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
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Arteriovenous access for hemodialysis

Preoperative management

Patient evaluation

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

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^o

Maintenance and surgical considerations

• Close monitoring of IV fluids

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

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications