Arteriovenous access for hemodialysis

Arteriovenous access for hemodialysis

Anesthesia type	General vs regional vs local + MAC
Airway	ETT vs LMA vs non-invasive O2
Lines and access	PIV x 1 (opposite side of the surgical limb)
Monitors	Standard, 5-lead EKG, temperature
Primary anesthetic considerations
Preoperative	Electrolytes, cardiovascular disease
Intraoperative	Fluid management
Postoperative	Perioperative MI, Significant fluid shifts, Electrolyte abnormalities
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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 . The preferred locations are distal compared to proximal fistula (radiocephalic vs brachiocephalic vs brachiobasilic) due to increased risk of steal syndrome as proximity increases. 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

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

• 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

• IV midazolam dosage for anxiety should be reduced

Regional and neuraxial techniques

• Supraclavicular block supplemented with intercostobrachial nerve field block
• Infraclavicular block supplemented with intercostobrachial nerve field block

Intraoperative management

Monitoring and access

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

Induction and airway management

• 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

• Supine with table turned 90^o
• Surgical limb abducted

Maintenance and surgical considerations

• Maintenance with volatile anesthetics for general supplemented with short acting opioids
• IV propofol, remifentanil , and dexetomidine for regional or MAC
• Minimize IV fluids

Emergence

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

Postoperative management

Disposition

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

Pain management

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

Potential complications

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

Procedure variants

	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