Anesthetic Management of Surgical Vascular Access for Hemodialysis

Special Article - Anesthetic Management

Austin J Anesthesia and Analgesia. 2018; 6(2): 1071.

Anesthetic Management of Surgical Vascular Access for Hemodialysis

Nandate K¹*, Ava Alamdari¹ and Ramaiah R²

¹Associate Professor, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA

²Instructor, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA

*Corresponding author: Koichiro Nandate, Associate Professor Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA

Received: June 06, 2018; Accepted: July 04, 2018; Published: July 11, 2018


Fistula; Renal Disease; Hyperkalemia; Anesthesia


Patients suffering from end-stage renal disease (ESRD) have an adjusted all-cause mortality rate that is 6.4-7.8, fold higher than the general population. Additionally, chronic kidney disease (CKD) is an independent risk factor for predicting postoperative death and cardiac events [1]. Surgical techniques to establish hemodialysis access are common and increasing in frequency as more and more patients are diagnosed with advanced and end-stage renal disease.

The purpose of this review is to focus on the fundamentals of perioperative anesthetic management of a patient who scheduled for hemodialysis access procedure. This involves not just the choice of anesthesia method but also pre-anesthesia preparation, intraoperative and post-operative management.

Pre-Anesthesia Preparation

Pre-anesthesia clinic

Safe and effective anesthesia management starts with comprehensive preoperative evaluation. This is most efficiently done in a pre-anesthesia clinic where it is essential to identify the comorbidities that are common to the patients with chronic or end-stage renal disease, including coronary artery disease and hypertension. Once identified, measures should be taken to medically optimize these patients to minimize or eliminate the risk of surgery and anesthesia. Current guidelines recommend checking a baseline electrocardiogram (ECG) in those patients who have cardiovascular risk factors or documented cardiovascular disease [1]. Additionally, the patient should be instructed to schedule hemodialysis the day prior to the surgery, as well as counseled on what to do regarding their routine medications. Basic laboratory tests may also be helpful, including a complete blood count, metabolic panel and coagulation panel.

Same Day Evaluation Typically most procedures done to establish hemodialysis access are outpatient procedures with patients arriving 1-2 hours prior to the planned procedure. The pre-anesthesia evaluation in the pre-operative holding area is one of the most important phases in preparing the patient for the administration of anesthesia. The anesthesia team should review the pre-anesthesia evaluation that was done in the pre-anesthesia clinic and confirm that the patient’s general condition has not changed since that time. Intravenous access and blood pressure monitoring should be avoided in the arteriovenous (AV) access arm. Obtaining peripheral venous access may be difficult, and an ultrasound guided method may be helpful to identify an appropriate vein and secure access. In cases where a patient has an existing indwelling catheter, consideration can be taken to gain access however this is generally avoided due to fear of increased infectious complications .

Special Anesthetic Considerations: Chronic vs End-Stage Renal Disease

In those patients who have chronic renal disease but has not yet started hemodialysis, it is important to elicit history regarding the volume and regularity of urine production with special attention to those who report a recent drop in volume and/or frequency. This may indicate a recent worsening of their renal function, which may necessitate closer attention to potassium changes or fluid management during the procedure. For those patients already on hemodialysis, it is important to establish when the last time patient underwent hemodialysis was. Ideally, the patient should have hemodialysis 12 to 24 hours prior to the procedure to allow their physiologic status to completely or near completely return to normal at the time of anesthetic administration. Additionally, the regularity at which the patient has recently undergone dialysis is also important as a single session of dialysis may not normalize the patient that has missed more than one session, particularly with regard to fluid status. Similarly, it is important to ask if the patient felt comfortable during and tolerated the last hemodialysis session. If the patient felt uncomfortable during hemodialysis, or the session was terminated prematurely, or the patient skipped a regular session because of feeling ill, it may indicate other factors that must be taken into account. These factors, along with laboratory abnormalities may necessitate cancelling/rescheduling the procedure.

Preoperative laboratory data

Verification of certain laboratory data is critical to check on the day of the procedure as these patients are subject to day-to-day changes.


The serum potassium levels in patients with chronic renal or endstage renal disease is typically elevated. It is essential to diagnose and treat hyperkalemia as it is potentially life threatening and therefore must not be neglected. There are no recommendations for absolute levels of pre-operative potassium levels that are considered safe. Therefore, the potassium level used to determine if the procedure can proceed or must be cancelled/rescheduled may vary among hospitals. It is worth noting that the serum potassium level is closely related with serum pH, thus if the patient is acidotic re-evaluation of serum potassium level must be considered after serum pH is corrected. In our institution, a potassium level higher than 6.0mmol/L prompts a discussion between the anesthesia and surgical teams regarding the need for urgent hemodialysis prior to the procedure. One additional consideration is that venous potassium levels can sometimes falsely be higher than arterial levels, and obtaining an arterial blood sample may be useful in confirming the correct true potassium level [2].

Occasionally, patients can have a lower preoperative potassium level (<3.5mmol/L). Hypokalemia is not as dangerous for patients as compared to hyperkalemia. Therefore, correction is required only if it is associated with frequent cardiac arrhythmias or with significant EKG changes such as QT prolongation. It is extremely difficult to correct hypokalemia in a patient with ESRD, and a nephrologist or cardiologist consultation maybe sought to avoid overcorrection with possible cardiac sequela.

Citation: Nandate K, Ava Alamdari and Ramaiah R. Anesthetic Management of Surgical Vascular Access for Hemodialysis. Austin J Anesthesia and Analgesia. 2018; 6(2): 1071.