FORMIRANJE ARTERIOVENSKE FISTULE U AKSILARNOM BLOKU I SEDACIJI KOD DETETA SA TERMINALNOM BUBREŽNOM INSUFICIJENCIJOM – PRIKAZ SLUČAJA
REGIONALNA ANESTEZIJA U FORMIRANJU ARTERIOVENSKE FISTULE KOD DETETA
Sažetak
Uvod/Cilj: Formiranje arteriovenske (AV) fistule predstavlja zlatni standard vaskularnog pristupa za hemodijalizu. Kod odraslih, primenom blokova brahijalnog pleksusa (BBP) za formiranje podlakatne AV fistule obezbeđujemo ne samo adekvatnu analgeziju već i pozitivno dejstvo na primarnu patentnost fistule. Takođe, usled ostvarenih uslova hirurške anestezije, intervenciju je moguće obaviti u uslovima proceduralne sedacije.
Prikaz slučaja: Pacijentkinja stara 12 godina primljena je zbog formiranja AV fistule radi izvođenja hemodijalize, a zbog terminalne bubrežne insuficijencije. Kifoskolioza torakalnog dela kičmenog stuba kao i kratak vrat ograničene pokretljivosti, te niski rast pacijentkinje, upućivali su na moguću otežanu intubaciju. Uprkos nedavno preležanoj infekciji gornjih disajnih puteva, koja je budila sumnju na njihovu pojačanu osetljivost, doneta je odluka o potrebi za hirurškim lečenjem. Odlučili smo se za aksilarni BBP u uslovima proceduralne sedacije. Primenjeno je osnovno praćenje vitalnih funkcija i data je kiseonička potpora od 3 l/min, putem maske. Blok je izveden pod kontrolom ultrazvuka, primenom 8 ml 0,5% levobupivakaina (1,4 mg/kg) i 5 ml 2% lidokaina (3,33 mg/kg). Tokom intervencije u trajanju od 100 minuta, pacijentkinja je bila u potpunosti hemodinamski i respiratorno stabilna, neometanog spontanog disanja. Buđenje je proteklo bez komplikacija, nakon čega je pacijentkinja upućena na odeljenje gde je analgezija održavana acetaminofenom, po potrebi. Ukupna perioperativna potrošnja opioida svedena je na uvodnu dozu fentanila od 0,83 μg/kg.
Zaključak: U ovom pedijatrijskom slučaju, aksilarni BBP obezbedio je adekvatnu analgeziju uz minimalnu upotrebu opioida prilikom formiranja AV fistule, kao i izbegavanje očekivane otežane intubacije. Neophodno je imati na umu maksimalne dozvoljene doze lokalnih anestetika, specifičnosti njihove primene kod dece sa komorbiditetima, kao i moguće komplikacije, među kojima je najznačajnija sistemska toksičnost lokalnih anestetika.
Reference
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.
