Fistula Complications
| Complication | Note |
|---|---|
| Thrombosis / failure to mature | Early — hypotension, low flow, technical; the block-induced vasodilation & good perfusion help prevent it |
| Steal syndrome | Blood diverted through the fistula → distal limb ischaemia (pain, coolness, pallor); may need banding/revision |
| High-output cardiac failure | A large, high-flow fistula adds to cardiac work — a later concern, especially with pre-existing LV dysfunction |
| Aneurysm / infection / bleeding | Uraemic platelet dysfunction & heparin → haematoma; long-term aneurysm & access infection |
Common Mistakes & Exam Pearls
Mistake 1
Putting a BP cuff or IV cannula on the fistula/access arm — can thrombose the access.
Mistake 2
Suxamethonium in a hyperkalaemic patient, or morphine/pethidine with accumulating metabolites.
Mistake 3
Allowing hypotension → new fistula thrombosis; or dialysing immediately before (residual heparin, hypovolaemia).
Pearl: a brachial plexus block is anaesthetic + analgesic + sympathectomy (vasodilation → better flow & maturation) — the near-ideal technique.
Pearl: the safest relaxant in renal failure is atracurium/cisatracurium (Hofmann elimination, organ-independent).
Pearl: dialyse ~24 h before — correcting K⁺, volume & acidosis — and re-check K⁺ before theatre.
References
- Stoelting's Anesthesia and Co-Existing Disease — Renal disease / chronic kidney disease.
- Miller's Anesthesia — Anesthesia and the renal patient; Peripheral nerve blocks of the upper limb.
- Morgan & Mikhail's Clinical Anesthesiology — Anesthesia for Patients with Renal Disease.
- Regional anaesthesia for vascular access surgery — narrative reviews on block-induced vasodilation & fistula outcomes.