Why Regional is Usually Preferred
The brachial plexus block does more than anaesthetise
Brachial plexus block
SympathectomyBlock-induced vasodilation → ↑ vessel diameter & blood flow → may improve fistula maturation & early patency
No airway instrumentationAvoids GA in a comorbid ESRD patient with a full-stomach/aspiration risk
Post-op analgesiaProlonged pain relief; avoids opioid accumulation
Stable haemodynamicsAvoids the pressor response & polypharmacy
Choosing & Dosing the Block
Options
- Supraclavicular / infraclavicular / axillary brachial plexus block — supraclavicular gives a dense whole-forearm block; ultrasound guidance improves success & safety
- Local infiltration for a simple distal (wrist) radiocephalic fistula
- Consider avoiding phrenic-nerve-sparing concerns (interscalene not needed for forearm)
LA dosing caution
- Uraemia/acidosis & hypoalbuminaemia → ↑ free LA fraction; shortened block duration & possibly lower LAST threshold — use the lowest effective dose
- Uraemic platelet dysfunction & anticoagulation → weigh bleeding risk of deep blocks
When GA is chosen instead: block failure/contraindication, patient preference, an uncooperative patient, or a long/proximal/graft procedure. Use a renal-safe technique (atracurium, avoid morphine, careful with fluids & potassium) and secure the airway given the aspiration risk. Sedation can supplement a regional block.