This case involves a 45-year-old male patient with end-stage renal failure, type-1 diabetes, high blood pressure, and moderate aortic stenosis who became severely and ill required dialysis. A right upper extremity AV graft was arranged for the patient. It was decided that rather than employing a nerve block, general anesthesia would be used. During the procedure, the patient went into cardiac arrest and was in a coma for three months before finally expiring. An expert anesthesiologist was sought to assess whether this patient would have been a candidate for a nerve block and what effect this treatment may have had on the patient’s outcome.
Question(s) For Expert Witness
- 1. What factors would you consider to determine whether general anesthesia or a nerve block is preferable for a patient undergoing an AV graft?
Expert Witness Response E-158692
There are many factors in choosing an anesthetic plan for this type of case. Advantages to performing a regional anesthetic include greater hemodynamic stability, less exposure to medication, less side effect profile. While a regional anesthetic can often times be safer, sometimes it may not be an option. For instance, if the AV graft is in a location such that the nerve block would not cover the surgical area, then supplemental anesthesia would be required. Also, if inadequate nerve visualization under ultrasound or lack of peripheral stimulation while performing the block is not achieved, then a successful block may not be achieved. In a patient with renal failure, there may be a concern for the increased risk of local anesthetic toxicity if a difficult block is encountered. A general anesthetic will ensure that an adequate level of anesthesia is achieved. Yet, there are inherent risks with a general anesthetic that are even more magnified in a sick patient. Hemodynamic instability can be detrimental in the setting of symptomatic aortic stenosis.