Jerome O’Hara

Correlation Between Loss of Renal Function and Loss of Renal Volume After Partial Nephrectomy for Tumor in a Solitary Kidney

PURPOSE We assessed the correlation between reduced renal function and parenchymal volume following partial nephrectomy. MATERIALS AND METHODS In 21 of 42 patients with tumors in a solitary kidney who were enrolled in a study measuring function before and after surgery underwent computerized tomography, and measurement of the glomerular filtration rate and estimated glomerular filtration rate (the latter at baseline and 2 to 6 months) before and after surgery. A segmentation algorithm was used to measure renal parenchymal volume. The percent of renal parenchymal volume loss was correlated with the percent loss in glomerular filtration rate using the Pearson correlation coefficient. RESULTS Mean +/- SD net preoperative volume was 284 +/- 67 cc (range 179 to 413) and mean net postoperative volume was 240 +/- 61 cc (range 119 to 346) with an absolute functional volume loss of between 5 and 160 cc. The average percent of parenchymal volume loss was 15% (range -2% to 47%). The mean loss of the measured glomerular filtration rate 3 days postoperatively was 33.9% (range -70.7% to 74.4%) and the estimated glomerular filtration rate 2 to 6 months postoperatively was 19.7 % (-6.0% to 45.5%). There was a low degree of correlation between the percent volume loss and the percent measured glomerular filtration rate loss at 3 days (r = 0.28, p = 0.22). However, there was a moderate degree of correlation between the percent volume loss and the percent estimated glomerular filtration rate loss at 2 to 6 months (r = 0.48, p = 0.03). CONCLUSIONS In patients with partial nephrectomy the renal parenchymal volume loss correlates best with the renal function loss several months after surgery. Estimates of volume loss may be useful for predicting postoperative renal function when planning partial nephrectomy in patients with a solitary kidney.

Diaspirin-crosslinked hemoglobin reduces blood transfusion in noncardiac surgery: a multicenter, randomized, controlled, double-blinded trial.

In this randomized, prospective, double-blinded clinical trial, we sought to investigate whether diaspirin-crosslinked hemoglobin (DCLHb) can reduce the perioperative use of allogeneic blood transfusion. One-hundred-eighty-one elective surgical patients were enrolled at 19 clinical sites from 1996 to 1998. Selection criteria included anticipated transfusion of 2–4 blood units, aortic repair, and major joint or abdomino-pelvic surgery. Once a decision to transfuse had been made, patients received initially up to 3 250-mL infusions of 10% DCLHb (n = 92) or 3 U of packed red blood cells (PRBCs) (n = 89). DCLHb was infused during a 36-h perioperative window. On the day of surgery, 58 of 92 (64%; confidence interval [CI], 54%–74%) DCLHb-treated patients received no allogeneic PRBC transfusions. On Day 1, this number was 44 of 92 (48%; CI, 37%–58%) and decreased further until Day 7, when it was 21 of 92 (23%; CI, 15%–33%). During the 7-day period, 2 (1–4) units of PRBC per patient were used in the DCLHb group compared with 3 (2–4) units in the control patients (P = 0.002; medians and 25th and 75th percentiles). Mortality (4% and 3%, respectively) and incidence of suffering at least one serious adverse event (21% and 15%, respectively) were similar in DCLHb and PRBC groups. The incidence of jaundice, urinary side effects, and pancreatitis were more frequent in DCLHb patients. The study was terminated early because of safety concerns. Whereas the side-effect profile of modified hemoglobin solutions needs to be improved, our data show that hemoglobin solutions can be effective at reducing exposure to allogeneic blood for elective surgery.

Heart Rate Variability and the Prone Position under General versus Spinal Anesthesia

Abstract Study Objective: To evaluate heart rate (HR) variability in the prone position with power spectral heart rate (PSHR) analysis during spinal and general anesthesia. Design: Prospective, clinical evaluation of HR variability in the prone position. Setting: Tertiary care teaching hospital. Patients: 20 healthy, ASA physical status I and II patients scheduled for elective lumbar spine surgery in the prone position. Interventions: Anesthetic technique was either a standard general anesthetic or spinal anesthetic, based on the preference of the patient. Power spectral heart rate, HR, and blood pressure (BP) readings were determined prior to anesthetic intervention and as soon as a stable PSHR reading was available in the prone position. Measurements and Main Results: Heart rate and BP were recorded at baseline prior to anesthesia and at the time of stable PSHR data in the prone position. Power spectral heart rate data included low-frequency activity (LFa), high-frequency activity (HFa), and the ratio (LFa/HFa). Spinal anesthesia level was recorded by thoracic dermatome at complete onset. Data were collected from 20 patients; 12 patients chose spinal anesthesia and 8 chose general anesthesia. The prone position resulted in significant increase in HR in the spinal group and significant decrease in BP in the general anesthesia group. Low-frequency activity and LFa/HFa ratio were unchanged in the spinal anesthesia group and were significantly decreased in the general anesthesia group. Spinal level was T8.7. Conclusions: The association of less change in LFa activity and preservation of BP on assumption of the prone position in patients during low spinal anesthesia suggests better preservation of autonomic nervous system compensatory mechanisms during low spinal anesthesia than with general anesthesia.

Nephron-sparing nephrectomy for giant renal angiomyolipoma associated with lymphangioleiomyomatosis

Renal angiomyolipomas are benign tumors known to occur sporadically and in association with genetic syndromes, including tuberous sclerosis and lymphangioleiomyomatosis. Surgical removal or radiographic embolization of angiomyolipomas larger than 4 cm is usually indicated because of an increased risk of spontaneous hemorrhage. We describe successful nephron-sparing surgery for a giant angiomyolipoma and discuss relevant management issues in a patient with lymphangioleiomyomatosis who had previously undergone bilateral pulmonary transplantation.

Potassium and anaesthesia

Potassium is the principle intracellular ion, and its concentration and gradients greatly infuence the electrical activity of excitable membranes. Because anaesthesia is so intimately involved with electrically active cells, potassium concentrations in surgical patients have received considerable attention in diagnostic and therapeutic applications. With the ongoing evolution in the indications for potassium, it is important to review the role of potassium in cellular activity, in storage and regulation, in diseases that alter potassium homeostasis, and in the therapeutic implications of perioperative alterations of potassium concentration. A rational approach to abnormal potassium values and the use of potassium in the operating room is sought, based on a physiological understanding of risks and benefits.RésuméLe potassium représente l’ion intracellulaire prédominant. Sa concentration et ses gradients ont une action primordiale sur l’excitabilité électrique des membranes. Comme l’anesthésie ellemême influence cette activité cellulaire, la kaliémie du malade chirurgical attire une attention considérable par ses applications diagnostiques et thérapeutiques. En facede l’évolution constante de ses indications, il est important de réviser le rôle du potassium sur l’activité cellulaire, son storage et sa régulation dans les états où l’hémostase du potassium est altérée, et les conséquences thérapeutiques de ces variations. Une attitude rationelle en regard des concentrations anormales de potassium et son utilisation en salle d’opération est recherchée tout en tenant compte des risques et des bénéfices.

Power Spectral Heart Rate Analysis Demonstrates Decreased Activity of the Sympathetic Nervous System During Low Bupivacaine Spinal Anesthesia

STUDY OBJECTIVE To evaluate the onset of spinal anesthesia with power spectral heart rate analysis to determine the influence of the block on the autonomic nervous system. DESIGN Prospective, clinical evaluation. SETTING Tertiary-care teaching hospital. PATIENTS 27 ASA physical status I and II patients scheduled for lower extremity orthopedic surgery and free of major cardiac disease or cardiac drugs with direct influence of heart rate (HR) or blood pressure (BP). INTERVENTIONS Prior to anesthesia, a baseline power spectral heart rate reading was taken in the supine position. Spinal anesthesia was established in the sitting position with 15 mg of bupivacaine and 0.2 mg epinephrine introduced at the L3-L4 interspace with a 22-gauge Quincke needle. The patient was returned supine, and power spectral heart rate data were again collected at 5-minute intervals throughout the procedure. Level of the spinal block was checked at 5-minute intervals until 30 minutes and considered complete when two consecutive readings were unchanged. MEASUREMENTS AND MAIN RESULTS Heart rate and BP were recorded at baseline and at five-minute intervals after injection. Power spectral heart rate data included low-frequency activity (LFa), high-frequency activity (HFa), and the ratio (LFa/HFa). Spinal level achieved was recorded by thoracic dermatome at complete onset. Heart rate and BP remained within 20% of control in all cases. Complete onset of the spinal block was present by 30 minutes in all cases. The average level of spinal anesthesia was T8. Compared with baseline, LFa activity decreased, HFa activity remained unchanged, and the ratio was decreased. During endoprosthesis insertion, 9 of 14 total hip patients had a transient ten-fold increase in LFa activity, without HFa change, and a corresponding increase in the ratio. CONCLUSIONS Power spectral heart rate analysis during low thoracic bupivacaine spinal anesthesia is compatible with decreased sympathetic activity during stable hemodynamic intervals. Insertion of hip endoprosthesis resulted in a dramatic, transient increase in sympathetic activity, indicating that sympathetic activation was still possible despite the presence of surgical anesthesia from the subarachnoid block.

Safety of HES 130/0.4 not yet settled.

To the Editor In a recent paper describing the safety of modern starches, Van Der Linden et al.1 did not mention the consensus statement of the European Society of Intensive Care Medicine task force on colloid use in critically ill patients recommending against the use of 6% hydroxyethyl starch (HES) 130/0.4 in this population.2 Similarly, the authors failed to cite a 2011 Cochrane review cautioning against the routine administration of HES,3 as well as a systematic review by Gattas et al.4 concluding that “there is no convincing evidence that thirdgeneration HES 130/0.4 is safe in surgical, emergency, or intensive care patients despite publication of numerous clinical studies.” Second, the recently published 7000-patient Crystalloid versus Hydroxyethyl Starch Trial5 showed that although there was no significant difference in 90-day mortality, patients randomized to HES 130/0.4 had more renal injury and requirement for renal-replacement therapy than those receiving saline. Third, we suggest that the authors may have left a falsely reassuring impression of the effects of HES 130/0.4 on coagulation. The coagulation studies included in their study were small trials comparing different synthetic colloids with HES 130/0.4. However, it is now known that HES 130/0.4 administration results in a weaker, smaller clot,6 a fact that might explain the increased transfusion rate in HES 130/0.4 treated individuals with blunt trauma compared with those treated with normal saline.7 Finally, we would like to point out that synthetic colloids do not always decrease tissue edema.8 This may be because Starling’s original model of semipermeable capillaries subject to hydrostatic and oncotic pressure differences is now known to be an oversimplification.9 In fact, an intact glycocalyx and lymphatic system are crucial to avoid tissue edema. REFERENCES 1. Van Der Linden P, James M, Mythen M, Weiskopf RB. Safety of modern starches used during surgery. Anesth Analg 2013;116:35–48 2. Myburgh JA, Finfer S, Bellomo R, Billot L, Cass A, Gattas D, Glass P, Lipman J, Liu B, McArthur C, McGuinness S, Rajbhandari D, Taylor CB, Webb SA; CHEST Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med 2012;367:1901–11 3. Gattas DJ, Dan A, Myburgh J, Billot L, Lo S, Finfer S; CHEST Management Committee. Fluid resuscitation with 6% hydroxyethyl starch (130/0.4) in acutely ill patients: an updated systematic review and meta-analysis. Anesth Analg 2012;114:159–69 4. Gattas D, Dan A, Myburgh J, Billot L, Lo S, Finfer S. Fluid resuscitation with 6% hydroxyethyl starch (130/0.4): systematic review of effects on mortality and treatment with renal replacement therapy. Intensive Care Med 2013;39:558-68 5. Hartog CS, Kohl M, Reinhart K. A systematic review of thirdgeneration hydroxyethyl starch (HES 130/0.4) in resuscitation: safety not adequately addressed. Anesth Analg 2011;112:635–45 6. Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson G, Åneman A, Madsen KR, Møller MH, Elkjær JM, Poulsen LM, Bendtsen A, Winding R, Steensen M, Berezowicz P, Søe-Jensen P, Bestle M, Strand K, Wiis J, White JO, Thornberg KJ, Quist L, Nielsen J, Andersen LH, Holst LB, Thormar K, Kjældgaard AL, Fabritius ML, Mondrup F, Pott FC, Møller TP, Winkel P, Wetterslev J; 6S Trial Group; Scandinavian Critical Care Trials Group. Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis. N Engl J Med 2012;367:124–34 7. Brunkhorst FM, Engel C, Bloos F, Meier-Hellmann A, Ragaller M, Weiler N, Moerer O, Gruendling M, Oppert M, Grond S, Olthoff D, Jaschinski U, John S, Rossaint R, Welte T, Schaefer M, Kern P, Kuhnt E, Kiehntopf M, Hartog C, Natanson C, Loeffler M, Reinhart K; German Competence Network Sepsis (SepNet). Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008;358:125–39 8. Guidet B, Martinet O, Boulain T, Philippart F, Poussel JF, Maizel J, Forceville X, Feissel M, Hasselmann M, Heininger A, Van Aken H. Assessment of hemodynamic efficacy and safety of 6% hydroxyethylstarch 130/0.4 vs. 0.9% NaCl fluid replacement in patients with severe sepsis: The CRYSTMAS study. Crit Care 2012;16:R94 9. James MF, Michell WL, Joubert IA, Nicol AJ, Navsaria PH, Gillespie RS. Resuscitation with hydroxyethyl starch improves renal function and lactate clearance in penetrating trauma in a randomized controlled study: the FIRST trial (Fluids in Resuscitation of Severe Trauma). Br J Anaesth 2011;107:693–702 10. Feldheiser A, Pavlova V, Bonomo T, Jones A, Fotopoulou C, Sehouli J, Wernecke KD, Spies C. Balanced crystalloid compared with balanced colloid solution using a goal-directed haemodynamic algorithm. Br J Anaesth 2013;110:231–40 11. Groeneveld AB, Navickis RJ, Wilkes MM. Update on the comparative safety of colloids: a systematic review of clinical studies. Ann Surg 2011;253:470–83 12. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009;339:b2700 13. James MFM, Michell WL, Joubert IA, Nicol AJ, Navsaria PH, Gillespie RS. Reply from the authors. Br J Anaesth 2012;108:322-4 14. Natanson C, Kern SJ, Lurie P, Banks SM, Wolfe SM. Cell-free hemoglobin-based blood substitutes and risk of myocardial infarction and death: a meta-analysis. JAMA 2008;299: 2304–12 15. Olofsson CI, Górecki AZ, Dirksen R, Kofranek I, Majewski JA, Mazurkiewicz T, Jahoda D, Fagrell B, Keipert PE, Hardiman YJ, Levy H; Study 6084 Clinical Investigators. Evaluation of MP4OX for prevention of perioperative hypotension in patients undergoing primary hip arthroplasty with spinal anesthesia: a randomized, double-blind, multicenter study. Anesthesiology 2011;114:1048–63 16. Mittermayr M, Streif W, Haas T, Fries D, Velik-Salchner C, Klingler A, Oswald E, Bach C, Schnapka-Koepf M, Innerhofer P. Hemostatic changes after crystalloid or colloid fluid administration during major orthopedic surgery: the role of fibrinogen administration. Anesth Analg 2007;105:905–17, table of contents 17. Schramko AA, Suojaranta-Ylinen RT, Kuitunen AH, Kukkonen SI, Niemi TT. Rapidly degradable hydroxyethyl starch solutions impair blood coagulation after cardiac surgery: a prospective randomized trial. Anesth Analg 2009;108:30–6 18. Hartog CS, Reuter D, Loesche W, Hofmann M, Reinhart K. Influence of hydroxyethyl starch (HES) 130/0.4 on hemostasis as measured by viscoelastic device analysis: a systematic review. Intensive Care Med 2011;37:1725–37 19. Hartog CS, Skupin H, Natanson C, Sun J, Reinhart K. Systematic analysis of hydroxyethyl starch (HES) reviews: proliferation of low-quality reviews overwhelms the results of well-performed meta-analyses. Intensive Care Med 2012;38:1258–71

Ischemic Optic Neuropathy After Spinal Fusion

PURPOSE We report a case of ischaemic optic neuropathy which occurred after prolonged spine surgery in the prone position in an obese, diabetic patient. CLINICAL FEATURES The patient was a 44-yr-old, 123 kg, 183 cm man for decompressive laminectomy and instrumented fusion of the lumbar spine. Anaesthesia was induced with thiopentone, fentanyl and succinylcholine and maintained with nitrous oxide, oxygen, isoflurane and a fentanyl infusion. He was positioned prone on the Relton-Hall frame and had an uneventful intraoperative course. Estimated blood loss was 3,000 ml. He was taken to the surgical intensive care unit (SICU) and the trachea was extubated 3.5 hr later. He had no pulmonary or haemodynamic problems and went to a regular nursing floor in the morning. He was discharged home on postoperative day #5. He telephoned his surgeon on postoperative day #7 to say that his vision had been blurry since surgery. His visual acuity was decreased, and on examination, he had a bilateral papillary defect, optic swelling and a splinter haemorrhage in the right eye. Magnetic resonance imaging (MRI) scan of the head and orbits detected no other abnormality. Based on this examination, he was felt to have bilateral ischaemic optic neuropathy and treated conservatively. By postoperative day #47, his visual acuity was greatly improved and near normal. Careful review of possible contributing factors suggests that the cause of the ischaemic optic neuropathy was venous engorgement. CONCLUSION This patient developed ischaemic optic neuropathy from a prolonged interval in the prone position of the Relton-Hall frame, which may be related to venous engorgement.

Acute airway obstruction following placement of a subclavian Hickman catheter

The purpose of this case report is to describe the events, intervention, and aetiology which led to acute airway obstruction in an adult patient after the placement of a Hickman catheter. Airway obstruction secondary to superior vena cava obstruction occurred after placement of a subclavian vein Hickman catheter. This was felt to occur, in part, to a narrowed superior vena cava as evident by subclavian venography. It resulted in emergency oral tracheal intubation to relieve airway obstruction. Shortly after removal of the Hickman catheter, the signs of superior vena cava obstruction syndrome resolved and the patient was extubated without incidence. It is concluded that, although rare, the serious complication of acute airway obstruction can occur after placement of a Hickman catheter.RésuméCette observation a pour sujet la description des évènements, l’intervention et l’étiologie d’une obstruction aiguë des voies respiratoires chez un adulte après la mise en place d’un cathéter de Hickman. L’obstruction respiratoire secondaire à l’obstruction de la veine cave supérieure est survenue après la mise en place dans la veine sousclavière d’un cathéter de Hickman. La vénographie sousclavière montrait un rétrécissement de la veine cave supérieure. La trachée a été intubée en urgence pour lever l’obstruction des voies respiratoires. Peu de temps après avoir le retrait du cathéter, les signes d’obstruction de la veine cave sont disparus et le patient a été extubé sans incidents. En conclusion, une complication grave telle que l’obstruction aiguë des voies respiratoires peut survenir après la mise en place d’un cathéter de Hickman.

Anesthesia for Renal Transplantation: Donor and Recipient Care

There remains a shortage of renal allografts to satisfy an ever-increasing demand from patients with end-stage renal disease who need a kidney transplant. Renal transplant remains the preferred treatment for these patients. The anesthesia care team is directly involved in managing kidney donor patient allograft harvests and recipients in the operating room. In these cases it is always urgent to proceed to transplant as cold ischemia time increases, although the sense of urgency should not prevent needed medical evaluation of a symptomatic patient for a correctable condition. This chapter reviews end-stage renal disease etiologies and suggests plans to optimize existing comorbidities. Factors associated with outcome include three perioperative situations: donor – deceased or living; allograft ischemia time – warm or cold; and recipient management. Different classifications of renal donors, causes of renal disease, and outcome in renal transplantation are presented. A comprehensive overview of anesthetic management of both the renal donor and recipient is included.