Careful Physical Examination Saves Unnecessary Duplex Ultrasonogram in Patients Who Need Vascular Access for Hemodialysis in Korea / 대한혈관외과학회지

PURPOSE: About 30% of the cause of admission of the patient with end-stage renal disease is reported to be related with complications of vascular access (VA). To achieve good outcome after VA surgery, routine mapping of artery and vein is recommended for the patients who are planned to have vascular access surgery. But evidence supporting routine application of ultrasonogram (USG) is scarce and the situation in Korea is different from western countries where most of the guidelines are produced. We compared the results of the vascular access surgery after physical examination only with those after selective examination with USG. METHODS: Two hundred and forty eight consecutive patients who received VA surgery in Dongsan Medical Center from Jun 2010 to May 2011 were included. Clinical data were retrospectively analyzed and the immediate postoperative failure and early suitability of hemodialysis were compared. RESULTS: One hundred eight patients (group 1) received VA without USG, 140 after USG study. Overall 13 failures were developed. There was no difference between the two groups in terms of early failure (5.6% vs. 5.0%). CONCLUSION: Selective application of duplex sonographic evaluation of vascular status in the patients who need vascular access surgery in Korea is a reasonable policy to save the limited health financial source with acceptable results.

Cervical Epidural Anesthesia for Arteriovenous Bridge Graft at Upper Arm in Chronic Renal Failure Patients

PURPOSE: Cervical epidural analgesia is used for pain control in head and neck or upper arm. But it is not commonly used for the purpose of pure regional anesthesia for upper arm surgery. Therefore, we investigated the usefulness of cervical epidural anesthesia (CEA) as a method of regional anesthesia for arteriovenous bridge graft (AVBG) for hemodialysis at upper arm and evaluated the effects of CEA on hemodynamics and respiration. METHODS: One hundred-fifty chronic renal failure patients scheduled for AVBG were randomly assigned. In the sitting position, an epidural catheter was inserted at C6-7 or C7-T1 and 15 ml of 0.375% ropivacaine with fentanyl 20microg was injected. Analgesic level, blood pressure and heart rate were measured at 5-minute intervals after injection of the drug. Arterial blood sampling was taken for aBGA before and twenty minutes after CEA. RESULTS: Average anesthetic dermatomalsensory levels were C3.4+/-1.2~T5.7+/-2.8. During surgery, hypotension was noted in 49% of patients. It was treated with ephedrine or phenylephrine i.v. Baseline PaCO2 changed from 42.4+/-2.9 mmHg to 44.6+/-3.6 mmHg. CONCLUSION: The above results suggest that CEA is suitable for AVBG at upper arm as a regional anesthesia.