ABSTRACT
Patients with end-stage renal disease (ESRD) who need to undergo anesthesia for dialysis access placement are therapeutic challenges by virtue of their numerous pathophysiological abnormalities (1). With the continuing growth of the ESRD population, more and more patients are requiring surgical procedures to establish or maintain dialysis access. The American Society of Anesthesiologists (ASA) Physical Status Classification of these patients is usually 3 (severe systemic disease, not incapacitating) and often 4 (severe systemic disease that is a constant threat to life), which indicates that extra care and vigilance are needed in providing anesthetic care to these patients. The anesthetic technique will vary between patients and no single approach (general vs. regional) has yet proven consistently superior over the other (2,3). Newer, shorter-acting hypnotics, muscle relaxants, and inhaled volatile agents as well as improvements in intraoperative monitoring allow for an individualized approach. Some surgeons are comfortable injecting local anesthetic into the operative site, thereby producing a field blockade, whereas others prefer a motionless field and an amnestic patient, which often requires a regional technique or a general anesthetic. Moreover, some anesthesiologists are adept at placing supraclavicular blocks for the upper extremity,
while others find that the small but significant risk of pneumothorax is prohibitive. Patients with chronic illness are sometimes quite anxious and demand to ‘‘be put to sleep,’’ subsequently refusing regional techniques. The ‘‘best’’ approach is what works safely for the patient, surgeon, and anesthesiologist.
