Tourniquet application during ipsilateral shoulder surgery in a hemodialysis patient - A case report of proximal tourniquet technique (proximal tourniquet technique in a hemodialysis patient during shoulder surgery)

INTRODUCTION AND IMPORTANCE: Surgical management of fractures in hemodialysis patients presents challenges due to altered bone metabolism, bleeding tendencies, and vascular access issues. The presence of an arteriovenous fistula (AVF) further complicates hemostasis, especially in upper extremity surgeries with extensive soft tissue dissection. CASE PRESENTATION: We report a 57-year-old female with end-stage renal disease (ESRD) on hemodialysis via a left AVF, who sustained a left shoulder dislocation with greater tuberosity fracture. During surgery, excessive bleeding obscured visualization. A proximal Esmarch tourniquet was applied above the AVF, reducing venous return and improving the operative field. The band was maintained for 60 min, with AVF patency confirmed before and after release. The patient recovered uneventfully, showing gradual functional improvement and radiographic union at five months. CLINICAL DISCUSSION: Hemodialysis patients face unique hemostatic issues from uremic platelet dysfunction, anticoagulant use, and venous hypertension. Conventional strategies include meticulous electrocautery, topical agents, anticoagulation adjustment, and scheduling after dialysis. In this case, the proximal tourniquet provided effective hemostasis and surgical visibility without compromising AVF function, consistent with vascular access preservation. Risks such as thrombosis, ischemia, or AVF dysfunction should be considered, with close intraoperative monitoring. CONCLUSION: Proximal tourniquet application may serve as a selective adjunct to control bleeding in carefully chosen hemodialysis patients with an ipsilateral AVF. This technique improved hemostasis and preserved AVF function, but further studies are required to confirm broader safety and applicability.