AV Fistula

PSH AVF Pathway Information

Proposed protocol for upper extremity AV Fistula perioperative surgical home pathway

No carbs loading, non-opioid adjuvants (like magnesium, ketamine), or pre-op PO analgesics in this pathway.

No modification to the NPO routine is necessary (no Breeze/DiabetiShield)

AVF in the lower extremities are excluded

AVF in combination with other invasive procedures are also excluded:

- peritoneal catheters

- tunneled catheters (TDC)

1. Presence of an H&P from the referring MD (or a PCP/internal medicine) (-which does not seem to be an issue per our PAU team anyway)

2. Documentation of dialysis frequency

3. Communication with APS so that they will be doing an upper extremity block that is appropriate for the surgical location

4. Conscious sedation (as opposed to GA) in patients with a successful block

As you see, most of the work is handled at the front end (i.e. PAU) where identified patients will be added on the PSH calendar, along with e-mail communication to the block team and anesthesia team. We will also make sure that a BMP order is in place for DOS.

From the surgeons perspective the regional block makes their targets larger and the surgery easier, so the pain team doesn’t have to clear it with the surgeon, unless there is a contraindication, all 3 surgeons request that their AVF have regional anesthesia.

Even with the blocks only 38% of our cases are done under sedation, although is unclear from the review why those patients went to sleep, we suggest that we should use the regional block as the main anesthetic. Unless of course is unsafe or unpractical as judged by the attending on the case.

Eventually we will review some endpoints like length of PACU stay, use of narcotics and versed, and maybe even total cost of the surgical event.

n=37 cases reviewed

Deleted concomitant peritoneal dialysis placement, tunneled catheter and emergencies.

Primary anesthetic:

GETA: 10 (27%)

LMA: 13 (35%)

MAC: 14 (38%)

- Precedex: 1 (7%)

- Propofol: 10 (71%)

- Versed: 3 (21%)

Block:

Supraclavicular: 21 (57%)

Supraclavicular + PECS2: 4 (11%)

Interscalene: 1 (3%)

No block performed: 11 (30%)

Versed use:

No use: 15

Yes use: 22

- 1mg: 3 (14%)

- 2mg: 18 (82%)

- 5mg: 1 (5%)

Fentanyl use:

No use: 4

Yes use: 33

- 25mg: 1 (3%)

- 50mg: 10 (30%)

- 75mg: 1 (3%)

- 100mg: 12 (36%)

- >100mg: 9 (27%)

One patient received 450mg

______________________________

German F. Barbosa-Hernandez MD

Assistant Professor of Anesthesiology

Oklahoma University Health Science Center

Oklahoma City, OK

Forearm AV graft removal—is a PSH

UE 2^nd stage basilic vein transposition—is a PSH per Dr. Barbosa (updated 7/2017)

Dr. Hawxby

Dr. Crepps—added per Dr. Ozcan (01/02/18)

Dr. Beteck—added per Dr. Ozcan (10/2018)