49th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

INTRODUCTION

oBenefits of regional anesthesia (RA) for arteriovenous fistula (AVF) creation and arteriovenous graft (AVG) placement include:

•Increased three-month and one-year primary and functional patency of fistulas1,2

•Increased likelihood of successful radio-cephalic AVF creations along with the brachiocephalic AVF and AVG placement3,4

•Transitioning from planned AVG to an AVF after regional block is placed4

•Avoiding general anesthesia (GA) in at risk-population

oHowever, rates of RA have remained low

•RA as primary anesthetic in AVF creation surgeries, 2023 meta-analysis: 2.1% (South), 6.1% (West), 6.4% (Midwest), 0.0% (Northeast)5

•At Virginia Mason Medical Center (Sept 2021 – Sept 2022:

§19.23% AVF and AVG surgeries received primary RA (surgical block)

§Another 11.5% received RA and GA, total 30.8% receiving RA

oGoal: Increase Primary RA rates to >50% and increase overall block rates to >66% for each month following initiation

METHODS

oRoot cause analysis survey and Value Stream Map: Attendings, residents, CRNAs, and vascular surgeons (Fig 1)

•Anticoagulation guidelines established

•Scheduled AVF/AVG cases identified for block

•Standardized protocol for certain procedures (increase plan awareness)

•Guidelines for contraindications established

•System placed for OR RN to see patient during prior case or at PACU drop-off

oClinical protocol was developed and implemented (Fig 2)

oProtocol live on February 7th 2023

oPerformance

•Surgical Block Rate: percent of target surgeries receiving RA and native airway

•Any Block Rate: percent of target surgeries receiving RA and GA

•Tracked until end of January 2024

Results (Fig 3)

oAny Block Rate: 63% vs 31% prior, (45/71)

oSurgical Block Rate: 44% vs 19% prior, (31/71)

oOverall trend positive since initiation, doubled our rates

oStudy DID NOT achieve intended goal

Discussion

oWhat improved ? (Qualitative date and pre-op note review)

•Better understanding of relative contraindications like anticoagulation

•Regional team identifying the relevant cases night prior and emailing the OR anesthesia team

•Establishing a protocol so anesthesia team, surgical team, preop nursing, OR nursing, and PACU aware

oWhat’s still a barrier ?

•Anesthesia attending comfort or preference to regional anesthesia

§Comfort with supraclavicular single shots or fear of surgical block failure was noted

§ 54.5% of the cases WITH a block were done by non-regional attendings, while 81.6% of the cases WITH NO block were done by non-regional attendings

•Patient factors: body habitus preventing a safe regional anesthetic, arriving late, and patient refusal

•Surgical consent delays and OR nursing delays can delay block start time, increase time crunch, and could influence the block rate

oWhat’s next?

•Increasing resources for procedural guidance (i.e. “back up” regional attendings)

•Increasing awareness of protocol given slow decrease since initial peak (i.e during department grand rounds)

49th Annual Regional Anesthesiology and Acute Pain Medicine Meeting

EFFECTING A LASTING INCREASE IN REGIONAL ANESTHESIA USE FOR VASCULAR ACCESS SURGERIES AT VIRGINIA MASON: A FOLLOW UP

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