Rachel Kearns

Effect of regional versus local anaesthesia on outcome after arteriovenous fistula creation: a randomised controlled trial

BACKGROUND Arteriovenous fistulae are the optimum form of vascular access in end-stage renal failure. However, they have a high early failure rate. Regional compared with local anaesthesia results in greater vasodilatation and increases short-term blood flow. This study investigated whether regional compared with local anaesthesia improved medium-term arteriovenous fistula patency. METHODS This observer-blinded, randomised controlled trial was done at three university hospitals in Glasgow, UK. Adults undergoing primary radiocephalic or brachiocephalic arteriovenous fistula creation were randomly assigned (1:1; in blocks of eight) using a computer-generated allocation system to receive either local anaesthesia (0·5% L-bupivacaine and 1% lidocaine injected subcutaneously) or regional (brachial plexus block [BPB]) anaesthesia (0·5% L-bupivacaine and 1·5% lidocaine with epinephrine). Patients were excluded if they were coagulopathic, had no suitable vessels, or had a previous failed ipsilateral fistula. The primary endpoint was arteriovenous fistula patency at 3 months. We analysed the data on an intention-to-treat basis. This study was registered with ClinicalTrials.gov (NCT01706354) and is complete. FINDINGS Between Feb 6, 2013, and Dec 4, 2015, 163 patients were assessed for eligibility and 126 patients were randomly assigned to local anaesthesia (n=63) or BPB (n=63). All patients completed follow-up on an intention-to-treat basis. Primary patency at 3 months was higher in the BPB group than the local anaesthesia group (53 [84%] of 63 patients vs 39 [62%] of 63; odds ratio [OR] 3·3 [95% CI 1·4-7·6], p=0·005) and was greater in radiocephalic fistulae (20 [77%] of 26 patients vs 12 [48%] of 25; OR 3·6 [1·4-3·6], p=0·03). There were no significant adverse events related to the procedure. INTERPRETATION Compared with local anaesthesia, BPB significantly improved 3 month primary patency rates for arteriovenous fistulae. FUNDING Regional Anaesthesia UK, Darlindas Charity for Renal Research.

A comparison of clinical practice guidelines for proximal femoral fracture.

Clinical practice guidelines are designed to assist clinical decision‐making by summarising evidence and forming recommendations. The number of available guidelines is vast and they vary in relevance and quality. We reviewed guidelines relevant to the management of a patient with a fractured neck of femur and explored similarities and conflicts between recommendations. As guidelines are often produced in response to an area of clinical uncertainty, recommendations differ. This can result in a situation where the management of a particular clinical problem will depend upon which guideline is followed. We explore the reasons for such differences.

Does regional compared to local anaesthesia influence outcome after arteriovenous fistula creation

BackgroundAn arteriovenous fistula is the optimal form of vascular access in patients with end-stage renal failure requiring haemodialysis. Unfortunately, approximately one-third of fistulae fail at an early stage. Different anaesthetic techniques can influence factors associated with fistula success, such as intraoperative blood flow and venous diameter. A regional anaesthetic brachial plexus block results in vasodilatation and improved short- and long-term fistula flow compared to the infiltration of local anaesthetic alone. This, however, has not yet been shown in a large trial to influence long-term fistula patency, the ultimate clinical measure of success.The aim of this study is to compare whether a regional anaesthetic block, compared to local anaesthetic infiltration, can improve long-term fistula patency.MethodsThis study is an observer-blinded, randomised controlled trial. Patients scheduled to undergo creation of either brachial or radial arteriovenous fistulae will receive a study information sheet, and consent will be obtained in keeping with the Declaration of Helsinki. Patients will be randomised to receive either: (i) an ultrasound guided brachial plexus block using lignocaine with adrenaline and levobupivicaine, or (ii) local anaesthetic infiltration with lignocaine and levobupivicaine.A total of 126 patients will be recruited. The primary outcome is fistula primary patency at three months. Secondary outcomes include primary patency at 1 and 12 months, secondary patency and fistula flow at 1, 3 and 12 months, flow on first haemodialysis, procedural pain, patient satisfaction, change in cephalic vein diameter pre- and post-anaesthetic, change in radial or brachial artery flow pre- and post-anaesthetic, alteration of the surgical plan after anaesthesia as guided by vascular mapping with ultrasound, and fistula infection requiring antibiotics.ConclusionsNo large randomised controlled trial has examined the influence of brachial plexus block compared with local anaesthetic infiltration on the long-term patency of arteriovenous fistulae. If the performance of brachial plexus block increases fistulae patency, this will have significant clinical and financial benefits as the number of patients able to commence haemodialysis when planned should increase, and the number of “redo” or revision procedures should be reduced.Trial registrationThis study has been approved by the West of Scotland Research Ethics Committee 5 (reference no. 12/WS/0199) and is registered with the ClinicalTrials.gov database (reference no. NCT01706354).

A randomised, controlled, double blind, non‐inferiority trial of ultrasound‐guided fascia iliaca block vs. spinal morphine for analgesia after primary hip arthroplasty

We performed a single centre, double blind, randomised, controlled, non‐inferiority study comparing ultrasound‐guided fascia iliaca block with spinal morphine for the primary outcome of 24‐h postoperative morphine consumption in patients undergoing primary total hip arthroplasty under spinal anaesthesia with levobupivacaine. One hundred and eight patients were randomly allocated to receive either ultrasound‐guided fascia iliaca block with 2 mg.kg−1 levobupivacaine (fascia iliaca group) or spinal morphine 100 μg plus a sham ultrasound‐guided fascia iliaca block using saline (spinal morphine group). The pre‐defined non‐inferiority margin was a median difference between the groups of 10 mg in cumulative intravenous morphine use in the first 24 h postoperatively. Patients in the fascia iliaca group received 25 mg more intravenous morphine than patients in the spinal morphine group (95% CI 9.0–30.5 mg, p < 0.001). Ultrasound‐guided fascia iliaca block was significantly worse than spinal morphine in the provision of analgesia in the first 24 h after total hip arthroplasty. No increase in side‐effects was noted in the spinal morphine group but the study was not powered to investigate all secondary outcomes.

Intrathecal opioid versus ultrasound guided fascia iliaca plane block for analgesia after primary hip arthroplasty: study protocol for a randomised, blinded, noninferiority controlled trial.

BackgroundHip replacement surgery is increasingly common due to an ageing population, and rising levels of obesity. The provision of excellent pain relief with minimal side effects is important in order to facilitate patient mobilisation and rehabilitation.Spinal opioids provide excellent analgesia but are associated with adverse effects. The fascia-iliaca block is an alternative technique which provides analgesia to the nerves innervating the hip. The success of fascia iliaca blocks has been demonstrated to be superior when using ultrasound compared to landmark techniques. However, the clinical benefit of this improvement has yet to be investigated.The aim of this study is to compare the efficacy and safety of ultrasound guided fascia iliaca block with spinal morphine for hip replacement surgery.Methods/DesignThis study is a randomised, blinded, placebo-controlled, noninferiority trial. Patients scheduled to undergo unilateral primary hip arthroplasty will receive a study information sheet and consent will be obtained in keeping with the Declaration of Helsinki. Patients will be randomised to receive either; (i) Ultrasound guided fascia iliaca block using levobupivacaine, plus spinal anaesthesia with hyperbaric bupivacaine containing no morphine, or (ii) sham ultrasound guided fascia iliaca block performed with sterile saline, and spinal anaesthesia containing hyperbaric bupivacaine and 0.1 mg of spinal morphine.A total of 108 patients will be recruited. Primary outcome is post-operative morphine consumption in a 24 hour period. Secondary outcomes include; pain scores at 3, 6, 12, 24, 36 and 48 hours, episodes of respiratory depression, hypotension, nausea and vomiting, pruritus, sedation, time to first mobilisation and patient satisfaction.ConclusionsThere are no studies to date comparing ultrasound guided fascia iliaca block with spinal morphine for pain control after hip arthroplasty. If the ultrasound guided fascia iliaca block provides pain relief which is not inferior to spinal morphine, then morphine could be removed from the spinal injection. This could reduce side effects and improve patient safety.Trial registrationThis study has been approved by the West of Scotland Research Ethics Committee 4 (reference no. 10/S0704/43) and is registered with ClinicalTrials.gov (reference no. NCT01217294).

Oral Hygiene Practices in Scottish Intensive Care Units – a National Survey:

Ventilator-associated pneumonia (VAP) is associated with prolonged intensive care (ICU) stay, increased mortality and costs. Although oral hygiene may help prevent VAP, there is little data about practice in ICU. Therefore a telephone survey of oral hygiene practice in Scottish ICUs was undertaken. All 24 respondents (100% of units) thought that providing oral hygiene care was a worthwhile use of nursing time in the ventilated ICU patient. Fifty-four percent of respondents recognised the importance of oral hygiene in the prevention VAP. Other benefits of oral care cited were maintenance of patient comfort and dignity, and of tooth, gum and oral mucosal health. Most ICUs also felt that further training would be beneficial. Oral hygiene is recognised as having an important role in patient comfort. There is still a lack of evidence concerning the place of oral hygiene care in preventing nosocomial infection in mechanically ventilated patients, as highlighted in the recent NICE guidelines.

Fascia iliaca block for hip replacement - adjuvants and ethics. A reply

reducing the consumption of morphine by 30–50% [2]. Do the authors have data on any difference between treatment groups preand postoperatively in NSAID consumption? Secondly, the authors reported a non-significant (p = 0.146) difference in pre-operative paracetamol consumption between treatment groups. Given that pain is a prominent feature prompting hip arthroplasty, could the authors comment on whether relative changes in pain scores might have been more appropriately reported than absolute pain scores? Finally, the authors suggest that a fascia iliaca block has a low complication rate, justifying the use of sham fascia iliaca blocks. However, in their study there was one incidence of temporary femoral nerve palsy (1 in 54). The sensory, motor and/or functional effects are not described, but this complication is important in a group of patients where a key aim of the surgical intervention is ambulation. Given that FIB does not offer any analgesic advantage (or perhaps even any analgesia [4]) over spinal morphine for hip arthroplasties, do the authors consider FIB to be too risky for hip patients? Also, if there is risk but no clear benefit of fascia iliaca for hip arthroplasty, do the authors think it was justified to use sham fascia iliaca blocks in this study?

Fascia iliaca block for primary hip arthroplasty - a reply

We commend Kearns et al. for their excellent randomised controlled trial that found ultrasound-guided fascia iliaca block (FIB) provided significantly worse analgesia than spinal morphine in the first 12 h (numeric rating scale) and 24 h (cumulative postoperative 24-h morphine consumption) after total hip arthroplasty [1]. The authors explain this finding by noting correctly that sacral nerve innervation of the postero-inferior hip joint is not affected by FIB. We would like to invite the authors to comment on other reasons that we think might have resulted in inferior analgesia after FIB. Firstly, the methods describe an ultrasound-guided FIB with 40 ml levobupivacaine administered cranially out-of-plane below the inguinal crease and laterally to the femoral nerve. The efficacy of the block was not assessed, and the authors acknowledge that this was a weakness of their study. We suggest that more reliable block of the lateral cutaneous nerve of the thigh is achieved by positioning a linear ultrasound probe 2 cm inferomedially to the anterior superior iliac spine angled towards the umbilicus and injecting 40 ml levobupivacaine in-plane just inferior to the ‘bow-tie’ knot at the confluence of internal oblique and sartorius muscles [2]. Assuming a block failure rate of 5% by a trained anaesthetist, insufficient postoperative analgesia might be expected in ~2–3 of the 54 FIB group participants. Could we invite the authors to re-analyse their comparison, omitting data suggestive of failed blocks (e.g. a mean numeric rating score 7 or more at 3 h and 6 h), to compare functioning FIB and spinal morphine? Secondly, not all surgeons use an anterolateral incision for total hip arthroplasty. Nationally, approximately 70% of incisions are posterior (2015 data, [3]) and may not be anaesthetised by blocking the lateral cutaneous nerve of the thigh as part of a FIB. Can the authors provide data about the type of incision used, and re-analyse their data to compare FIB vs. spinal morphine in patients who only received non-posterior incisions, provided any new sample size is sufficiently powered to do so? Thirdly, can we invite the authors to comment on why patients over the age of 85 were excluded from the study, given that ~13,000/85,000 (15%) of patients undergoing primary total hip arthroplasty are over 80 years of age (~5% > 85 years) (2015 data, [4]). Do the authors think that their results/conclusions would have been affected by the inclusion of data from this age group? Given the variety of approaches used in primary total hip arthroplasty and the disparate innervation of the hip, it is perhaps not surprising that FIB is not as effective a postoperative analgesic technique as spinal morphine. However, we would like to encourage the authors to use their research framework experience to conduct further similar trials involving comparison between local anaesthesia infiltration and spinal morphine in primary hip arthroplasty, between FIB and spinal morphine, and between spinal morphine and diamorphine, in both dynamic hip screw insertion and hemi-arthroplasty operations for hip fracture. S. White P. Stott Royal Sussex County Hospital, Brighton, UK Email: stuart.white@bsuh.nhs.uk

The introduction of an oral surgical service in an intensive care unit serving a deprived inner city population

Much of the population of Glasgow has poor oral health. Poor oral hygiene is associated with the development of ventilator-associated pneumonia (VAP). In a survey of Scottish intensive care units (ICUs), none incorporated oral surgical review into their care. We evaluated the introduction of oral surgical review into our routine practice. An oral surgeon who was experienced in oral care provision in the critically ill reviewed patients who were expected to be mechanically ventilated for more than 48 hours. Oral health was assessed and interventions documented. One hundred patients were examined and forty-seven patients underwent oral surgical intervention. Thirteen patients required dental extraction. Of the patients not requiring additional oral care, 24/53 (45%) were edentulous. Our findings demonstrate that the oral care needs of this patient group were not being met by the current unit oral hygiene protocol. Further work is required to determine the optimal way to provide such a service cost effectively, and its impact on VAP prevention.