ESRD for AV fistula

[Noyac]

This is not a terribly exciting case but it has some teaching points. Hopefully, some of you and I can learn something from it.

60 yo male for redo AV fistula with ESRD, dialysis MWF. Case is on monday in the morning. HE has not had dialysis since friday. H/o HTN otherwise fairly healthy.

What next?

Old timers, this should be a pretty basic case so let the residents respond. There will be a time for you to enter later and criticize me and my approach.

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[bogatyr]

Supraclavicular block. Minimal sedation. Dialysis post-op. You could check his K preop.

 

[Zie]

Preoperatively, I would do focused H&P emphasizing cardio-pulmonary and renal systems. I would wipe the dust off of my stethoscope and listen to the b/l lungs to see if the pt is already fluid overloaded, otherwise he may need dialysis preop. I would also order CXR, lytes specifically K, bun, creatinine, cbc, PT, PTT. I know that some may not order the coags, but I figure the uremia is already screwing up our platelets and truthfully I don't trust our vascular surgeons. Preoperative chest x-ray is optional IMHO, but I know the books would say so. I would obtain IV access and place microdrip tubing. Obtain informed consent for Regional anesthesia with minimal sedation.

To Block room with 2 versed and perform ultrasound guided supraclavicular. If the surgeon can decide on specific surgical site (upper arm, or lower arm), a interscalene or infraclavicular would work well without ultrasound.

TO OR, standard ASA monitors, O2, and titrated versed. All goes okay, but if not, RSI due to slowed GI motility. NMBAs: sux okay if K <5.5. I would use Roc 1.2mg/kg for RSI instead of sux with high K. Nimbex/roc post sux for maintenence titrated to train of four. Reversal at standard dose. I would minimize fluids and sedation.

Postop, I would observe for signs of residual sedation/fluid overload and have pt follow up in dialysis.

 

[SleepIsGood]

I agree with Zie's answer.

If it's Monday, I would check what the guy's K is. If it's close to what his 'baseline' is, then I would just go ahead with the case.

I believe one does not want to perform dialysis the day of the surgery, the pt will be volume depleted.

I will try to do the case with MAC with liberal local from the surgeons. I would look at the EKG for changes. IF not then just do the case.

 

[toughlife]

I agree with Zie's answer.

If it's Monday, I would check what the guy's K is. If it's close to what his 'baseline' is, then I would just go ahead with the case.

I believe one does not want to perform dialysis the day of the surgery, the pt will be volume depleted.

I will try to do the case with MAC with liberal local from the surgeons. I would look at the EKG for changes. IF not then just do the case.

I second that.

 

[huktonfonix]

Preoperatively, I would do focused H&P emphasizing cardio-pulmonary and renal systems. I would wipe the dust off of my stethoscope and listen to the b/l lungs to see if the pt is already fluid overloaded, otherwise he may need dialysis preop. I would also order CXR, lytes specifically K, bun, creatinine, cbc, PT, PTT. I know that some may not order the coags, but I figure the uremia is already screwing up our platelets and truthfully I don't trust our vascular surgeons. Preoperative chest x-ray is optional IMHO, but I know the books would say so. I would obtain IV access and place microdrip tubing. Obtain informed consent for Regional anesthesia with minimal sedation.

To Block room with 2 versed and perform ultrasound guided supraclavicular. If the surgeon can decide on specific surgical site (upper arm, or lower arm), a interscalene or infraclavicular would work well without ultrasound.

TO OR, standard ASA monitors, O2, and titrated versed. All goes okay, but if not, RSI due to slowed GI motility. NMBAs: sux okay if K <5.5. I would use Roc 1.2mg/kg for RSI instead of sux with high K. Nimbex/roc post sux for maintenence titrated to train of four. Reversal at standard dose. I would minimize fluids and sedation.

Postop, I would observe for signs of residual sedation/fluid overload and have pt follow up in dialysis.

I would probably only order the K and possible the CBC if the surgeons a hack. The xrays not going to be very useful if the patient is asymptomatic and the lungs sound clear. Why a microdrip? You can control fluids just as easily with regular tubing if youre paying attention. I only use microdrips for kiddies and infusions.

 

[huktonfonix]

I agree with Zie's answer.

If it's Monday, I would check what the guy's K is. If it's close to what his 'baseline' is, then I would just go ahead with the case.

I believe one does not want to perform dialysis the day of the surgery, the pt will be volume depleted.

I will try to do the case with MAC with liberal local from the surgeons. I would look at the EKG for changes. IF not then just do the case.

We do it with our renal transplants all the time if they need it. If theyre hypervolemic and symptomatic they need it. You can always give more fluid later. You cant take it away unless you do intraop dialysis (or bleed em)

 

[dhb]

Local: we had nothing to do with these patient at my previous institution.
I would do an infra-clav if the surgeon is cool and needs it.

 

[dhb]

listen to the b/l lungs to see if the pt is already fluid overloaded, otherwise he may need dialysis preop.

Well if his fistula isn't working you might be out of luck

I would also order CXR, lytes specifically K, bun,creatininecbc

if the cre is too high are you going to dialyse him??

PT, PTT. I know that some may not order the coags, but I figure the uremia is already screwing up our platelets and truthfully I don't trust our vascular surgeons.

Why would his coag be affected? If your vascular surgeons can't control bleeding from a fistula maybe they should switch to another field in any case bleeding from the fistula will not be controlled by good coagulation!

I would obtain IV access and place microdrip tubing.

not extremly usefull

To Block room with 2 versed

Why versed in an ESRD patient if i were to provide sedation which i don't think he needs i'd go with a little propofol

RSI due to slowed GI motility. NMBAs: sux okay if K <5.5. I would use Roc 1.2mg/kg for RSI instead of sux with high K. Nimbex/roc post sux for maintenence titrated to train of four. Reversal at standard dose. I would minimize fluids and sedation.

i wouldn't put him to sleep

 

[dhb]

.

 

[drccw]

K check
then to the room
ASA monitors.
MAC and local
dc to dialysis from room

our vascular surgeons have the hands of gods... too bad they are connected to arseholes

 

[Noyac]

So some of you wanted a K
- K-6.7
- nobody really asked for a Na but it was 130
- I can't remember BUN/Cr but who cares.
- No need for coag's IMHO

Others would have listen to him and I forgot to tell you guys that he has a h/o asthma.
- PE reveals wheezing throughout with bil basilar rales
- sats are low 90's
- he feels "OK"
- CXR not done yet

He has a dialysis catheter in situ due to failure of the AV fistula which I didn't make clear but I did mention that he had dialysis on friday.

I didn't get an ECG b/c I knew what it was going to show. I just put him on the monitor to confirm my suspicions. Peaked T waves w/c were as large as I can remember ever seeing.

Plan?

 

[aredoubleyou]

History and physical exam concentrating on his current physical status (breathing ok, no orthopnea, etc). If the pt has no angina and can lay flat, proceed.

If recent labs that would be good enough, otherwise I might get electrolytes, but I dont think they are absolutely necessary for this particular case and I'm not really sure what I'm going to do with them. If K is high I'll avoid sux unless its chronically high (6.0 last week, 6.1 today) and I have a bad airway. Cr is irrelevant. Not going to transfuse so wont get a Hb - I'll get it intraop if somehow this becomes a disaster. If he walked in from home he's not uraemic, so no coags, etc. Prolly oreder a preop ECG.

Ax block or local by surgeons. MAC with midazolam. If I have to convert to general, titrate propofol or slam etomidate and put in LMA. If very active GERD, use rocuronium RSI. If bad airway (would get electrolytes ahead in that case), use sux unless high K without previous comparrison or acutely higher K.

 

[aredoubleyou]

So some of you wanted a K
- K-6.7
- nobody really asked for a Na but it was 130
- I can't remember BUN/Cr but who cares.
- No need for coag's IMHO

Others would have listen to him and I forgot to tell you guys that he has a h/o asthma.
- PE reveals wheezing throughout with bil basilar rales
- sats are low 90's
- he feels "OK"
- CXR not done yet

He has a dialysis catheter in situ due to failure of the AV fistula which I didn't make clear but I did mention that he had dialysis on friday.

I didn't get an ECG b/c I knew what it was going to show. I just put him on the monitor to confirm my suspicions. Peaked T waves w/c were as large as I can remember ever seeing.

Plan?

Posted before I got these results.
High K in the setting of peaked T waves in an elective case = high chance of cancellation.
Low sats can be overcome with a facemask and asthma can be bronchodilated, but peak T waves makes me worry he has an acute K increase. If he has a great airway and you can defenitely get away without using sux and you trust your surgeons skills you can do it - but bad airway or academic surgeons, cancel the case.

 

[huktonfonix]

Posted before I got these results.
High K in the setting of peaked T waves in an elective case = high chance of cancellation.
Low sats can be overcome with a facemask and asthma can be bronchodilated, but peak T waves makes me worry he has an acute K increase. If he has a great airway and you can defenitely get away without using sux and you trust your surgeons skills you can do it - but bad airway or academic surgeons, cancel the case.

While its possible that its asthma, his symptoms are more likely to be fluid overload. That plus the hyperkalemia with EKG changes would lead me to send him for dialysis then come back and do the case. A fistula is no emergency.

 

[huktonfonix]

Posted before I got these results.
Low sats can be overcome with a facemask and asthma can be bronchodilated, but peak T waves makes me worry he has an acute K increase. If he has a great airway and you can defenitely get away without using sux and you trust your surgeons skills you can do it - but bad airway or academic surgeons, cancel the case.

Thats a concerning statement for so many reasons

 

[dfk]

i agree with huktonfonix, but is a 3 lead definitive of hyper K+? irreguardless, why not look at K+ trend with s/sx, and do a regional, such as supraclavicular with sedation. i'm not sure about dialysis after surgery, but that's what i would lean towards as long as fluid replacement can match loss overall.

 

[Noyac]

If recent labs that would be good enough, otherwise I might get electrolytes, but I dont think they are absolutely necessary for this particular case and I'm not really sure what I'm going to do with them. If K is high I'll avoid sux unless its chronically high (6.0 last week, 6.1 today) and I have a bad airway. Cr is irrelevant. Not going to transfuse so wont get a Hb - I'll get it intraop if somehow this becomes a disaster. If he walked in from home he's not uraemic, so no coags, etc. Prolly oreder a preop ECG.

What good are "recent labs" if they were done b/4 his last dialysis?

 

[Noyac]

While its possible that its asthma, his symptoms are more likely to be fluid overload. That plus the hyperkalemia with EKG changes would lead send him for dialysis then come back and do the case. A fistula is no emergency.

NA is 130. Does this help us any?

 

[Noyac]

i agree with huktonfonix, but is a 3 lead definitive of hyper K+? irreguardless, why not look at K+ trend with s/sx, and do a regional, such as supraclavicular with sedation. i'm not sure about dialysis after surgery, but that's what i would lean towards as long as fluid replacement can match loss overall.

What would those s/sx be?

What more do you want that a 3 lead won't give you?

What's wrong with dialysis after surgery?

What K+ trend, and why does it matter?

 

[Planktonmd]

i agree with huktonfonix, but is a 3 lead definitive of hyper K+? irreguardless, why not look at K+ trend with s/sx, and do a regional, such as supraclavicular with sedation. i'm not sure about dialysis after surgery, but that's what i would lean towards as long as fluid replacement can match loss overall.

I am sorry but I am having difficulty understanding what you are trying to say, could you please repeat it in English??

 

[Arch Guillotti]

i agree with huktonfonix, but is a 3 lead definitive of hyper K+? irreguardless, why not look at K+ trend with s/sx, and do a regional, such as supraclavicular with sedation. i'm not sure about dialysis after surgery, but that's what i would lean towards as long as fluid replacement can match loss overall.

How much fluid loss do you expect to see w/an AV fistula?

 

[Planktonmd]

What would those s/sx be?

What more do you want that a 3 lead won't give you?

What's wrong with dialysis after surgery?

What K+ trend, and why does it matter?

Wow, at least you were able to understand some of his statements, I really couldn't figure out what he was saying.

 

[Noyac]

Wow, at least you were able to understand some of his statements, I really couldn't figure out what he was saying.

I didn't understand his comments. Thats why I asked so many questions. Hell I had to ask a question for every comment he made.

 

[Noyac]

DFK, I don't want to lead to the hijacking of my own thread but seriously dude, who is teaching you? Are you ever supervised by a real physician? Or do you guys only get training from other crna's?

 

[aredoubleyou]

Thats a concerning statement for so many reasons

What I mean is that a person presenting for MAC with a sat of 93% on RA can typically be greatly improved with facemask and that alone is not a reason to necessarily cancel a case. Done cataracts with room air sats high 80's for example.

In this case low sats are likely 2/2 pulmonary oedema +/-asthma.

 

[aredoubleyou]

What good are "recent labs" if they were done b/4 his last dialysis?

Chronic vs acute hyperkalemia, although in the setting of peaked T waves its kinda irrelevant since I'd cancel an elective case on that alone.

Setting aside the ecg, if his last K was 5.2, and now its 6.7, chance of having conduction problems is many times higer than if he lives at 6.5.

BTW, I realize none of what I am saying is oral board answers, but I do think the risk of hyperkalaemia is way overstated in academic anesthesia in general.

 

[aredoubleyou]

NA is 130. Does this help us any?

To me it is further confirmation that he is hypervolaemic and has renal failure and has not had dialysis for three days.

 

[Noyac]

Chronic vs acute hyperkalemia, although in the setting of peaked T waves its kinda irrelevant since I'd cancel an elective case on that alone.

Setting aside the ecg, if his last K was 5.2, and now its 6.7, chance of having conduction problems is many times higer than if he lives at 6.5.

BTW, I realize none of what I am saying is oral board answers, but I do think the risk of hyperkalaemia is way overstated in academic anesthesia in general.

You start out saying that you'd cancel for peaked T waves alone but then claim that hyperkalemia is way overstated in academia. It can't be both ways.

But I get what your train of thought. So If I told you that the he has a history of hyperkalemia but never with peaked T waves. Now what?

 

[Noyac]

To me it is further confirmation that he is hypervolaemic and has renal failure and has not had dialysis for three days.

In the setting of B basilar rales with diminished sats and wheezing does this mean anything to you?

I think of CHF in this setting. But volume overload is another way of saying it.

 

[huktonfonix]

What I mean is that a person presenting for MAC with a sat of 93% on RA can typically be greatly improved with facemask and that alone is not a reason to necessarily cancel a case. Done cataracts with room air sats high 80's for example.

In this case low sats are likely 2/2 pulmonary oedema +/-asthma.

fair enough. I dont care so much about the Os sat is, as what it represents. If someone had a RA sat of high 80s with S/S of CHF its a cancellation. If they have pulmonary fibrosis and are as good as they get, then its a go. In this case the O2 may improve the sat, but its only covering up the underlying problem which should probably be corrected prior to the procedure.

 

[aredoubleyou]

You start out saying that you'd cancel for peaked T waves alone but then claim that hyperkalemia is way overstated in academia. It can't be both ways.

But I get what your train of thought. So If I told you that the he has a history of hyperkalemia but never with peaked T waves. Now what?

No baseline labs, K 6.7, no ekg changes, then the question is am I going to cause the K to elevate further (although I think hyperkalemia is overstated 6.7 is unquestionably high). If I can manage the airway with complete confidence without sux if everything goes wrong, in the setting of chronic renal failure I would defenitely do it if there was any sense of urgency and probably do it if it were this particular case (routine) if I was comfortable with the surgeon.

My initial reaction is to cancel it based purely on the number, but I do think it can be done safely if he lives at a high K.

 

[OB1🤙]

The decision to proceed is probably going to end up being dependent on the culture of the institution.

This case screams "MAC/local."

Given this pulmonary exam and the relative volume overload for this pt, I'd personally stay away from an interscalene or supraclavicular block. You could probably get away with it but I'd rather not alter the pt's pulmonary physiology any more than necessary by bagging the phrenic. When local by the surgeons should work just as well, I don't see the benefit. Infraclavicular would work fine but again, local infiltration should be just as good and probably more comfortable.

But back to the issue at hand- hyperK and T-waves- well, shoot. Elective case, dude's got a temporary line, and you have a Na of 130 with a crappy pulmonary exam-> sounds volume overloaded. He's got more than one indication for it here, so ship him up to his favorite dialysis nurse, and do the case in a couple of hours. He's getting dialyzed today one way or another, may as well do it preprocedure and simmer those T waves down.

But if the surgeon throws a hissy fit at postponing and you decide to proceed- local + dash of propofol and done.

 

[huktonfonix]

The decision to proceed is probably going to end up being dependent on the culture of the institution.

This case screams "MAC/local."

Given this pulmonary exam and the relative volume overload for this pt, I'd personally stay away from an interscalene or supraclavicular block. You could probably get away with it but I'd rather not alter the pt's pulmonary physiology any more than necessary by bagging the phrenic. When local by the surgeons should work just as well, I don't see the benefit. Infraclavicular would work fine but again, local infiltration should be just as good and probably more comfortable.

But back to the issue at hand- hyperK and T-waves- well, shoot. Elective case, dude's got a temporary line, and you have a Na of 130 with a crappy pulmonary exam-> sounds volume overloaded. He's got more than one indication for it here, so ship him up to his favorite dialysis nurse, and do the case in a couple of hours. He's getting dialyzed today one way or another, may as well do it preprocedure and simmer those T waves down.

But if the surgeon throws a hissy fit at postponing and you decide to proceed- local + dash of propofol and done.

You know damn well that its gonna be a 4-6 hour ordeal (with transport time) over at the big house before youre seeing that patient again......If the surgeon really wants to go, he doesnt need me. He can just book the OR and use local.

 

[aredoubleyou]

fair enough. I dont care so much about the Os sat is, as what it represents. If someone had a RA sat of high 80s with S/S of CHF its a cancellation. If they have pulmonary fibrosis and are as good as they get, then its a go. In this case the O2 may improve the sat, but its only covering up the underlying problem which should probably be corrected prior to the procedure.

I think thats the underlying issue: do you have to correct the underlying problem (hypervolaemia) before starting a routine case like this (I know the boards answer- but do you really have to do it and still have a safe anesthetic). I dont tink anyone would say your wrong in medical terms to dialyze him first, but is he really gunna have a worse outcome if you dont? I am leaning towards the opposite way you are leaning.

To me this case is a grey area. I really think he'll do fine, but if he doesnt you have nothing leagally to stand on (which is a different issue)

 

[Planktonmd]

fair enough. I dont care so much about the Os sat is, as what it represents. If someone had a RA sat of high 80s with S/S of CHF its a cancellation. If they have pulmonary fibrosis and are as good as they get, then its a go. In this case the O2 may improve the sat, but its only covering up the underlying problem which should probably be corrected prior to the procedure.

Exactly.
I can't tell you how many times I walked into the PACU and found the nurses giving a patient 100% oxygen unnecessarily just to make the SPO2 look better while the patient is obviously over sedated and his main problem is ventilation not oxygenation.

 

[jwk]

Exactly.
I can't tell you how many times I walked into the PACU and found the nurses giving a patient 100% oxygen unnecessarily just to make the SPO2 look better while the patient is obviously over sedated and his main problem is ventilation not oxygenation.

That's why John Downes and others advocate no supplemental O2 for sedation cases - supplemental O2 gives you a false sense of security when your patient is hypoventilating.

 

[Noyac]

OK some want dialysis b/4 surgery w/c I can't really argue with.

But I'm sure it will come as no surprise that I didn't go this route. And many of you are sounding like you would do the case and then send him to dialysis post-op. We can talk about why I did the case later and I'm sure one or two people here will criticize me for doing it.

But I'd rather we talk about the case. If you are planning on proceeding then How? I would warn heavily against an interscalene block in this guy b/c of respiratory issues. The site is going to be the right forearm and his temporary dialysis cath is on the right.

Also, what would be your plan for the hyperkalemia and peak T waves.? How about for his wheezing? What are your concerns during the case?

 

[toughlife]

So some of you wanted a K
- K-6.7
- nobody really asked for a Na but it was 130
- I can't remember BUN/Cr but who cares.
- No need for coag's IMHO

Others would have listen to him and I forgot to tell you guys that he has a h/o asthma.
- PE reveals wheezing throughout with bil basilar rales
- sats are low 90's
- he feels "OK"
- CXR not done yet

He has a dialysis catheter in situ due to failure of the AV fistula which I didn't make clear but I did mention that he had dialysis on friday.

I didn't get an ECG b/c I knew what it was going to show. I just put him on the monitor to confirm my suspicions. Peaked T waves w/c were as large as I can remember ever seeing.

Plan?

kyexalate. If the surgeons are fast, give him K cocktail and once fistula is in place send pt to dialysis. I would not want to instrument his airway if he is actively wheezing.

 

[Spandex]

C BIG K

That's probably the simple answer, but the B would certainly be beneficial in hitting two birds with one stone as they say. And of course stabilization of that heart thingy with Ca probably wouldn't hurt you. Insulin has a synergistic effect on improving hyperkalemia when given with a B agonist and glucose. Kayexalate rectally just because I want to make the nurse that pissed me off earlier do it and that way I can keep my NPO status. So I vote drive the K into the cells, stabilzie cardium, bind some up with Kayexalate, IV sedation, Local.

However, at my institution we'd probably make him get dialysis first to pull of some of that excess fluid, pulm consult to tune up his "asthma," cards consult for "EKG changes," and do him Tuesday morning.

 

[Noyac]

kyexalate. If the surgeons are fast, give him K cocktail and once fistula is in place send pt to dialysis. I would not want to instrument his airway if he is actively wheezing.

Kayexalate is a good idea since he is also hyponatremic. Kayexalate exchanges sodium for K in the gut but its onset of action is anywhere from 2-24 hrs. Not fast enough.

 

[Noyac]

C BIG K

That's probably the simple answer, but the B would certainly be beneficial in hitting two birds with one stone as they say. And of course stabilization of that heart thingy with Ca probably wouldn't hurt you. Insulin has a synergistic effect on improving hyperkalemia when given with a B agonist and glucose. Kayexalate rectally just because I want to make the nurse that pissed me off earlier do it and that way I can keep my NPO status. So I vote drive the K into the cells, stabilzie cardium, bind some up with Kayexalate, IV sedation, Local.

However, at my institution we'd probably make him get dialysis first to pull of some of that excess fluid, pulm consult to tune up his "asthma," cards consult for "EKG changes," and do him Tuesday morning.

Yes, but my approach went something like this. Albuterol nebs in pre-op (kill 2 birds with one stone wheezing maybe and start to correct K) and 1/2 amp D50 since his glu was 80. To the OR with monitors and once glu was 100-120 i gave 10 units insulin. I reserve CaCl for cardiac disturbances like ectopy, pauses or brady. I don't give it emperically. I gave 2mg versed for the whole case and surgeon did his usual local. Pt went to dialysis 30 post-op. I did call the nephrologist b/4 surgery to inform him and request dialysis be ready post-op.

I chose albuterol b/c recent studies show it to be the most effective and fastest means of treating hyperkalemia. I monitored peak T waves throughout the case even printing a graph at teh start and the end. The T waves actually dropped some by the end of the case.

 

[toughlife]

Noyac, plankton et al. You guys are ruthless with the murse. I like it.

 

[Noyac]

Noyac, plankton et al. You guys are ruthless with the murse. I like it.

It's not cause he's a nurse.
If you were as clueless then we'd be on your arse too but your not.

 

[sigrhoillusion]

You know damn well that its gonna be a 4-6 hour ordeal (with transport time) over at the big house before youre seeing that patient again......If the surgeon really wants to go, he doesnt need me. He can just book the OR and use local.

Bumping an old thread, but saw this statement "He can just book the OR and use local."

At our intstituion this becomes such a big issue cause it's more of a hassle for a surgeon to book a room with just local than it is to do a MAC case. So if they do it with just local then anesthesia staff isn't involved but then they need to pull a seperate nurse outside of the circulator and scrub to monitor the patient, which is usually mpossible in the middle of the day. And supposedly insurances haven't been reimbursing some cases if all we give is some versed...(?!) So in order to get some of the cases done and billable, some people will push a little propofol just so the room doesn't get delayed.

 

[sigrhoillusion]

And before anyone thinks this is anesthesia trying to get out of work, it's usually the opposite. The surgeon is the one who usually says "well I can probably just do this under local!" but then doesn't realize that we're not involved. It also becomes an issue later in the day when they add cases on and want to get the case done, but anesthesia staff is tied up and although the surgeon might be free, we can't dedicate an OR room to them usually because of the nursing staff, and they don't want to wait since they are like 5th on the add-on list which means we're not getting to them for a few hours.

 

[Mman]

And supposedly insurances haven't been reimbursing some cases if all we give is some versed...(?!) So in order to get some of the cases done and billable, some people will push a little propofol just so the room doesn't get delayed.

There is no requirement on what meds to give for a case to be reimbursed. The patient can get 2 mg of versed in preop holding and you can give them absolutely nothing in the OR and that is still MAC if you are monitoring the patient during the procedure.

 

[deleted162650]

I woulda postponed this one just to teach the dipsheet a lesson that scheduled this guy for an elective fistula on a Monday morning after he hasn't been dialyzed for nearly 3 days.