What are people doing for their AV Fistulas?

[neuroride]

We do alot of them under Local MAC at our place but we have a new vascular guy that freaks out if they are not under general. I have done quite a few with a supraclavicular block and then sedation in residency that seems to work well but none in the last year.

What is everyone else doing? Are you guys just doing it under general despite some crappy labs and renal function?

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[ssmallz]

2 of versed and a bunch of local will usually do the trick

 

[jwk]

We do alot of them under Local MAC at our place but we have a new vascular guy that freaks out if they are not under general. I have done quite a few with a supraclavicular block and then sedation in residency that seems to work well but none in the last year.

What is everyone else doing? Are you guys just doing it under general despite some crappy labs and renal function?

Most of them have crappy labs and renal function, so that doesn't really make much difference. We do most of ours under MAC, but will do general if we think the patient may not tolerate MAC well, particularly with our slow surgeons. Some of ours do AV fistulas in about an hour, but then there are those that take three hours. 😱 We have a good rapport with our surgeons, and have a general understanding that we don't tell them how to do their surgery and they don't tell us how to do anesthesia. Works pretty well.

 

[OB1🤙]

Supraclavicular.

 

[Arch Guillotti]

2 of versed and a bunch of local will usually do the trick

Not too good if you don't have surgeon buy-in.

 

[Arch Guillotti]

We do alot of them under Local MAC at our place but we have a new vascular guy that freaks out if they are not under general. I have done quite a few with a supraclavicular block and then sedation in residency that seems to work well but none in the last year.

What is everyone else doing? Are you guys just doing it under general despite some crappy labs and renal function?

supra

 

[Planktonmd]

Ga, lma 100%

 

[Mman]

A little of this, a little of that. Depends on the patient and depends on which surgeon I'm working with.

Probably a roughly equal split between GA, sedation + local by surgeon, and supraclavicular block.

I really don't think there is one best answer for this one.

 

[urge]

pent sux tube

 

[risnwb]

Supraclavicular +/- local by surgeon. Ive had them request a block because they feel the vasodilation makes the surgery easier...

 

[Arch Guillotti]

Supraclavicular +/- local by surgeon. Ive had them request a block because they feel the vasodilation makes the surgery easier...

same here

 

[fakin' the funk]

Infraclav (institutional preference) +/- intercostobrachial if high. Usually zero to minimal sedation for the sick ones

 

[Trisomy13]

supraclav with mepivacaine (or whatever is in the drawer). drape up, and touches of STFU juice as needed to maintain the illusion they are asleep.

 

[caligas]

Droperidol, nimbex, retrograde intubation.

Seriosuly though I like axillary blocks. LMA fine too if surgeon prefers and cardiac function half decent.

 

[countingdays]

Ga, lma 100%

Yep. And they don't move.

 

[Mman]

Yep. And they don't move.

Problem with LMAs for our fistulas is that the vast majority of our ESRD patients are horribly controlled diabetics with major gastroparesis. Most are obese as well. Less than ideal candidates, although it works well for some patients.

 

[Gasworks]

problem with "MAC" is that the surgeons don't want the pt to move, talk, respond to pain or hear them yelling and cursing at the nurses. So now you have some poor oversedated schmuck reaping the benefits of hypoventilation and hypotension while the surgeon pats you on the back for giving "great sedation". Personally I'd rather give them the gentlest induction that will let me get the LMA in, run them on just a whiff of gas and ask the surgeon to use local.

 

[Planktonmd]

pent sux tube

👍

 

[Planktonmd]

Problem with LMAs for our fistulas is that the vast majority of our ESRD patients are horribly controlled diabetics with major gastroparesis. Most are obese as well. Less than ideal candidates, although it works well for some patients.

I think you worry too much!
just forget all that crap about LMA , GERD, gastroparesis...
It's only true in residency and the oral boards!

 

[Southpaw]

In residency we did supraclav + intercostobrachial. The surgeons were big time on board with this b/c they loved the vasodilation.

The standard for my private practice group is prop bolus followed by the surgeon slamming in some local. It works fine too.

 

[deleted162650]

.

 

[deleted162650]

I think you worry too much!
just forget all that crap about LMA , GERD, gastroparesis...
It's only true in residency and the oral boards!

OK Plank, hold on. In one thread you're gonna crucify Blade for advocating the use of an LMA in an otherwise healthy, fasted parturient at 18wks but now your gonna recommend one in an ESRD, diabetic with known gastroparesis?! Ya that's real consistent and makes a lot of sense 😕 . I'm not saying I necessarily agree with the pregnant LMA (remember pregnancy does not negatively affect gastric emptying, labor does. The decreased LES tone shouldn't be a big problem if the pt is fasted and doesn't c/o GERD), but I'll bet you dollars to donuts that AVF pt aspirates before that healthy cerclage pt does every time.

 

[Planktonmd]

OK Plank, hold on. In one thread you're gonna crucify Blade for advocating the use of an LMA in an otherwise healthy, fasted parturient at 18wks but now your gonna recommend one in an ESRD, diabetic with known gastroparesis?! Ya that's real consistent and makes a lot of sense 😕 . I'm not saying I necessarily agree with the pregnant LMA (remember pregnancy does not negatively affect gastric emptying, labor does. The decreased LES tone shouldn't be a big problem if the pt is fasted and doesn't c/o GERD), but I'll bet you dollars to donuts that AVF pt aspirates before that healthy cerclage pt does every time.

I did not say that it's clinically a bad idea to put an LMA in a pregnant woman... I said it is a legal mistake because it is not the standard of care in this country.
As for Gastroparesis unless it was a documented diagnosis in the patient's chart I wouldn't automatically consider every diabetic ESRD to have gastroparesis.
And by the way.. every patient under GA has gastroparesis and an incompetent GE sphincter.

 

[somedumbDO]

Supraclavicular.

Plus a touch versed