Difference between revisions of "Arteriovenous access for hemodialysis"
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Arteriovenous access for | 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. | ||
== Preoperative management == | == Preoperative management == | ||
| Line 20: | Line 20: | ||
|- | |- | ||
|Neurologic | |Neurologic | ||
| | |Assess for any uremic or diabetic neuropathy, uremic central nervous system symptoms, history of cerebrovascular disease, and carotid stenosis | ||
|- | |- | ||
|Cardiovascular | |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 | ||
|- | |- | ||
|Respiratory | |Respiratory | ||
| | |Assess for COPD, smoking history, pulmonary edema and other reversible respiratory pathology | ||
Smoking cessation at least 8 weeks prior to surgery | |||
|- | |- | ||
|Hematologic | |Hematologic | ||
| | |Assess for chronic anemia and platelet dysfunction | ||
|- | |- | ||
|Renal | |Renal | ||
| | |Assess volume status, electrolyte imbalance | ||
|- | |- | ||
|Endocrine | |Endocrine | ||
| | |Assess for diabetes and use of insulin | ||
|- | |- | ||
|Other | |Other | ||
| Line 46: | Line 45: | ||
=== 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. --> === | === 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 | * BMP to assess renal dysfunction and potassium and glucose | ||
* EKG for baseline and abnormal arrhythmias | * EKG for baseline and abnormal arrhythmias | ||
| Line 52: | Line 51: | ||
=== 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. --> === | ||
* 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. --> === | === 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 | * Interscalene block | ||
* Supraclavicular block | * Supraclavicular block supplemented with intercostobrachial nerve field block | ||
* Infraclavicular block | * Infraclavicular block supplemented with intercostobrachial nerve field block | ||
== Intraoperative management == | == Intraoperative management == | ||
| Line 65: | Line 66: | ||
* Standard ASA monitors | * Standard ASA monitors | ||
* 5-lead EKG | * 5-lead EKG | ||
* PIV x 1 | * 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. --> === | === 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 | * If general is chosen, standard induction | ||
** Cautious use of rocuronium as its metabolism is partially renal | ** ETT or LMA | ||
*** Consider reversal with neostigmine and glycopyrrolate given that sugamadex-rocuronium complexes are cleared renally (theoretic risk of recurarization ) | *** Succinylcholine use is appropriate if potassium is < 5.5 mEq/L | ||
*** Alternative include cisatracurium | |||
*** 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). | |||
* 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 90<sup>o</sup> | ||
* Surgical limb abducted | |||
=== 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 | ||
* IV propofol, remifentinil , and dexetomidine for regional or MAC | |||
* Avoid renally cleared opioids including morphine | |||
* 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. --> === | ||
* Possible prolonged emergence | |||
** Acid-base status | |||
** Temperature | |||
** Prolonged or incomplete reversal of neuromuscular blockade | |||
* | * | ||
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=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | === Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ||
* Pain is mild | * Pain is mild | ||
* Multimodal analgesia | * Multimodal analgesia | ||
** Avoidance of NSAIDs | ** Avoidance of NSAIDs | ||
| Line 108: | Line 119: | ||
=== 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. --> === | ||
* Bleeding | * Intimal hyperplasia | ||
* Thrombosis | |||
* Infection | |||
* Aneurysm formation | |||
* Limb ischemia | |||
* Bleeding/hematoma | |||
* Nerve damage | |||
* Vascular injury | * Vascular injury | ||
* Arrhythmias | * Arrhythmias | ||
* Pulmonary edema | * 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). --> == | == 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). --> == | ||
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|- | |- | ||
|Position | |Position | ||
| | |Supine with surgical limb abducted | ||
| | |Supine with surgical limb abducted | ||
|- | |- | ||
|Surgical time | |Surgical time | ||
| | |1-2 hours | ||
| | | | ||
|- | |- | ||
|EBL | |EBL | ||
| | |Minimal | ||
| | |Minimal | ||
|- | |- | ||
|Postoperative disposition | |Postoperative disposition | ||
| | |PACU and then home | ||
| | |PACU and then home | ||
|- | |- | ||
|Pain management | |Pain management | ||
| | |Multimodal | ||
| | |Multimodal | ||
|- | |- | ||
|Potential complications | |Potential complications | ||
Revision as of 15:19, 18 January 2022
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 | |
| Article quality | |
| Editor rating | |
| User likes | 0 |
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 [1]. 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.
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 |
| Respiratory | 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 |
| Other |
Labs and studies
- BMP to assess renal dysfunction and potassium and glucose
- EKG for baseline and abnormal arrhythmias
Operating room setup
Patient preparation and premedication
- IV midazolam dosage for anxiety should be reduced
Regional and neuraxial techniques
- Interscalene block
- 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
- Consider reversal with neostigmine and glycopyrrolate given that sugamadex-rocuronium complexes are cleared renally (theoretic risk of recurarization).
- 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 90o
- Surgical limb abducted
Maintenance and surgical considerations
- Maintenance with volatile anesthetics for general supplemented with short acting opioids
- IV propofol, remifentinil , and dexetomidine for regional or MAC
- Avoid renally cleared opioids including morphine
- 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
Potential complications
- Intimal hyperplasia
- Thrombosis
- Infection
- Aneurysm formation
- Limb ischemia
- Bleeding/hematoma
- Nerve damage
- Vascular injury
- Arrhythmias
- Pulmonary edema
- LAST
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | Supine with surgical limb abducted | Supine with surgical limb abducted |
| Surgical time | 1-2 hours | |
| EBL | Minimal | Minimal |
| Postoperative disposition | PACU and then home | PACU and then home |
| Pain management | Multimodal | Multimodal |
| Potential complications |
References
- ↑ 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)
Top contributors: Cornel Chiu, Tony Wang and Chris Rishel