P251 Ultrasound-guided costoclavicular and intercostobrachial nerve blocks for brachial-axillary arteriovenous fistula: a case report

<h3>Background and Aims</h3> Selection of an anesthetic technique for upper medial arm procedures is challenging due to its complex innervation. We report a case of successful anesthesia for a brachial-axillary arteriovenous fistula using a combination of ultrasound-guided costoclavicular and intercostobrachial nerve blocks. <h3>Methods</h3> A 49-year-old female patient with hypothyroidism and acquired immunodeficiency syndrome (AIDS), undergoing hemodialysis, was scheduled for a brachial-axillary arteriovenous fistula procedure in the right upper limb. A regional anesthesia approach was chosen, combining an ultrasound-guided intercostobrachial nerve block with a costoclavicular brachial plexus block. A general anesthesia plan was kept as a backup. Initially, 1 mg of intravenous midazolam was administered. Using a high-frequency ultrasound transducer and a 100-mm needle, the costoclavicular block was performed with 25 mL of 0.5% ropivacaine. Subsequently, the intercostobrachial nerve was blocked via the axillary region using 15 mL of the same anesthetic solution. Ultrasound imaging suggested appropriate spread of the injectate and displacement of the relevant anatomical structures for both injections. <h3>Results</h3> Sensory blockade was confirmed 10 minutes post-injection. During the procedure, the patient reported discomfort in the upper medial arm at 20 minutes and again after one hour. These episodes were effectively managed with an additional 1 mg of midazolam, 15 mg of ketamine, and 40 mcg of fentanyl. The surgery lasted 3.5 hours and was completed without complications. Postoperative analgesia was successfully maintained with 750 mg of oral paracetamol every six hours, without the need for additional analgesics. <h3>Conclusions</h3> Alternative anesthetic techniques such as PECS, serratus plane, ESP, intercostal, and paravertebral blocks, or subcutaneous infiltration, often present limitations including higher failure rates, delayed onset, increased local anesthetic requirements, or airway manipulation. This case demonstrates the efficacy and safety of the combined approach, which successfully avoided general anesthesia while ensuring effective intraoperative analgesia and patient comfort.