Hybrid Airway Management in an Elderly Patient with Chronic Kidney Disease on Maintenance Haemodialysis undergoing Lower Limb Orthopaedic Surgery: A Case Report

Chronic Kidney Disease (CKD) is defined as kidney damage leading to a decline in Glomerular Filtration Rate (GFR) for three or more months. CKD affects multiple organ systems and poses significant perioperative risks due to impaired sodium and water excretion, fluid overload, pulmonary complications, cardiovascular dysfunction, electrolyte imbalance, and neurological manifestations. Perioperatively, patients with CKD exhibit increased incidences of hypotension, arrhythmias, pulmonary oedema, sepsis, and need for vasopressors or mechanical ventilation, resulting in markedly elevated morbidity and Intensive Care Unit (ICU) mortality compared to non CKD individuals. This case report describes a 69-year-old hypertensive male with End-Stage Renal Disease (ESRD) on haemodialysis, who presented with a right femoral neck fracture for hemiarthroplasty. His medical history included hypertension, CKD stage V, prior bladder carcinoma treated with intravesical Bacillus Calmette-Guérin, and recent deranged renal function requiring intensive dialysis. Preoperative evaluation revealed American Society of Anaesthesiologists-Physical Status (ASA-PS) class IV, Mallampati grade III with restricted neck movement and oral fibrosis, anaemia, electrolyte imbalance, and preserved left ventricular systolic function with diastolic dysfunction. General anaesthesia was induced with thiopentone, fentanyl, and midazolam. Initial airway management using a Guedel’s airway was ineffective; oxygenation was subsequently secured with a second-generation supraglottic device, followed by successful intubation using a McCoy laryngoscope after administration of rocuronium. The patient was extubated on postoperative day 2 in critical care unit and later shifted to the ward after receiving 2 units of blood transfusion and 2 cycles of haemodialysis. This case highlights the anaesthetic challenges in ESRD patients with difficult airways and multiple co-morbidities, emphasising the need for careful planning and multidisciplinary management.