ARTERIOVENOUS ACCESS FOR HEMODIALYSIS

 

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Arteriovenous access for hemodialysis is typically created through surgical procedures such as AV fistulas or AV grafts.

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Arteriovenous (AV) access for hemodialysis is a crucial component of treatment for patients with end-stage renal disease (ESRD) or chronic kidney disease (CKD). Hemodialysis involves filtering the patient's blood through a dialysis machine to remove waste products, excess fluids, and electrolytes when the kidneys are no longer able to function effectively. To facilitate this, an AV access is created to allow for easy, repetitive, and efficient blood flow between the patient and the dialysis machine

 

There are two common types of AV access created through surgical procedures: arteriovenous fistulas (AVF) and arteriovenous grafts (AVG).

 

Arteriovenous Fistula (AVF): An AV fistula is considered the gold standard for hemodialysis access due to its lower risk of complications and longer-lasting patency compared to other access types. The procedure involves surgically connecting a patient's own artery and vein, usually in the arm. Over time, the vein becomes larger and stronger, allowing for easy insertion of dialysis needles and efficient blood flow during hemodialysis sessions. It usually takes several weeks to months for the fistula to mature and become usable for hemodialysis.

 

Arteriovenous Graft (AVG): An AV graft is an alternative option for patients who have poor quality veins or other factors that make AV fistula creation challenging. In this procedure, a synthetic tube (usually made of polytetrafluoroethylene or PTFE) is surgically implanted to connect an artery and a vein, creating a bridge for blood flow. The graft can be placed in various locations, such as the arm or the thigh, depending on the patient's vascular anatomy and needs. AV grafts can be used for hemodialysis sooner than AV fistulas, often within 2-3 weeks after surgery. However, they generally have a higher risk of complications, such as infection and clotting, and a shorter overall lifespan compared to AV fistulas.

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The choice between an AV fistula and an AV graft depends on the patient's individual circumstances, including their vascular anatomy, overall health, and other factors. A vascular surgeon, in consultation with a nephrologist and the patient, will determine the most appropriate type of AV access. It is essential to monitor and maintain the patency of the AV access regularly to ensure efficient and safe hemodialysis treatments.

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                                                Anesthetic Implications for Arteriovenous Access for Hemodialysis

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Anesthesia type: General or regional/local/MAC

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Airway: ETT/LMA if general anesthesia

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Preoperative:

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• Assess volume status and electrolyte imbalance​

• Assess for chronic anemia and platelet dysfunction

• The patient may have uremia and diabetic neuropathy (peripheral and autonomic)

• Check potassium level​

• Check date of the last dialysis

• Patients may be hypervolemic, hyperkalemic or volume-depleted

• Hypoventilation can worsen hyperkalemia

• Succinylcholine use is normally appropriate if potassium is < 5.5 mEq/L

• Pulmonary edema may be present from fluid overload

• Uremic patients may have defective aortic and carotid body reflex arcs

• Patients can adjust to chronic anemia through increased cardiac output and increased 2,3-DPG levels

• Uremic patients are prone to developing GI bleeding

• Renal failure decreases gastric emptying, making the patient susceptible to aspiration

• Hyponatremia is common in ESRD

• Metabolic acidosis and increased 2,3-DPG shift the oxyhemoglobin curve to the right

• Avoid IV placement on the operative site. Avoid blood pressure cuff on operative arm

• IV placement may be difficult in this population

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Intraoperative:

 

• Use caution with rocuronium as its metabolism is partially renal cleared

• Sugammadex-rocuronium complexes are renally cleared

• Cisatracurium undergoes organ-independent Hofmann elimination—a chemical process dependent on pH and temperature

• Minimize IV fluids due to ESRD

• Position: Supine with surgical limb abducted 

• Avoid administration of NSAIDs

• Avoid morphine due to its metabolites (really cleared)

• Surgical time 1-2 hours

• EBL minimal (10-50 ml)

• Treatment of hyperkalemia includes: Insulin and glucose, albuterol, sodium bicarbonate, and calcium chloride/gluconate

• Calcium chloride/gluconate stabilizes cardiomyocyte membranes

• Insulin and bicarbonate shift potassium intracellularly

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Postoperative:

 

• Multimodal analgesia

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Complications:

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• Infection

• Thrombosis

• Bleeding/hematoma

• Aneurysm formation

• Arrhythmias

• Limb ischemia

• Nerve damage

• Vascular injury

• Pulmonary edema

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Sources:

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Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice. 

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Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.). 

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Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.

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