区域麻醉下动静脉瘘创建的长期功能通畅率和成本效益：一项随机对照试验。
Long-Term Functional Patency and Cost-Effectiveness of Arteriovenous Fistula Creation under Regional Anesthesia: a Randomized Controlled Trial.
机构信息
Department of Renal Surgery, Queen Elizabeth University Hospital, Glasgow, United Kingdom
Department of Anaesthesia, Critical Care and Pain Medicine, University of Glasgow, Glasgow, United Kingdom.
出版信息
J Am Soc Nephrol. 2020 Aug;31(8):1871-1882. doi: 10.1681/ASN.2019111209. Epub 2020 Jul 24.
BACKGROUND
Regional anesthesia improves short-term blood flow through arteriovenous fistulas (AVFs). We previously demonstrated that, compared with local anesthesia, regional anesthesia improves primary AVF patency at 3 months.
METHODS
To study the effects of regional versus local anesthesia on longer-term AVF patency, we performed an observer-blinded randomized controlled trial at three university hospitals in Glasgow, United Kingdom. We randomly assigned 126 patients undergoing primary radiocephalic or brachiocephalic AVF creation to receive regional anesthesia (brachial plexus block; 0.5% L-bupivacaine and 1.5% lidocaine with epinephrine) or local anesthesia (0.5% L-bupivacaine and 1% lidocaine). This report includes findings on primary, functional, and secondary patency at 12 months; reinterventions; and additional access procedures (primary outcome measures were previously reported). We analyzed data by intention to treat, and also performed cost-effectiveness analyses.
RESULTS
At 12 months, we found higher primary patency among patients receiving regional versus local anesthesia (50 of 63 [79%] versus 37 of 63 [59%] patients; odds ratio [OR], 2.7; 95% confidence interval [95% CI], 1.6 to 3.8; =0.02) as well as higher functional patency (43 of 63 [68%] versus 31 of 63 [49%] patients; OR, 2.1; 95% CI, 1.5 to 2.7; =0.008). In 12 months, 21 revisional procedures, 53 new AVFs, and 50 temporary dialysis catheters were required. Regional anesthesia resulted in net savings of £195.10 (US$237.36) per patient at 1 year, and an incremental cost-effectiveness ratio of approximately £12,900 (US$15,694.20) per quality-adjusted life years over a 5-year time horizon. Results were robust after extensive sensitivity and scenario analyses.
CONCLUSIONS
Compared with local anesthesia, regional anesthesia significantly improved both primary and functional AVF patency at 1 year and is cost-effective.
CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER
Local Anaesthesia versus Regional Block for Arteriovenous Fistulae, NCT01706354.
背景
区域麻醉可改善动静脉瘘（AVF）的短期血流。我们之前的研究表明，与局部麻醉相比，区域麻醉可提高 3 个月时 AVF 的初始通畅率。
方法
为了研究区域麻醉与局部麻醉对 AVF 长期通畅率的影响，我们在英国格拉斯哥的 3 所大学医院进行了一项观察者设盲的随机对照试验。我们将 126 例接受初次头静脉或肱动脉 AVF 成形术的患者随机分配至接受区域麻醉（臂丛神经阻滞；0.5%L-布比卡因和 1.5%利多卡因加肾上腺素）或局部麻醉（0.5%L-布比卡因和 1%利多卡因）。本报告包括 12 个月时的初次通畅率、功能性通畅率和继发性通畅率；再干预；以及其他通路程序（主要结局指标之前已报道）。我们采用意向治疗进行数据分析，并进行了成本效益分析。
结果
在 12 个月时，与接受局部麻醉的患者相比，接受区域麻醉的患者的初次通畅率更高（63 例患者中 50 例[79%] vs 63 例患者中 37 例[59%]；比值比[OR]，2.7；95%置信区间[95%CI]，1.6 至 3.8；=0.02），功能性通畅率也更高（63 例患者中 43 例[68%] vs 63 例患者中 31 例[49%]；OR，2.1；95%CI，1.5 至 2.7；=0.008）。12 个月时，21 例需进行修订程序，53 例新的 AVF，50 例临时透析导管。1 年时，区域麻醉使每位患者的净节省为 195.10 英镑（237.36 美元），在 5 年时间内，每增加 1 个质量调整生命年的增量成本效益比约为 12900 英镑（15694.20 美元）。经过广泛的敏感性和情景分析，结果稳健。
结论
与局部麻醉相比，区域麻醉可显著提高 AVF 在 1 年内的初次通畅率和功能性通畅率，并且具有成本效益。
临床试验注册号及名称
Local Anaesthesia versus Regional Block for Arteriovenous Fistulae，NCT01706354。
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