View source for Arteriovenous access for hemodialysis

{{Infobox surgical procedure
| anesthesia_type = General or regional/local/MAC
| airway = ETT/LMA if GA
| lines_access = PIV (nonsurgical limb)
| monitors = Standard
5-lead ECG
Temperature
| considerations_preoperative = Electrolytes
Cardiovascular disease
| considerations_intraoperative = Fluid management
| considerations_postoperative = Perioperative MI
Significant fluid shifts
Electrolyte abnormalities
}}

A procedure to establish '''arteriovenous access for hemodialysis''' involves creating an AV fistula by anastomosing the cephalic vein to the radial artery at the wrist level <ref>{{Cite book|url=https://www.worldcat.org/oclc/1117874404|title=Anesthesiologist's manual of surgical procedures|date=2020|others=Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu|isbn=978-1-4698-2916-6|edition=Sixth edition|location=Philadelphia|oclc=1117874404}}</ref>. The preferred locations are distal compared to proximal fistula (radiocephalic vs brachiocephalic vs brachiobasilic) due to increased risk of steal syndrome as proximity increases<ref name=":0">{{Cite journal|last=Bradley|first=Tom|last2=Teare|first2=Thomas|last3=Milner|first3=Quentin|date=2017-08|title=Anaesthetic management of patients requiring vascular access surgery for renal dialysis|url=https://linkinghub.elsevier.com/retrieve/pii/S2058534917301610|journal=BJA Education|language=en|volume=17|issue=8|pages=269–274|doi=10.1093/bjaed/mkx008}}</ref>. AV graft is used when there are no suitable veins in patient. A prosthetic graft is used to provide communication between the radial or ulnar artery to the antecubital or brachial vein or between brachial artery to these veins. Indication for this procedure include long term need for dialysis. 

== Preoperative management ==

=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|Assess for any uremic or diabetic neuropathy, uremic central nervous system symptoms, history of cerebrovascular disease, and carotid stenosis 
|-
|Cardiovascular
|Assess for myocardial ischemia, previous myocardial infarction (MI), valvular disease, arrhythmias, heart failure, and peripheral arterial disease as patient's are at increased risk for preoperative MI
|-
|Pulmonary
|Assess for COPD, smoking history, pulmonary edema and other reversible respiratory pathology

Smoking cessation at least 8 weeks prior to surgery
|-
|Hematologic
|Assess for chronic anemia and platelet dysfunction 
|-
|Renal
|Assess volume status, electrolyte imbalance
|-
|Endocrine
|Assess for diabetes and use of insulin 
|}

=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===

* BMP to assess renal dysfunction and potassium and glucose
* EKG for baseline and abnormal arrhythmias
* CBC for anemia and requirement of transfusion

=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===

* IV midazolam dosage for anxiety should be reduced 

=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===

* Supraclavicular block supplemented with intercostobrachial nerve field block<ref>{{Cite book|url=https://www.worldcat.org/oclc/1280374077|title=Stoelting's anesthesia and co-existing disease|date=2022|others=Roberta L. Hines, Stephanie B. Jones, Robert K. Stoelting|isbn=978-0-323-71861-5|edition=Eighth edition|location=Philadelphia, PA|oclc=1280374077}}</ref>
* Infraclavicular block supplemented with intercostobrachial nerve field block

== Intraoperative management ==

=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===

* Standard ASA monitors 
* 5-lead EKG 
* PIV x 1 

=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===

* If general is chosen, standard induction
** ETT or LMA
*** Succinylcholine use is appropriate if potassium is < 5.5 mEq/L
*** Alternative include cisatracurium
*** Cautious use of rocuronium as its metabolism is partially renal cleared
**** Consider reversal with neostigmine and glycopyrrolate given that sugamadex-rocuronium complexes are cleared renally
* If regional is chosen, minimal to deep sedation is reasonable 
* If local anesthetic and MAC chosen, minimal to deep sedation is reasonable

=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===

* Supine with table turned 45-90<sup>o</sup> 
* Surgical limb abducted on hand table

=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===

* Maintenance with volatile anesthetics for general supplemented with short acting opioids
* IV propofol for regional or MAC (remifentanil and dexmetetomidine optional)
* Minimize IV fluids given ESRD

=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

* Possible prolonged emergence 
** Acid-base status 
** Temperature 
** Prolonged or incomplete reversal of neuromuscular blockade 

== Postoperative management ==

=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===

* PACU
* Usually home 
* Floor if electrolyte or fluid management complications

=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===

* Pain is mild 
* Multimodal analgesia 
** Avoidance of NSAIDs 
** IV/PO acetaminophen 
** IV opioids 
** Regional block 
* Avoid renally cleared opioids including morphine

=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===

* Intimal hyperplasia
* Thrombosis
* Infection
* Aneurysm formation
* Limb ischemia 
* Bleeding/hematoma
* Nerve damage
* Vascular injury 
* Arrhythmias 
* Pulmonary edema 
* LAST

== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Arteriovenous Fistula
!Arteriovenous Graft
|-
|Position
|Supine with surgical limb abducted
|Supine with surgical limb abducted
|-
|Surgical time
|1-2 hours
|1-2 hours
|-
|EBL
|Minimal 
|Minimal
|-
|Postoperative disposition
|PACU and then home
|PACU and then home
|-
|Pain management
|Multimodal
|Multimodal
|-
|Potential complications
|
|Increase risk of thrombosis, increased rate of infection<ref name=":0" />
|}

== References ==

[[Category:Surgical procedures]]
<references />
[[Category:Vascular surgery]]