**3. Intraoperative anesthesia management**

#### **3.1 Monitoring**

Standard monitoring recommended by the American Society of Anesthesiologists, such as two leads ECG, every 3 to 5 minutes measurement of noninvasive blood pressure and pulse oximetry is mandatory for intraoperative monitoring, especially if either LA or RA is primary anesthesia. If GA is an initial plan or required in the middle of the case for several reasons, close monitoring of BP (Blood Pressure) by invasive arterial line may be required due to cardiopulmonary comorbidities.

As to fluid administration, potassium-free crystalloids such as normal saline must be the first choice to reduce the possibility of intraoperative increases in potassium. It should be noted that potassium may increase so suddenly in the middle of the case even if preoperative potassium is at an acceptable level and/or the patient has a full HD one day before the surgery.

The surgery for HD access is not a major surgery and it barely loses blood. However, if the patient is anemic and vital signs become very unstable, especially in the case of GA, blood transfusion should be considered.
