Ardon, Alberto E.

Objective: To evaluate the efficacy of regional anesthesia (RA) in enabling arteriovenous fistula (AVF) creation in patients with small-caliber veins who would typically receive arteriovenous grafts (AVG), and to compare access outcomes between AVF and AVG cohorts. Methods: We conducted a retrospective analysis of a prospectively maintained database from 2018 through 2024 involving patients with chronic kidney disease (CKD) requiring access creation. Eligible patients were those aged 18 years or older with inadequate veins for AVF creation based on initial ultrasound vein mapping. All patients underwent RA prior to the access creation and had a repeated intraoperative vein mapping at least 30 min after RA. Patients whose veins were sufficiently dilated and met the criteria for AVF creation underwent AVF formation; otherwise, an AVG was created. Outcomes included access maturation, patency rates, access failure, abandonment, and mortality. Statistical analysis was performed using R software, with significance set at p < 0.05. Results: Of the 106 patients, 67 (63.2%) underwent AVF creation post-RA due to sufficient vein dilation, while 39 (36.8%) received AVGs. Baseline vein diameters and comorbidities were comparable between groups. AVF maturation was achieved in 83.6% of AVF patients, with longer times to successful cannulation compared to AVG (median 187.0 vs 80.0 days, p = 0.037). Kaplan-Meier analysis revealed no difference in primary patency ( p = 0.97), but AVF patients had superior primary assisted ( p = 0.015) and secondary patency ( p = 0.033), and lower access failure rates ( p = 0.034) compared to AVG patients. Access abandonment and mortality rates did not differ significantly between groups. Conclusions: RA-induced venodilation enables the use of veins previously deemed inadequate for AVF creation, leading to improved access outcomes compared to AVG placement. Implementing RA may increase AVF utilization and enhance patient outcomes in hemodialysis access surgery.

Purpose of review To summarize recent evidence that discusses the clinical, financial, and logistical implications of a 23 h stay postsurgical stay unit in an ambulatory surgical center (ASC). Recent findings Twenty-three-hour stays in ambulatory surgery centers are safe, but proper patient selection and optimization are key to maintaining a high level of safety. The financial implications of overnight stays in ASCs rely heavily on payment structures and comparative costs at hospital-based outpatient surgery centers. The establishment of pathways and protocols for clinical care are key to the success of a 23 h stay at an ASC Summary A concurrent concern with the recent increase in outpatient surgery and medical complexity of cases performed in an ambulatory surgical center (ASC) is the possibility that patients may need overnight stay. Further, whether certain patients would benefit from anticipated 23 h observation rather than same-day discharge is an emerging topic. Overnight stays in ASCs may have financial advantages and decrease the risk of unanticipated admission with proper patient selection. The use of protocols and established pathways is key to the success of this model.

Background Anesthesia-focused short courses might be an effective and sustainable way to further the ongoing training and evidence-based practice skills of anesthesia professionals in low- and middle-income countries (LMICs). Instructional design, the process by which formalized learning theory is incorporated into education planning and delivery, is a tool that can strengthen learning in these short courses. As part of an ongoing multilateral project between the University of Minnesota (UMN) and Kabul University of Medical Sciences (KUMS), this project sought to identify the feasibility and potential educational impact of a newly designed postoperative analgesia short-course employing instructional design principles. The Afghan faculty learners’ subjective viewpoint of the short course experience was also investigated and is described in this article. Methods Afghan learners and United States based faculty met in Bangalore, India in August 2018 for this short course. During the 6-day course, learners participated in didactics and workshops discussing regional anesthesia techniques, multimodal analgesia, safety, pain assessment and management, and the influence of ethno-cultural context on pain control. Interactive games, model-based nerve block simulations, and flipped classroom approaches were educational strategies used in the course. The Afghan faculty also participated in instructional design workshops designed to strengthen their teaching skills for use with both students and faculty colleagues. Pretests, posttests, and opinion surveys were completed by the Afghan faculty learners. Results All learners completed the course with full participation. A median of 5 out of 10 technical questions were answered correctly by the learners on the pretest; this score improved to a median of 6.5 on the posttest. The number of learners who ranked their understanding of the role of regional anesthesia in their perioperative care practice as “very well” increased from 2 to 5 faculty. Likewise, the number of learners who described their understanding of postoperative pain and their ability to perform regional anesthesia as “not well at all” decreased from 2 to 0 in both categories. Further, the majority of the participants agreed that at the end of the course their ability to understand and apply instructional design concepts had improved. Conclusions The short course in postoperative pain management appeared to improve short-term knowledge among Afghan faculty participants. Afghan faculty had a favorable opinion of the course and increased confidence in their ability to use instructional design best practices. The results of this project suggest that short courses based in instructional design can be useful and effective for short-term knowledge gain in an LMIC setting such as Afghanistan.