Arteriovenous access for hemodialysis - Revision history

Chris.Rishel at 08:02, 5 April 2022

2022-04-05T08:02:23Z

← Older revision		Revision as of 01:02, 5 April 2022
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	{{Infobox surgical procedure		{{Infobox surgical procedure
	\| anesthesia_type = General vs regional vs local + MAC		\| anesthesia_type = General or regional/local/MAC
	\| airway = ETT vs LMA ~~vs non-invasive O2~~		\| airway = ETT/LMA if GA
	\| lines_access = PIV ~~x 1~~ (~~opposite side of the surgical~~ limb)		\| lines_access = PIV (nonsurgical limb)
	\| monitors = Standard, 5-lead ~~EKG, temperature~~		\| monitors = Standard
	\| considerations_preoperative = Electrolytes~~, cardiovascular~~ disease		5-lead ECG
			Temperature
			\| considerations_preoperative = Electrolytes
			Cardiovascular disease
	\| considerations_intraoperative = Fluid management		\| considerations_intraoperative = Fluid management
	\| considerations_postoperative = Perioperative MI, Significant fluid shifts, Electrolyte abnormalities		\| considerations_postoperative = Perioperative MI
			Significant fluid shifts
			Electrolyte abnormalities
	}}		}}

	~~Arteriovenous (AV) fistula or~~ arteriovenous ~~graft are surgical procedures creating a vascular~~ access ~~to provide~~ hemodialysis. AV fistula ~~is created~~ 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.		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 ==		== Preoperative management ==
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	[[Category:Surgical procedures]]		[[Category:Surgical procedures]]
			<references />
			[[Category:Vascular surgery]]

Tony.Wang: Small clarifications

2022-03-22T14:05:23Z

Small clarifications

← Older revision		Revision as of 07:05, 22 March 2022
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	=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===		=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===

	* Supine with table turned 90<sup>o</sup>		* Supine with table turned 45-90<sup>o</sup>
	* Surgical limb abducted		* 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 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		* Maintenance with volatile anesthetics for general supplemented with short acting opioids
	* IV propofol~~, remifentanil , and dexetomidine~~ for regional or MAC		* IV propofol for regional or MAC (remifentanil and dexmetetomidine optional)
	* Minimize IV fluids		* Minimize IV fluids given ESRD

	=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===		=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
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	** Temperature		** Temperature
	** Prolonged or incomplete reversal of neuromuscular blockade		** Prolonged or incomplete reversal of neuromuscular blockade

	*

	== Postoperative management ==		== Postoperative management ==

Chris.Rishel: Text replacement - "|Respiratory" to "|Pulmonary"

2022-02-22T05:44:55Z

Text replacement - "|Respiratory" to "|Pulmonary"

← Older revision		Revision as of 22:44, 21 February 2022
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	\|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		\|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
	\|-		\|-
	\|~~Respiratory~~		\|Pulmonary
	\|Assess for COPD, smoking history, pulmonary edema and other reversible respiratory pathology		\|Assess for COPD, smoking history, pulmonary edema and other reversible respiratory pathology

Cornel.Chiu at 02:55, 20 January 2022

2022-01-20T02:55:27Z

← Older revision		Revision as of 19:55, 19 January 2022
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	!Arteriovenous Fistula		!Arteriovenous Fistula
	!Arteriovenous Graft		!Arteriovenous Graft
	\|-
	~~\|Unique considerations~~
	\|
	\|
	\|-		\|-
	\|Position		\|Position

Cornel.Chiu: references

2022-01-19T17:06:25Z

references

← Older revision		Revision as of 10:06, 19 January 2022
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	\| considerations_preoperative = Electrolytes, cardiovascular disease		\| considerations_preoperative = Electrolytes, cardiovascular disease
	\| considerations_intraoperative = Fluid management		\| considerations_intraoperative = Fluid management
	\| considerations_postoperative =		\| considerations_postoperative = Perioperative MI, Significant fluid shifts, Electrolyte abnormalities
	}}		}}

	Arteriovenous (AV) fistula or arteriovenous graft are surgical procedures creating a vascular access to provide hemodialysis. AV fistula is created 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 (~~radial-cephalic~~ vs ~~brachial~~-~~basilic)~~. 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.		Arteriovenous (AV) fistula or arteriovenous graft are surgical procedures creating a vascular access to provide hemodialysis. AV fistula is created 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 ==		== Preoperative management ==
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	\|Endocrine		\|Endocrine
	\|Assess for diabetes and use of insulin		\|Assess for diabetes and use of insulin
	\|-
	~~\|Other~~
	\|
	\|}		\|}

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	* BMP to assess renal dysfunction and potassium and glucose		* BMP to assess renal dysfunction and potassium and glucose
	* EKG for baseline and abnormal arrhythmias		* EKG for baseline and abnormal arrhythmias
			* CBC for anemia and requirement of transfusion
	~~=== Operating room setup<!-- Describe any unique aspects~~ of ~~operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===~~

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

	* Interscalene block		* 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>
	* Supraclavicular block supplemented with intercostobrachial nerve field block
	* Infraclavicular block supplemented with intercostobrachial nerve field block		* Infraclavicular block supplemented with intercostobrachial nerve field block

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	*** Succinylcholine use is appropriate if potassium is < 5.5 mEq/L		*** Succinylcholine use is appropriate if potassium is < 5.5 mEq/L
	*** Alternative include cisatracurium		*** Alternative include cisatracurium
	*** Cautious use of rocuronium as its metabolism is partially renal		*** 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 ~~(theoretic risk of recurarization).~~		**** 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 regional is chosen, minimal to deep sedation is reasonable
	* If local anesthetic and MAC chosen, minimal to deep sedation is reasonable		* If local anesthetic and MAC chosen, minimal to deep sedation is reasonable
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	* Maintenance with volatile anesthetics for general supplemented with short acting opioids		* Maintenance with volatile anesthetics for general supplemented with short acting opioids
	* IV propofol, ~~remifentinil~~ , and dexetomidine for regional or MAC		* IV propofol, remifentanil , and dexetomidine for regional or MAC
	* Avoid renally cleared opioids including morphine
	* Minimize IV fluids		* Minimize IV fluids

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	** IV opioids		** IV opioids
	** Regional block		** Regional block
			* Avoid renally cleared opioids including morphine

	=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===		=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
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	\|+		\|+
	!		!
	!~~Variant 1~~		!Arteriovenous Fistula
	!~~Variant 2~~		!Arteriovenous Graft
	\|-		\|-
	\|Unique considerations		\|Unique considerations
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	\|Surgical time		\|Surgical time
	\|1-2 hours		\|1-2 hours
	\|		\|1-2 hours
	\|-		\|-
	\|EBL		\|EBL
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	\|Potential complications		\|Potential complications
	\|		\|
	\|		\|Increase risk of thrombosis, increased rate of infection<ref name=":0" />
	\|}		\|}

Cornel.Chiu: additional edits

2022-01-18T22:19:43Z

additional edits

Show changes

Cornel.Chiu: Most categories

2022-01-18T18:14:58Z

Most categories

New page

{{Infobox surgical procedure
| anesthesia_type = General vs regional vs local + MAC
| airway = ETT vs LMA vs non-invasive O2
| lines_access = PIV x 1 (opposite side of the surgical limb)
| monitors = Standard, 5-lead EKG, temperature
| considerations_preoperative = Electrolytes, cardiovascular disease
| considerations_intraoperative = Fluid management
| considerations_postoperative =
}}

Arteriovenous access for hemodialysis

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Respiratory
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

* BMP to assess renal dysfunction and potassium
* EKG for baseline and abnormal arrhythmias

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

* Interscalene block
* Supraclavicular block
* Infraclavicular block

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors
* 5-lead EKG
* PIV x 1 (at least 18 G)

=== Induction and airway management ===

* If general is chosen, standard induction
** Cautious use of rocuronium as its metabolism is partially renal
*** Consider reversal with neostigmine and glycopyrrolate given that sugamadex-rocuronium complexes are cleared renally (theoretic risk of recurarization )
*** Alternative include cisatracurium
** ETT or LMA
* If regional is chosen, minimal to deep sedation is reasonable
* If local anesthetic and MAC chosen, minimal to deep sedation is reasonable

=== Positioning ===

* Supine with table turned 90<sup>o</sup>

=== Maintenance and surgical considerations ===

* Close monitoring of IV fluids

=== Emergence ===

*

== Postoperative management ==

=== Disposition ===

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

=== Pain management ===

* Pain is mild to moderate
* Multimodal analgesia
** Avoidance of NSAIDs
** IV/PO acetaminophen
** IV opioids
** Regional block

=== Potential complications ===

* Bleeding
* Vascular injury
* Arrhythmias
* Pulmonary edema

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]