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Anesthesia Considerations During Nephrolithotomy with Slush
Vol. 11:3. Printed in
THE JOURNAL OF UROLOGY
Copyright © 1975 by The Williams & Wilkins Co.
=================================::,"'"""'=" ....
"nal A
les
ANESTHESIA CONSIDERATIONS DURING NEPHROLITHOTOMY WITH SLUSH ALEXANDER A. BIRCH AND GROVER R. MIMS From the Department of Anesthesia, Bowman Gray School of Medicine of Wake Forest University and North Caroline Baptist Hospital, Winston-Salem, North Carolina
Our institution is located in a geographical area where there is a high incidence of nephrolithiasis. Modern have allowed the surto open the kidney and remove these stones. H"'""""'r, from the anesthetist's viewpoint there are several adverse conditions during these operations which may affect the outcome: 1) the patient is in a lateral and flexed position (fig. 1), 2) the legs are not wrapped with elastic bandages, 3) the operation and anesthesia time are and 4) the kidney is ischemic and surrounded frozen Ringer-Locke slush during stone removal and .A study was undertaken to gain additional insight into the
METHODS AND MATERIALS
The anesthesia records of 113 patients operated upon for staghorn nephrolithiasis between 1962 and 1973 were reviewed. Record was made of the age, sex and temperature, the anesthesia time, the time, the anesthetic agents, the muscle relaxants used, the anesthesia which side was down, if blood was if occurred and the tions as documented x-ray or examination. Also were patients in whom the blood pressure decreased to less than 80 mm. Hg the first hour of anesthesia or later and whether any deaths in the had occurred. The data were not recorded on the chart so that the following statistics were with the number of recorded observations. RESULTS
some of which were done on the same patient. There were 54 and 38 male patients, with an average age of 43 years and a range of 5 to 77 years. Of the 18 per cent were either repeat on the opposite kidney. The amount of time patients were under anesthesia and v.uuLLF,'JH'" the operation is shown in table 1. 1thot<)rny was done in 48 patients in 65. the opera(54 per cent) blood and Accepted for publication August 2, 1974. 433
the average amount received was 1,104 were no cases recorded of postoperative The types of anesthesia and the muscle used are listed in tables 2 and 3. Decreases in blood pressure anesthesia occurred in 57 patients, or approximately 50 cent. In 54 patients the blood pressure was within the first hour of anesthesia patients it decreased after 2 hours. The change in recorded temperature type of anesthesia and is shown in figure 2. Each point represents the average temperature with the number of patients recorded in brackets. Recorded tions occurred in 42 patients (37 per cent) There were no mortalities during in any of the studied. DISCUSSION
Despite prolonged anesthesia an air-conditioned packed in the wound surgical tions and with the patient in one of compromising positions, no operative mortalities occurred. However, more important were the areas of ated with this type of most of these areas were the which occurred in 37 per cent of the patients and appeared to be distributed betvveen 2 lungs without a Adding to this distribution recorded incidences of tive side. This finding agrees of and Elkins who also pneumothorax in l.00 consecutive operations.' received bl.ood More than suffered clinical. during the hepatitis. to the close screening of the and the healthy population from temperature showed a definite trend down· ward initially during this but tended tc stabilize after 2 hours. How v.;ith their temperature is unknown to us, 1 Boyce, W. H. and Eikins, I. B.. Reconstructive surgery following anatrophic followup of 100 consecutive cases. J.
434
BIRCH AND MIMS
FIG. 1. Patient positioned before left nephrolithotomy TABLE
1. Anesthesia and operation times in
nephrolithotomy patients Average (hrs.)
Range (hrs./mins.)
5.34 4.37
2/15 to 11/15 2/15 to 9/10
Anesthesia time Operation time
37
Types of anesthesia used for nephrolithotomy No. Pts.
Halothane, N,O, 0 2 Penthrane, N,O, 0 2 Ethrane, N,O, 0 2 lnnovar, fentanyl, N 2 0, 0 Total
TABLE
2
No. Pts. d-tubocurarine Succinylcholine drip Pavulon None Total
76 27
an inability to shiver and an absence of any sizable amounts of brown fat. During the first hour of anesthesia the patient was positioned and draped. The operation had just started and, therefore, blood loss was not considered a factor in accounting for the hypotension. Of the 54 patients who had an initial decrease in blood pressure 47 (87 per cent) had received d-tubocurarine. The d-tubocurarine does release histamine and has a mild ganglion blocking ability that may have contributed to the decrease in blood pressure, since we noticed that only 1 of 8 patients (12 per cent) who had received pancuronium had a decrease in blood pressure to the same degree. In addition to the d-tubocurarine all patients were put in a position in which the legs were dependent
(35)
34
PRE.
OP
2
3
4
5
Time (Hrs)
FIG. 2. Average temperatures recorded during nephrolithotomy with ice slush. Numbers in brackets indicate number of patients when temperatures were recorded.
TABLE
4. Recorded pulmonary complications
8
2 113
(49)
35
33 7 1 72 113
3. Muscle re/,axants used during nephrolithotomy
(50)
Temp.
c• TABLE 2.
(48)
Esophagea I 3 6
No. Pts. Atelectasis Pneumothorax Pulmonary embolism Aspiration pneumonia Total
30 4
2 1
37
and this may have contributed to additional hypotension. What is needed to resolve some of these questions is a well controlled prospective study. Thus, more accurate preoperative, intraoperative and postoperative temperatures should be recorded, and closer observation of pulmonary status which would include preoperative and postoperative chest x-rays should be undertaken. Perhaps heated humidifiers could be used to reduce heat loss by these patients during the operation. It is also possible that intense pulmonary ther-
ANESTHESIA CONSIDERATIONS DURING NEPHROLITHOTOMY
apy postoperatively would decrease the incidence of pulmonary complications, and also perhaps shorten the hospital stay. (The average hospital stay in the study by Boyce and Elkins was 10. 7 days. 1 ) SUMMARY
A retrospective study was made of 113 patients who underwent nephrolithotomy between 1962 and
435
1973. Multiple parameters from a surgical and anesthesia viewpoint were tabulated. The main findings were a high incidence of pulmonary complications (37 per cent), a general lowering of body temperature during anesthesia and operation and initial decreases in blood pressure, apparently related to the use of d-tubocurarine. Currently, prospective studies are underway to more clearly delineate these problems and perhaps find ways to eliminate them.
THE JOURNAL OF UROLOGY
Copyright © 1975 by The Williams & Wilkins Co.
=================================::,"'"""'=" ....
"nal A
les
ANESTHESIA CONSIDERATIONS DURING NEPHROLITHOTOMY WITH SLUSH ALEXANDER A. BIRCH AND GROVER R. MIMS From the Department of Anesthesia, Bowman Gray School of Medicine of Wake Forest University and North Caroline Baptist Hospital, Winston-Salem, North Carolina
Our institution is located in a geographical area where there is a high incidence of nephrolithiasis. Modern have allowed the surto open the kidney and remove these stones. H"'""""'r, from the anesthetist's viewpoint there are several adverse conditions during these operations which may affect the outcome: 1) the patient is in a lateral and flexed position (fig. 1), 2) the legs are not wrapped with elastic bandages, 3) the operation and anesthesia time are and 4) the kidney is ischemic and surrounded frozen Ringer-Locke slush during stone removal and .A study was undertaken to gain additional insight into the
METHODS AND MATERIALS
The anesthesia records of 113 patients operated upon for staghorn nephrolithiasis between 1962 and 1973 were reviewed. Record was made of the age, sex and temperature, the anesthesia time, the time, the anesthetic agents, the muscle relaxants used, the anesthesia which side was down, if blood was if occurred and the tions as documented x-ray or examination. Also were patients in whom the blood pressure decreased to less than 80 mm. Hg the first hour of anesthesia or later and whether any deaths in the had occurred. The data were not recorded on the chart so that the following statistics were with the number of recorded observations. RESULTS
some of which were done on the same patient. There were 54 and 38 male patients, with an average age of 43 years and a range of 5 to 77 years. Of the 18 per cent were either repeat on the opposite kidney. The amount of time patients were under anesthesia and v.uuLLF,'JH'" the operation is shown in table 1. 1thot<)rny was done in 48 patients in 65. the opera(54 per cent) blood and Accepted for publication August 2, 1974. 433
the average amount received was 1,104 were no cases recorded of postoperative The types of anesthesia and the muscle used are listed in tables 2 and 3. Decreases in blood pressure anesthesia occurred in 57 patients, or approximately 50 cent. In 54 patients the blood pressure was within the first hour of anesthesia patients it decreased after 2 hours. The change in recorded temperature type of anesthesia and is shown in figure 2. Each point represents the average temperature with the number of patients recorded in brackets. Recorded tions occurred in 42 patients (37 per cent) There were no mortalities during in any of the studied. DISCUSSION
Despite prolonged anesthesia an air-conditioned packed in the wound surgical tions and with the patient in one of compromising positions, no operative mortalities occurred. However, more important were the areas of ated with this type of most of these areas were the which occurred in 37 per cent of the patients and appeared to be distributed betvveen 2 lungs without a Adding to this distribution recorded incidences of tive side. This finding agrees of and Elkins who also pneumothorax in l.00 consecutive operations.' received bl.ood More than suffered clinical. during the hepatitis. to the close screening of the and the healthy population from temperature showed a definite trend down· ward initially during this but tended tc stabilize after 2 hours. How v.;ith their temperature is unknown to us, 1 Boyce, W. H. and Eikins, I. B.. Reconstructive surgery following anatrophic followup of 100 consecutive cases. J.
434
BIRCH AND MIMS
FIG. 1. Patient positioned before left nephrolithotomy TABLE
1. Anesthesia and operation times in
nephrolithotomy patients Average (hrs.)
Range (hrs./mins.)
5.34 4.37
2/15 to 11/15 2/15 to 9/10
Anesthesia time Operation time
37
Types of anesthesia used for nephrolithotomy No. Pts.
Halothane, N,O, 0 2 Penthrane, N,O, 0 2 Ethrane, N,O, 0 2 lnnovar, fentanyl, N 2 0, 0 Total
TABLE
2
No. Pts. d-tubocurarine Succinylcholine drip Pavulon None Total
76 27
an inability to shiver and an absence of any sizable amounts of brown fat. During the first hour of anesthesia the patient was positioned and draped. The operation had just started and, therefore, blood loss was not considered a factor in accounting for the hypotension. Of the 54 patients who had an initial decrease in blood pressure 47 (87 per cent) had received d-tubocurarine. The d-tubocurarine does release histamine and has a mild ganglion blocking ability that may have contributed to the decrease in blood pressure, since we noticed that only 1 of 8 patients (12 per cent) who had received pancuronium had a decrease in blood pressure to the same degree. In addition to the d-tubocurarine all patients were put in a position in which the legs were dependent
(35)
34
PRE.
OP
2
3
4
5
Time (Hrs)
FIG. 2. Average temperatures recorded during nephrolithotomy with ice slush. Numbers in brackets indicate number of patients when temperatures were recorded.
TABLE
4. Recorded pulmonary complications
8
2 113
(49)
35
33 7 1 72 113
3. Muscle re/,axants used during nephrolithotomy
(50)
Temp.
c• TABLE 2.
(48)
Esophagea I 3 6
No. Pts. Atelectasis Pneumothorax Pulmonary embolism Aspiration pneumonia Total
30 4
2 1
37
and this may have contributed to additional hypotension. What is needed to resolve some of these questions is a well controlled prospective study. Thus, more accurate preoperative, intraoperative and postoperative temperatures should be recorded, and closer observation of pulmonary status which would include preoperative and postoperative chest x-rays should be undertaken. Perhaps heated humidifiers could be used to reduce heat loss by these patients during the operation. It is also possible that intense pulmonary ther-
ANESTHESIA CONSIDERATIONS DURING NEPHROLITHOTOMY
apy postoperatively would decrease the incidence of pulmonary complications, and also perhaps shorten the hospital stay. (The average hospital stay in the study by Boyce and Elkins was 10. 7 days. 1 ) SUMMARY
A retrospective study was made of 113 patients who underwent nephrolithotomy between 1962 and
435
1973. Multiple parameters from a surgical and anesthesia viewpoint were tabulated. The main findings were a high incidence of pulmonary complications (37 per cent), a general lowering of body temperature during anesthesia and operation and initial decreases in blood pressure, apparently related to the use of d-tubocurarine. Currently, prospective studies are underway to more clearly delineate these problems and perhaps find ways to eliminate them.