Chapter 11 Dialysis Access

We have a high volume of patients undergoing surgery for permanent dialysis access. They either present as inpatient consults or outpatients who undergo same-day procedures.

11.1 Common issues

  1. Access maturation – We often need to address the acute need for dialysis with temporary catheters until access matures. The earliest most surgical access can be used is 4-6wks post-operatively, but depends on maturation particularly for autogenous fistulas.
  2. Bleeding – Access ulcerations or bleeding after access in HD can be vascular emergencies. Acute bleeding can often be controlled with a permanent figure of 8 stitch and a pressure dressing. Depending on the extent of ulceration or severity of bleeding, then the patient should either be taken emergently to the OR for ligation/revision or evaluated for central stenosis via ultrasound.
  3. Thrombosis – these are often managed by medical teams and IR, but sometimes we are called to assist if it is relatively fresh access that we created.
  4. Steal syndrome – presents as acute or chronic limb ischemia, often associated with worsening pain, motor or sensory deficits.

11.2 Perioperative Pathway

11.2.1 Pre-op

  • Diet: NPO at midnight the night before the planned procedure
  • Radiology: Bilateral upper extremity venous mapping
  • Nursing:
    • Limb alert on the non-dominant upper extremity, remove all IVs

11.2.2 POD 0

  • Level of care: Back to primary team or discharge to home
  • Diet: Renal diet
  • Activity: No heavy lifting in operated extremity
  • Nursing: Neurovascular checks until discharge from PACU
  • Wound care: All dressings should be removed, and dressing wound with dry gauze per patient preference

11.2.3 POD 1

  • Wound care: All dressings should be removed, and dressing wound with dry gauze per patient preference