Ismail Jainulabedin Namazi 1 , Arati Bhaskar Jadhav 2 , Sheetal Kamalakar Desai 3 , Kishore Kumar Nanjareddy 4 , Madhurima Sinharay
PRESENTATION OF CASE A 52-year-old male presented to the Orthopaedics OPD with history of fall on an outstretched arm. He complained of pain, swelling and deformity of left arm. CLINICAL DIAGNOSIS A 52-year-old male patient weighing 52kgs presented to the preanaesthetic clinic with fracture of proximal humerus posted for ORIF surgery. He was hypertensive since 2 years on Tab. Nicardia 10mg b.i.d. He did not have any other comorbidities such as diabetes, ischaemic heart disease (IHD) and asthma. On examination, he was conscious and oriented with pain, swelling and deformity of left proximal humerus. Preoperative blood investigations revealed a normal haemogram (Hb10.9mg/dL, TLC7, 600cells/mm3 , platelet count 3,32,000 cells/mm3 ) RBS 121.3mg/dL, blood urea 55.6mg/dL, serum creatinine 4.9mg/dL with urine protein 2+, ECG and chest x-ray were unremarkable. Coagulation profile and serum electrolytes were within normal limits. Further workup with ultrasound revealed bilateral renal parenchymal disease with grade 4 arteriosclerosis. He was in stage 5 CKD with eGFR of 13mL/min./1.73m2 . Cervicalspine x-ray was done to rule out any anatomical abnormalities. He was posted electively for proximal humerus fracture plating with PHILOS. PATHOLOGICAL DISCUSSION Proximal humerus fracture surgery is routinely performed under general anaesthesia or brachial plexus block by interscalene approach, but patients with compromised renal function are at increased risk of morbidity and mortality. We report successful perioperative management of a 52-year-old male patient with proximal humerus fracture with compromised renal function under cervical epidural anaesthesia. Chronic Kidney Disease (CKD) is defined as either kidney damage or GFR 3months. There is progressive loss in kidney function over a period of months or years. It is a multisystem dysfunction in which the pathophysiological effects exerts a considerable influence on the pharmacokinetics of anaesthetic agents and hence the response to anaesthesia. CKD presents as a unique challenge to the anaesthetist as it comes with its sequelae such as cardiac arrhythmias, acid-base disorders, anaemia, uraemia, renal osteodystrophy and also the underlying disease state that caused it. Drugs and metabolites normally excreted by the kidney can accumulate to toxic levels due to impaired glomerular filtration and renal tubular function leading to delayed recovery, elective ventilation in ICU and prolonged hospital stay. Proximal humerus surgeries are conventionally performed under GA or brachial plexus block with interscalene approach or a combination of both. Interscalene brachial plexus block is associated with a high failure rate of 20-30%, which again requires supplementation with GA. Complications like PONV1and CNS toxicity seizures (1.4%), both have increased incidence in CKD. 2 Pneumothorax and accidental injection into vertebral artery, subarachnoid or epidural space3 are other possible complications. CEA is effective in sensory blockade of superficial C1-C4 and brachial plexus. It can be administered in surgeries of neck, upper arm and chest.4 Our patient was grade 5 CKD, so considering drawbacks of interscalene block and GA, we opted for cervical epidural anaesthesia, which is a routinely performed technique in our institute for thyroid and breast surgeries in ASA grade 3 and 4 patients. In epidural anaesthesia, commonly higher concentrations (bupivacaine0.5% or lignocaine 2%) and higher volumes (up to 20-25mL) are used, but for CEAdiluted concentrations (bupivacaine0.25% or lignocaine 1%) and lower volumes are preferable, which benefitted us in this patient to prevent local anaesthetic-related drug toxicity and also motor blockade, which is a undesired effect of CEA, which may lead to respiratory muscle paresis requiring assisted ventilation.5,6,
