Arteriovenous access for hemodialysis

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Arteriovenous access for hemodialysis
Anesthesia type

General or regional/local/MAC



Lines and access

PIV (nonsurgical limb)


Standard 5-lead ECG Temperature

Primary anesthetic considerations

Electrolytes Cardiovascular disease


Fluid management


Perioperative MI Significant fluid shifts Electrolyte abnormalities

Article quality
Editor rating
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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


  • 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


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

Postoperative management


  • 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]


  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)