Arteriovenous Fistula Creation (Hemodialysis Access)
Patient phenotype
ESRD pre- or peri-dialysis. Multi-comorbid (HTN, DM, CAD, CHF, anemia). Often elderly + frail. Outpatient or 23-h obs.
Procedure
Surgical anastomosis of artery + vein at wrist (radiocephalic Brescia-Cimino), forearm, or upper arm. ~60-90 min. Patient supine, arm extended on board.
Anesthetic plan
Regional anesthesia preferred — supraclavicular or infraclavicular brachial plexus block + sedation. Avoids airway management + faster recovery. Local + MAC sometimes adequate.
Setup
- ·Standard ASA monitors
- ·PIV CONTRALATERAL to surgical arm (don't ruin future access)
- ·BP cuff CONTRALATERAL (preserves vessels)
- ·Brachial plexus block kit + ultrasound
- ·Light sedation: midaz + fentanyl + propofol infusion
Biggest concerns by phase
Vein preservation — DON'T touch the surgical arm
ESRD patients need every potential access vein. NO IV, BP cuff, or art line in arm being operated on, OR in a future access arm. Use opposite arm or foot for IV. Communicate with nursing.
Dialysis status + electrolytes
Verify last dialysis (within 24h ideal), K (< 5.5 ideal), volume status. May need urgent dialysis post-op if K continues to climb. AV fistula doesn't work for 2-4 weeks (maturation), so HD catheter often still in place.
Brachial plexus block — supraclavicular or infraclavicular
Supraclavicular: highest success, fastest onset. Phrenic block ~50% (caution in COPD). Infraclavicular: less phrenic, more comfortable for patient. US-guided. 20-30 mL of 0.5% ropivacaine. Light sedation throughout.
Hemodynamic stability + sedation
Light sedation. Avoid hypotension (preserves graft flow). Treat with phenylephrine, not fluid bolus (volume overload risk in ESRD).
Steal syndrome screening + Allen's test pre-op
After radial-cephalic anastomosis, distal hand may be hypoperfused. Allen's test pre-op confirms ulnar collateral. If positive Allen → may need a different site or banding procedure.
Discharge — fistula thrill + outflow patency
Surgeon palpates thrill (continuous vibration) + auscultates bruit at the anastomosis. If absent, immediate re-exploration. Patient teaching: protect arm, no BP/IVs ever, daily thrill check.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
ESRD patient for AV fistula creation. Last dialysis 36 hours ago, K is 5.6, weight up 3 kg from dry weight. What do you do?
What an examiner probes for
- ▹K 5.6 borderline — review ECG, peaked T waves
- ▹Risk-benefit: surgical urgency low (elective procedure) — defer for dialysis
- ▹If proceeding: regional only, avoid sux, monitor K trend
- ▹Plan: dialysis post-op if K rises further
Sources
- KDOQI Vascular Access Guidelines
- ASRA Regional Block Guidelines
Anatomy reference
Sourced reference images. 4 matches for "vessels arterial vein arm radial".
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