Zastosowanie jednostronnej blokady podpajęczynówkowej do totalnej alloplastyki stawu kolanowego u chorych dializowanych w przebiegu chorób reumatycznych – opis przypadków

*Renata Ćwiek¹, Paweł Małdyk², Barbara Lisowska¹, Leszek Jung², Iwona Słowińska²

Summary
Patients with juvenile rheumatoid arthritis (RA), who are frequently scheduled for various surgical and orthopaedic procedures, present a serious challenge to the anaesthetist. Among other limitations, they frequently develop chronic kidney failure and are usually allocated to the ASA category III. The cardiodepressant effect of bupivacaine is more pronounced in these patients. We describe two cases of RA patients in whom knee arthroplasty was performed under unilateral spinal anaesthesia.
Case 1. A 45-yr-old male RA patient was scheduled for a right knee arthroplasty. During the history of his illness, he had developed chronic renal failure, hypertension, and coronary artery disease, including myocardial infarction. He was being treated with transdermal fentanyl, erythropoietin and metoprolol. Enoxaparine-based haemodialysis was performed one day before surgery. Spinal anaesthesia was performed via the L₃-L₄ interspace, with the patient in the left lateral decubitus position. 3.4 ml of 0.5% bupivacaine was injected over 7 minutes, resulting in unilateral block reaching the Th₈ dermatome. The surgery was uneventful, with the patient requiring several bolus doses of ephedrine. The total volume of transfused fluids was 1500 ml over 24 hours, and he also received five units of RBC. Haemodialysis was performed on the second day after surgery and the postoperative course was uneventful.
Case 2. A 28-year-old male RA patient, treated for RA since he was one year old, was scheduled for a left knee arthroplasty. The patient was emotionally unstable, hypertensive and anaemic. Long lasting NSAiDS abuse had resulted in chronic renal failure. He was being treated with steroids, (captopril and clonidine). A standard haemodialysis was performed one day before surgery. The spinal injection of 2.4 ml of 0.5% bupivacaine over 5 minutes was performed with the patient in the right decubitus position. He stayed in this position for 10 minutes and was then turned to the supine position. Unilateral spinal block reaching the Th₁₀ dermatome provided excellent conditions for surgery and cardiovascular stability. The postoperative course was uneventful.
Discussion and conclusion. The method as described, seems be especially useful for high risk dialyzed patients, because of the cardiovascular stability, limited dose of bupivacaine and sympathetic blockade. The technique is time consuming and requires some patience from the anaesthetist.

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