA never occurred even after surgical repairs for infectious AAP. The use of an AAP as a shunt-less vascular access could be an alternative to BA superficialization with avoidance of direct BA puncture.

Ultrasound-guided block of selective branches of the brachial plexus for vascular access surgery in the forearm: a preliminary report.

PURPOSE: The operative field for vascular access (VA) surgery in the forearm is on the volar surface, and motor nerve block is not necessary for regional anesthesia. Therefore, selective block of branches of the brachial plexus may be a more efficient anesthesia technique. METHODS: Individual nerve blocks in the axillary brachial plexus and selective blocks of the musculocutaneous and medial antebrachial cutaneous nerves in the upper arm were performed using low doses and concentrations of a local anesthetic mixture of lidocaine and ropivacaine under ultrasound (US) guidance in patients undergoing VA surgery in the forearm. The targeted nerves were identified by continuous US tracing along the upper arm to the axilla in a short-axis view. We performed three VA surgeries in the forearm using an axillary brachial plexus block and four using a selective two-nerve bock in the upper arm. We recorded any additional anesthetic requirement and evaluated intraoperative pain using the Wong-Baker Faces Pain Rating Scale (WBFRS; 0 = no pain; 10 = worst pain). RESULTS: All of the target nerve branches were clearly identified by US tracing. All patients had satisfactory intraoperative pain control (0 or 2 score on WBFRS). Four patients required small additional doses of local anesthetic. CONCLUSIONS: US-guided block of individual branches of the brachial plexus at the axilla achieved effective anesthesia using small amounts of local anesthetic. An advanced selective nerve block in the upper arm allows minimum necessary anesthesia and provides safe and efficient analgesia for VA surgery in the forearm.

Meta-analysis of the risk of upper gastrointestinal hemorrhage with combination therapy of selective serotonin reuptake inhibitors and non-steroidal anti-inflammatory drugs.

It is thought that both selective serotonin reuptake inhibitors (SSRIs) and non-steroidal anti-inflammatory drugs (NSAIDs) can cause the adverse reaction of upper gastrointestinal hemorrhage (UGIH). To evaluate differences in the probability of UGIH occurring when SSRIs, NSAIDs, or both combined are administered, the authors performed a systematic review of related articles and a meta-analysis of data in those articles, which were identified by searching the literature published between 1999 and 2012 using PubMed, Scirus, and Google Scholar. The odds ratios were calculated using the Mantel-Haenszel method. The integrated odds ratios for SSRIs only, NSAIDs only, and the combination were 1.73 (0.65-2.82), 2.55 (1.51-3.59), and 4.02 (2.89-5.15), respectively. Use of the combination resulted in an odds ratio 2.32 times higher than use of either alone. Since the combination of SSRIs and NSAIDs resulted in a significantly higher risk of UGIH than either type of drug alone, clinicians should avoid use of the combination as much as possible. If it is necessary to administer both kinds of drugs, the minimum dosage should be prescribed for the shortest time period possible, and patients, particularly elderly patients, should be closely monitored for development of UGIH and other complications.

Sevelamer hydrochloride dose-dependent increase in prevalence of severe acidosis in hemodialysis patients: analysis of nationwide statistical survey in Japan.

Metabolic acidosis has a negative impact on prognosis of dialysis patients. The aim of this study was to determine the prevalence of severe metabolic acidosis in dialysis patients treated with sevelamer hydrochloride. In 2004, a nationwide survey (101,516 dialysis patients) was conducted by the Japanese Society for Dialysis Therapy. We analyzed 32,686 dialysis patients whose bicarbonate levels were measured in the survey. Sevelamer hydrochloride was prescribed to 9231 dialysis patients while 23,455 dialysis patients were not prescribed sevelamer hydrochloride. In the present study, we defined severe acidosis as bicarbonate <15.8 mmol/L. The mean serum bicarbonate level correlated significantly and negatively with the daily dose of sevelamer hydrochloride (R(2) = 0.806, P < 0.0001). Logistic regression analysis indicated that the percentage of patients with severe acidosis increased significantly with increased dose of sevelamer hydrochloride (R(2) = 0.885, P < 0.00001). The estimated doses of sevelamer hydrochloride associated with severe acidosis in 10% and 15% of patients were 3.5 g/day (95% confidence interval [95%CI], 2.8-4.4) and 7.7 g/day (95%CI = 5.9-10.9), respectively. Severe acidosis was noted in 4.5% of patients who were not treated with sevelamer hydrochloride and in 16.1% of patients treated with sevelamer hydrochloride at ≥ 5.25 g/day (P < 0.0001). The results call for careful monitoring of serum bicarbonate level in hemodialysis patients treated with sevelamer hydrochloride.

A review article: sevelamer hydrochloride and metabolic acidosis in dialysis patients.

Sevelamer hydrochloride is a phosphate binder and its effectiveness to reduce the cardiovascular mortality of dialysis patients has been tested. Sevelamer hydrochloride also contains chlorine, so a decrease in bicarbonate due to chlorine load was anticipated and metabolic acidosis thought to associate with sevelamer hydrochloride has been reported in some papers. We reported that sevelamer hydrochloride exacerbated metabolic acidosis in hemodialysis patients, depending on the dosage. Also a Japanese nationwide survey suggested that sevelamer hydrochloride usage potentially aggravates acidosis in dialysis patients. A multi-institute research study by Edmung et al. has shown that metabolic acidosis, with serum CO2 below 17.5 mmol/L, is by itself associated with increased risk of death in dialysis patients. Furthermore, the Dialysis Outcomes and Practice Patterns Study (DOPPS) revealed that both high (> 27 mmol/L) and low (< or = 17 mmol/L) serum bicarbonate (total CO2) levels were associated with increased risk for mortality and hospitalization. There has not been any significant evidence to show that sevelamer hydrochloride has reduced the cardiovascular mortality of dialysis patients compared with calcium-based binder. Clinicians should check not only the level of chlorine but also the level of total CO2 or bicarbonate during the treatment with sevelamer hydrochloride, and control metabolic acidosis.

Sevelamer hydrochloride exacerbates metabolic acidosis in hemodialysis patients, depending on the dosage.

Sevelamer hydrochloride, as a phosphate binder that contains neither aluminum nor calcium, is expected to improve the prognosis of dialysis patients. However, sevelamer hydrochloride has been reported to lower the serum bicarbonate level. In the present study, we performed a retrospective study on the potential influences of sevelamer hydrochloride on metabolic acidosis in hemodialysis patients. The subjects were 72 patients who underwent hemodialysis at our hospital. Thirty-six patients taking sevelamer hydrochloride and 36 patients matched for sex, diabetes mellitus, age and duration of dialysis who were not taking sevelamer hydrochloride were studied. We assigned the 36 patients who had been taking sevelamer hydrochloride to the 'sevelamer group', and the 36 patients not taking sevelamer hydrochloride were the control group. Statistical significance was evaluated by a t-test and Pearson's correlation coefficient. In the sevelamer group, the mean levels of bicarbonate, base excess and pH decreased significantly after administration, compared with the values before administration, but in the control group, aggravation of acidosis was not seen. The levels of bicarbonate, base excess and pH after the medication of sevelamer hydrochloride were found to be significantly and negatively correlated with the daily dose of sevelamer hydrochloride. The levels were also found to be significantly and negatively correlated with the cumulative dose of sevelamer hydrochloride; however, the value of the mean levels of chlorine and the anion gap did not increase with sevelamer hydrochloride. Sevelamer hydrochloride caused metabolic acidosis in a dose-dependent manner in hemodialysis patients without hyperchloremia.

Lowering of oxidative stress in hemodialysis patients by dialysate cleaning: in relation to arteriosclerosis.

The objective of this study was to investigate changes in oxidative stress associated with the cleaning of the dialysate. Thirty-six dialysis patients were studied. Changes in soluble CD-14 (sCD-14), malondialdehyde-low-density lipoprotein (MDA-LDL), and oxidized-LDL (Ox-LDL) were monitored for 1 year before and 1 year after dialysate cleaning. The mean endotoxin (ET) level in the dialysate had previously been confirmed to decrease from 39.0 EU/L to an undetectable level after the cleaning. The mean levels of sCD-14, MDA-LDL, and Ox-LDL decreased significantly after the cleaning (sCD-14, P < 0.0001; MDA-LDL, P < 0.001; Ox-LDL, P < 0.001). One year after the cleaning, six cases still showed high levels of MDA-LDL and Ox-LDL. Cardiovascular events occurred in four of those six cases within 2.8 years after the cleaning. These four patients suffered from strong oxidative stress during dialysis, even after the cleaning. We therefore concluded that high levels of MDA-LDL and Ox-LDL are improved in dialysis patients by cleaning of the dialysate. These results indicate that even a dialysate containing 50 EU/L or less ET may stimulate monocytes and cause oxidative stress. They also suggest that even low levels of ET may aggravate arteriosclerosis in dialysis patients. Thus, in order to prevent cardiovascular events in dialysis patients, it is necessary to purify the dialysate.