AXILLARY BRACHIAL PLEXUS BLOCK UNDER PROCEDURAL SEDATION FOR ARTERIOVENOUS FISTULA FORMATION IN A CHILD WITH END-STAGE RENAL DISEASE – A CASE REPORT
REGIONAL ANESTHESIA FOR ARTERIOVENOUS FISTULA FORMATION IN A CHILD
Abstract
Introduction/Objective: Arteriovenous (AV) fistula formation has become the gold standard for hemodialysis vascular access. The use of brachial plexus blocks (BPB) for antebrachial AV fistula formation in adults provides not just adequate analgesia but a potentially positive effect on primary fistula patency. Additionally, the resultant state of surgical anesthesia may enable the surgery to be performed under procedural sedation.
Case report: A 12-year-old patient was admitted for AV fistula formation for the purpose of hemodialysis due to end-stage renal disease. Kyphoscoliosis of the thoracic spine, the patient’s short neck with limited mobility, and her short stature posed a potential difficulty for intubation. Despite a recently resolved upper respiratory tract infection, which raised suspicion of airway hyperreactivity, the decision was made to proceed with surgical treatment and perform an axillary BPB under procedural sedation. Basic monitoring of vital functions was applied, with oxygen support at 3 l/min via mask. The ultrasound-guided block was performed using 8 ml of 0.5% levobupivacaine (1.4 mg/kg) and 5 ml of 2% lidocaine (3.33 mg/kg). During the one-hundred-minute surgical procedure, the patient maintained hemodynamic and respiratory stability and spontaneous breathing. The patient awoke without complications and was referred to the hospital ward. Her pain was managed with acetaminophen, as needed. The total perioperative opioid consumption was limited to the induction dose of 0.83 μg/kg of fentanyl.
Conclusion: In this pediatric case, the use of axillary BPB provided adequate analgesia with minimal opioid administration for the formation of an AV fistula. It also enabled the surgical team to avoid an expectedly difficult intubation. One needs to keep in mind the maximum safe dose of local anesthetics, the nuances of their use in children with comorbidities, as well as the potential complications, among which local anesthetic systemic toxicity is the most important.
References
Preka E, Shroff R, Stronach L, Calder F, Stefanidis CJ. Update on the creation and maintenance of arteriovenous fistulas for haemodialysis in children. Pediatr Nephrol. 2021 Jul;36(7):1739-49. doi: 10.1007/s00467-020-04746-6.
Raina R, Joshi H, Chakraborty R, Sethi SK. Challenges of long-term vascular access in pediatric hemodialysis: Recommendations for practitioners. Hemodial Int. 2021 Jan;25(1):3-11. doi: 10.1111/hdi.12868.
Ahmed OF, Hamodat OM, Kakamad FH, Abduljabbar RS, Salih AM, Omar DA, et al. Outcomes of arteriovenous fistula for hemodialysis in pediatric age group. Ann Med Surg (Lond). 2021 Nov 23;72:103100. doi: 10.1016/j.amsu.2021.103100.
Montelongo S, Brooks DE, Klopfenstein J, Peden EK. Surgical creation of upper extremity arteriovenous fistula and grafts: a narrative review. Cardiovasc Diagn Ther. 2023 Feb 28;13(1):147-55. doi: 10.21037/cdt-21-565.
Tomas VG, Hollis N, Ouanes JP. Regional Anesthesia for Vascular Surgery and Pain Management. Anesthesiol Clin. 2022 Dec;40(4):751-73. doi: 10.1016/j.anclin.2022.08.016.
Weeks JJ, Johnson PA, Garcia-Tomas V. Regional anesthesia for peripheral vascular surgery: what does the evidence tell us? Curr Opin Anaesthesiol. 2025 Oct 1;38(5):645-51. doi: 10.1097/ACO.0000000000001551.
Nijs K, Hertogen P', Buelens S, Coppens M, Teunkens A, Jalil H, et al. Axillary Brachial Plexus Block Compared with Other Regional Anesthesia Techniques in Distal Upper Limb Surgery: A Systematic Review and Meta-Analysis. J Clin Med. 2024 May 29;13(11):3185. doi: 10.3390/jcm13113185.
Pinto N, Sawardekar A, Suresh S. Regional Anesthesia: Options for the Pediatric Patient. Anesthesiol Clin. 2020 Sep;38(3):559-75. doi: 10.1016/j.anclin.2020.05.005.
He Y, Wang R, Wang F, Chen L, Shang T, Zheng L. The clinical effect and safety of new preoperative fasting time guidelines for elective surgery: a systematic review and meta-analysis. Gland Surg. 2022 Mar;11(3):563-75. doi: 10.21037/gs-22-49.
Eccleston C, Fisher E, Howard RF, Slater R, Forgeron P, Palermo TM, et al. Delivering transformative action in paediatric pain: a Lancet Child & Adolescent Health Commission. Lancet Child Adolesc Health. 2021 Jan;5(1):47-87. doi: 10.1016/S2352-4642(20)30277-7.
Raney EM, van Bosse HJP, Shea KG, Abzug JM, Schwend RM. Current State of the Opioid Epidemic as it Pertains to Pediatric Orthopaedics from the Advocacy Committee of the Pediatric Orthopaedic Society of North America. J Pediatr Orthop. 2018 May/Jun;38(5):e238-44. doi: 10.1097/BPO.0000000000001143.
Kenth J, Walker R. Assessment and management of the predicted difficult airway in neonates, infants and children. Anaesth Intensive Care Med. 2024 Oct;25(10):685-702. doi: 10.1016/j.mpaic.2024.07.006.
Kim HS, Kim YS, Lim BG, Lee JH, Song J, Kim H. Risk Assessment of Perioperative Respiratory Adverse Events and Validation of the COLDS Score in Children with Upper Respiratory Tract Infection. Medicina (Kaunas). 2022 Sep 23;58(10):1340. doi: 10.3390/medicina58101340.
Hii J, Templeton TW, Sommerfield D, Sommerfield A, Matava CT, von Ungern-Sternberg BS. Risk assessment and optimization strategies to reduce perioperative respiratory adverse events in pediatric anesthesia—Part 1 patient and surgical factors. Paediatr Anaesth. 2022 Feb;32(2):209-16. doi: 10.1111/pan.14377.
Lin C, Guerrero AL, Jesin J, Tangri R, Luginaah NA, Kumar K, et al. Comparing block characteristics of mixtures of short/intermediate- and long-acting local anesthetics for peripheral nerve block: a systematic review and meta-analysis. Braz J Anesthesiol. 2025 May-Jun;75(3):844617. doi: 10.1016/j.bjane.2025.844617.
Almasi R, Rezman B, Kriszta Z, Patczai B, Wiegand N, Bogar L. Onset times and duration of analgesic effect of various concentrations of local anesthetic solutions in standardized volume used for brachial plexus blocks. Heliyon. 2020 Sep 2;6(9):e04718. doi: 10.1016/j.heliyon.2020.e04718.
Aguilera G, Tabilo C, Jara Á, Aliste J. 0.25% bupivacaine-1% lidocaine vs 0.5% bupivacaine for ultrasound-guided infraclavicular brachial plexus block: a randomized controlled trial. Reg Anesth Pain Med. 2025 Aug 5;50(8):627-34. doi: 10.1136/rapm-2024-105511.
Pietroski Dos Santos N, Silva VP, Oliveira GSDS, Musacchio VC, Carvalho VH. Efficacy of long-acting local anesthetics versus their mixture with shorter-acting local anesthetics for peripheral nerve blocks guided by ultrasound: a systematic review with meta-analysis of randomized controlled trials. Reg Anesth Pain Med. 2026 Feb 5;51(2):132-41. doi: 10.1136/rapm-2024-106104.
Heppolette CAA, Brunnen D, Bampoe S, Odor PM. Clinical Pharmacokinetics and Pharmacodynamics of Levobupivacaine. Clin Pharmacokinet. 2020 Jun;59(6):715-45. doi: 10.1007/s40262-020-00868-0.
Uppal NN, Jhaveri M, Hong S, Shore-Lesserson L, Jhaveri KD, Izzedine H. Local anesthetics for the Nephrologist. Clin Kidney J. 2021 Jul 2;15(2):186-93. doi: 10.1093/ckj/sfab121. Erratum in: Clin Kidney J. 2021 Oct 05;15(1):182. doi: 10.1093/ckj/sfab144.
Schweitzer-Chaput A, Callot D, Bouazza N, Lesage F, Oualha M, Paret N, et al. Local anesthetics systemic toxicity in children: analysis of the French pharmacovigilance database. BMC Pediatr. 2023 Jun 24;23(1):321. doi: 10.1186/s12887-023-04126-7.
