Son Andrew, Mannoia Kristyn, Herrera Anthony, Chizari Mohammad, Hagdoost Muhammad, Molkara Afshin
Division of Vascular and Endovascular Surgery, Riverside Department of Surgery, University of California, Riverside County Regional Medical Center, Moreno Valley, CA.
Division of Vascular and Endovascular Surgery, Riverside Department of Surgery, University of California, Riverside County Regional Medical Center, Moreno Valley, CA.
Ann Vasc Surg. 2016 May;33:116-9. doi: 10.1016/j.avsg.2015.12.005. Epub 2016 Mar 8.
Creation of an arteriovenous fistula (AVF) is the preferred method of establishing long-term dialysis access. There are multiple anesthetic techniques used for patients undergoing this surgery including general endotracheal intubation, laryngeal mask airway, regional anesthesia with nerve blocks, and monitored anesthesia care with local infiltration. It is unclear what effect the method of anesthesia has on AVF creation success rate. It is our objective to determine if anesthesia type affects success of these surgeries defined by complication and maturation rates.
A retrospective review was performed in a single institution, single surgeon study of 253 patients who underwent AVF creation between January 2003 and December 2010. Patients were cross analyzed between 3 anesthesia types (General Endotracheal Intubation, Laryngeal Mask Airway and Local Infiltration with Monitored Anesthesia Care) and AVF creation surgeries (radiocephalic, brachiocephalic, and basilic vein transposition). No patients had regional anesthesia performed. Demographic data including comorbidities and risk factors were stratified among all categories. Analysis of variance, chi-squared testing, and Fisher's exact P testing was performed across all anesthesia types and specific operations and measured according to success of fistula maturation and complication rates (including death within 30 days, myocardial infarction within 30 days, respiratory insufficiency, venous hypertension, wound infections, neuropathy, and vascular steal syndrome).
There were no significant differences in maturation rate in terms of all 3 anesthesia types for radiocephalic (P = 0.191), brachiocephalic (P = 0.191), and basilic vein transposition surgeries (P = 0.305). In addition, there were no differences in complication rates between the surgeries and the 3 types of anesthesia (P = 0.557).
Our study shows that despite anesthesia type, outcomes in terms of maturation and complication rate are not statistically different in AVF creation surgeries. The use of monitored anesthesia care with local anesthesia may improve operative efficiency in terms of time in the operating room and in the recovery unit and therefore may be the preferred method of anesthesia. This recommendation may also parallel the preference to avoid general anesthesia in a patient population with more medical comorbidities. It is our conclusion that dialysis access surgery should therefore be performed under local anesthesia with monitored anesthesia care.
动静脉内瘘（AVF）的建立是实现长期透析通路的首选方法。针对接受该手术的患者，有多种麻醉技术可供使用，包括全身气管插管、喉罩气道通气、神经阻滞区域麻醉以及局部浸润监护麻醉。目前尚不清楚麻醉方法对AVF建立成功率有何影响。我们的目的是确定麻醉类型是否会影响这些手术的成功率，手术成功的定义为并发症发生率和内瘘成熟率。
在一家机构开展了一项回顾性研究，该研究由同一位外科医生对253例在2003年1月至2010年12月期间接受AVF建立手术的患者进行研究。对3种麻醉类型（全身气管插管、喉罩气道通气和局部浸润监护麻醉）与AVF建立手术（桡动脉-头静脉内瘘、肱动脉-头静脉内瘘和贵要静脉转位）进行交叉分析。没有患者接受区域麻醉。所有类别中均对包括合并症和危险因素在内的人口统计学数据进行了分层。对所有麻醉类型和具体手术进行方差分析、卡方检验和Fisher精确P检验，并根据内瘘成熟成功率和并发症发生率（包括30天内死亡、30天内心肌梗死、呼吸功能不全、静脉高压、伤口感染神经病变和血管窃血综合征）进行测量。
对于桡动脉-头静脉内瘘手术（P = 0.191）、肱动脉-头静脉内瘘手术（P = 0.191）和贵要静脉转位手术（P = 0.305），所有3种麻醉类型在内瘘成熟率方面均无显著差异。此外，手术与3种麻醉类型之间的并发症发生率也无差异（P = 0.557）。
我们的研究表明，尽管麻醉类型不同，但在AVF建立手术中，内瘘成熟和并发症发生率方面的结果并无统计学差异。使用局部麻醉监护麻醉可能会提高手术室和恢复室的手术效率，因此可能是首选的麻醉方法。这一建议也可能符合在合并症较多的患者群体中避免全身麻醉的偏好。我们的结论是，透析通路手术因此应在局部麻醉监护麻醉下进行。
