Difference between revisions of "Arteriovenous access for hemodialysis"

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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 =  
| 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.  
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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|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


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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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=== 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, remifentinil , and dexetomidine for regional or MAC
* IV propofol for regional or MAC (remifentanil and dexmetetomidine optional)
* Avoid renally cleared opioids including morphine
* Minimize IV fluids given ESRD
* Minimize IV fluids


=== 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 ==
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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
|
|
|-
|-
|Position
|Position
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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" />
|}
|}


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

Latest revision as of 00:02, 5 April 2022

Arteriovenous access for hemodialysis
Anesthesia type

General or regional/local/MAC

Airway

ETT/LMA if GA

Lines and access

PIV (nonsurgical limb)

Monitors

Standard 5-lead ECG Temperature

Primary anesthetic considerations
Preoperative

Electrolytes Cardiovascular disease

Intraoperative

Fluid management

Postoperative

Perioperative MI Significant fluid shifts Electrolyte abnormalities

Article quality
Editor rating
Comprehensive
User likes
0

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 [1]. The preferred locations are distal compared to proximal fistula (radiocephalic vs brachiocephalic vs brachiobasilic) due to increased risk of steal syndrome as proximity increases[2]. 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[3]
  • 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 45-90o
  • Surgical limb abducted on hand table

Maintenance and surgical considerations

  • 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

  • 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[2]

References

  1. ↑ Anesthesiologist's manual of surgical procedures. Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu (Sixth edition ed.). Philadelphia. 2020. ISBN 978-1-4698-2916-6. OCLC 1117874404. |edition= has extra text (help)CS1 maint: others (link)
  2. ↑ 2.0 2.1 Bradley, Tom; Teare, Thomas; Milner, Quentin (2017-08). "Anaesthetic management of patients requiring vascular access surgery for renal dialysis". BJA Education. 17 (8): 269–274. doi:10.1093/bjaed/mkx008. Check date values in: |date= (help)
  3. ↑ Stoelting's anesthesia and co-existing disease. Roberta L. Hines, Stephanie B. Jones, Robert K. Stoelting (Eighth edition ed.). Philadelphia, PA. 2022. ISBN 978-0-323-71861-5. OCLC 1280374077. |edition= has extra text (help)CS1 maint: others (link)

Top contributors: Cornel Chiu, Tony Wang and Chris Rishel

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