Urine Output and Fluid Therapy During Anaesthesia and Surgery

To try to determine whether fluid therapy during surgery should be on a large or a small scale 23 patients and six control subjects were studied. The control subjects were fasted and transfused with 2 litres of Ringer-lactate solution in one hour, the volume of urine output being measured at intervals for four hours. The patients were transfused similarly under varying conditions of anaesthesia and surgery. The characteristic urine output during abdominal hysterectomy followed a low, irregular pattern, and this occurred whether or not substantial amounts of fluid were transfused. In two patients anaesthesia and minimal trauma were associated with oliguria. An established diuresis was altered by anaesthesia and inhibited by surgery. These results indicate that excess Ringer-lactate solution administered during surgery may not be excreted and that overtransfusion could easily occur.     

Hypothermia and acute renal failure in the elderly

During 1993-1998, in winter time 14 elderly patients: 8 female and 6 male aged 65-88, were treated because of hypothermia. Rectal temperature on admission was 20-34.9 degrees C. Sopor was present in 2 and various grades of coma were present in 10 patients. Arterial hypotension was recorded in 5, and shock in 9 patients. Increased serum creatinine level was found in 8 patients. The mean rectal temperature in the whole group was 31.3 degrees C +/- 4.7, ranging from 20.0 to 34.9 degrees C, and the mean serum creatinine level was 172.2 +/- 93.5, in range of 66.0 to 360.0 mumol/L. Negative correlation between those two parameters was found: r = -0.572. In 2 of them parameters of renal failure were analyzed: urine sodium concentration, creatinine urine/plasma ratio, urine osmolality, urine/plasma osmolality ratio, renal failure index and fractional excretion of filtered sodium. In one of the patients all parameters were within the range of functional oliguria, in an other the urine sodium concentration serum showed acute renal failure, but all other findings showed borderline values between functional oliguria and acute renal failure. Twelve out of 14 patients died within 1-216 hours from admission.     

Haemofiltration for profound dialysis-induced hypotension: removal of sodium and water without blood-pressure change.

Two patients with profound dialysis-induced hypotension were seen, in both of whom sequential ultrafiltration and haemodialysis failed to alleviate their symptoms; in one bicarbonate dialysis similarly produced no improvement. The hypotension was frequently severe enough to necessitate premature termination of the dialysis. Haemofiltration was associated with almost total resolution of symptoms, adequate biochemical control of uraemia, and satisfactory removal of weight gain between dialysis sessions. Profound hypotension during dialysis may become more common as older patients enter dialysis programmes; haemofiltration is a valuable technique in such cases.     

NONOBSTRUCTIVE OLIGURIA—Differential Diagnosis

A review is presented of ten years'' experience with the differential diagnosis of oliguria, utilizing the standard tests of renal function with the addition of the phenolsulfonphthalein excretion and urinary chloride measurements. The histories of 60 patients seen in consultation because of 24-hour urinary volume of less than 400 ml were studied in order to clarify the value of these tests. Particular attention was given to the postoperative “dilution state,” the oliguria of which tends to mimic that of “acute tubular necrosis.”In only 25 per cent of the 60 cases was “acute tubular necrosis” responsible for the oliguria. In the remaining 75 per cent of patients, oliguria was due either to the effects of simple dehydration without tubular damage, or to tubular dysfunction on a physiologic rather than an organic basis. Thus, three out of four patients with oliguria required aggressive and specific fluid-electrolyte therapy, often with the intensive use of potassium. One out of four required the opposite in therapy—controlled dehydration without added potassium and, on occasion, peritoneal or extracorporeal dialysis, in order to allow six to ten days for tubular repair.     

Cyclical edema in a patient with hypothalamic disorders and chronic glomerulonephritis: arginine vasopressin-dependent atrial natriuretic hormone release.

A 28-year-old woman had hypothalamic disorders (amenorrhea, obesity, psychiatric abnormalities, polydipsia and fever) and chronic glomerulonephritis. She also suffered from general edema associated with cyclical oliguria and polyuria. Her body weight and plasma osmolality increased during the oliguria phase lasting 2 to 8 days and decreased after paroxysmal polyuria accompanied by the natriuresis. These episodes occurred repeatedly, regardless of the treatment with or without diuretics. The release of arginine vasopressin in response to increased plasma osmolality was exaggerated, but changes in plasma volume did not affect arginine vasopressin release. Plasma atrial natriuretic hormone increased in response to a rise in plasma arginine vasopressin and plasma volume during the oliguria phase, thereby resulting in the diuresis and natriuresis. The renin-angiotensin-aldosterone system was secondarily activated by body fluid depletion and diuretics, and this might play an additive role in general swelling. Plasma gonadal hormones did not change to explain the edema. The mechanism of this cyclical edema remains unknown, but it is likely that hypothalamic dysfunction related to psychiatric abnormalities may exaggerate arginine vasopressin release, and enhanced renal sympathetic activity may cause retention of Na and water, and the increase in atrial natriuretic hormone release responding to the plasma volume expansion may bring about the diuresis and natriuresis.     

SPORADIC ACUTE GLOMERULONEPHRITIS IN ADULTS

Nineteen adults who had acute glomerulonephritis were reviewed with respect to the clinical course and long-term follow-up. The age range was from 17 to 55 years. Only one patient died during the acute episode. In 11 cases, onset occurred between November and January and 15 of the patients had a known respiratory tract infection three to 30 days before the onset. The most important symptoms noted were weight gain, edema, dyspnea, oliguria and red or smoky urine. The most prominent physical signs were elevated blood pressure, edema, abnormalities in the chest and fever of over 100° F. Fifteen patients showed roentgen evidence of pulmonary vascular congestion, pleural effusion, cardiomegaly, pneumonia or a combination of these abnormalities. All the patients had proteinuria and red blood cells in the urine, and half of them had red blood cell casts. Azotemia, when present, subsided in 9.4 days. The average diastolic pressure was 105 mm. of mercury and the mean fall was 26 mm. in 23.5 days. At six months, nine of the 13 patients still being observed continued to show proteinuria or microscopic hematuria (seven showed both). A late follow-up of ten patients showed one to have significant hypertension and one to have early functional impairment and inconstant proteinuria. In these cases the average blood pressure was 140/91 mm. as compared with 119/74 mm. at the time of discharge.Sporadic glomerulonephritis in adults presents essentially the same pattern as it does in children. Urinary abnormalities may persist for months or even years, and neither the present series nor those reported by others clearly reveal the ultimate prognosis.     

The choice of estrogen preparations in the treatment of prostatic cancer.

A total of 154 patients with carcinoma of the prostate received estrogen therapy with diethylstillbestrol (DES), chlorotrianisene or ethinyl estradiol. During a mean follow-up period of 26 months the incidence of complications -- thromboembolic episodes, fluid retention and gynecomastia -- was recorded. Although the incidence of cardiovascular complications was significantly higher in the DES group, the differences in mortality between the groups were not significant. The differences in incidence of fluid retention and gynecomastia also lacked significance. All three compounds produced adrenal cortical hyperplasia as indicated by the increased serum cortisol values.     

Management of uraemic pericarditis.

Of 250 patients undergoing haemodialysis from 1967 to 1974 17 presented with uraemic pericarditis. Seven of these patients who had been transferred early enough to peritoneal dialysis treatment were cured without pericardiectomy (mean survival 18 months (range 6-36); no deaths). Only one patient was cured from his pericarditis by "aggressive haemodialysis." In seven out of 10 patients treated with haemodialysis, pericardiectomy finally had to be performed because of pericardial tamponade (postoperative survival 20 months (range 8-36); one death). Two patients died from pericardial tamponade before surgery. In patients with evidence of uraemic pericarditis frequent peritoneal dialysis with high fluid withdrawal is the treatment of choice, but in cardiac tamponade pericardiectomy should follow a preoperative pericardiocentesis with limited fluid aspiration. Of possible significance in the aetiology of pericarditis were the findings that 10 of the 17 patients had hypertension with cardiac enlargement and that 14 presented with evidence of underdialysis, possibly due to the reuse of dialysis components.     

The Clinical Spectrum of Renal Insufficiency During Acute Glomerulonephritis in the Adult

Twenty-seven adults with acute poststreptococcal glomerulonephritis were divided into two groups according to the severity of reduction in renal function: (1) 14 patients with mild depression of renal function, and (2) 13 patients with more severe renal insufficiency. In the first group the outcome was favourable, with complete clinical recovery in 11 patients. Only two patients in the second group have recovered. Five have died of renal failure and in six the chronic stage has developed. The most notable histopathological lesion observed in this group of patients was severe proliferative glomerulonephritis with a large number of epithelial crescents. According to the mode of development and time of onset of renal failure, these 13 patients could be divided into three sub-groups: (1) early renal failure without oliguria (three patients), (2) early renal failure with severe oliguria or anuria (three patients) and (3) delayed renal failure (seven patients).Although there are exceptions, the development of renal insufficiency in an adult patient suffering from acute glomerulonephritis is usually associated with a guarded prognosis.     

The 131I Ortho-iodohippurate Photoscan in Human Renal Allografts

Nine examples, in seven patients, from a large cadaver renal allograft program, illustrate the value of radio-hippuran photoscans in differentiating causes of post-implant oliguria. Hippuran scans are shown to be more valuable than chlormerodrin scans when renal function is acutely depressed. Hippuran scans aided in the decision to remove kidneys in four cases of severe oliguria and to retain kidneys in two others. In two further examples, extravasation of urine was detected by scanning after radio-hippuran injection when other tests had failed to do so.The technique of radio-hippuran scanning has a place in the differentiation of acute and subacute renal dysfunction and has proved particularly valuable in the early oliguric complications of a cadaver renal transplant program.     

Disorders of urine volume in the critically ill child.

This article will provide a pathophysiologic basis for the assessment of critically ill children who have developed disorders of urine volume. The anatomical and pathophysiologic causes of oliguria and polyuria are considered. The physiologic basis for the use of urinary sodium and osmolarity as a guide to the assessment of patients with disorders of urine volume are discussed in detail. In addition, guidelines for the management of children with acute renal failure, with particular emphasis on the consideration for nutritional support of these patients, is discussed as a part of the comprehensive approach to this problem. This article emphasizes an understanding of the pathophysiology of salt and water excretion by the kidney as a foundation to the diagnosis and management of patients with oliguria and polyuria.     

应用电视胸腔镜诊治病因不明胸腔积液的疗效观察

目的:探讨电视胸腔镜(video-assisted thoracoscopic surgery VATS)在诊治病因不明胸腔积液中的应用价值.方法:回顾分析2005年4月～2011年4月196例病因不明胸腔积液经电视胸腔镜手术的临床资料.均应用电视胸腔镜进行探查,根据病变情况选择切口部位.排净胸腔积液后,分离粘连,进行胸膜活检后恶性患者行胸膜固定术.结果:196例均明确诊断:140例恶性胸腔积液,36例结核胸腔积液,20例炎性胸腔积液.胸腔镜手术178例,胸腔镜辅助胸壁小切口手术18例.手术时间30～75min,平均54 min.出血量10～120mL,平均53 mL.10例出现术后肺漏气,胸腔引流量＜50 mL/24h拔除胸腔引流管,胸管留置时间4～19天,平均9.4天.191例成功控制胸腔积液,全组无院内死亡.22例接受化疗的恶性胸腔积液患者,随访14～34个月,平均23个月,复查胸片显示无胸腔积液、积气.结论:电视胸腔镜安全、有效、微创,便于操作,可作为诊治病因不明胸腔积液的主要方法.     

Arteriovenous hemofiltration as an adjuvant therapy in peritoneal dialysis and hemodialysis in a patient with terminal renal failure]

In the uraemic patient regularly treated with peritoneal dialyses occurring peritonitis caused a decrease of ultrafiltration and transfer abilities of the peritoneum. Other symptoms dangerous for life also appeared: uraemic pericarditis and significant overhydration. Peritoneal dialyses lost its effectiveness. Therefore they were supplemented by arterio-venous haemofiltration. Haemofiltration was also conducted at the beginning of haemodialysis treatment, which was initially unregular. Application of haemofiltration enabled the patient to survive during the time of waiting for regular haemodialyses. It may be useful to consider such a treatment, when the adequacy of proper renal substitutive management of uraemia by other methods is impossible to obtain.     

Spontaneous resolution of severe chronic glue ear in children and the effect of adenoidectomy,tonsillectomy, and insertion of ventilation tubes (grommets).

OBJECTIVE--To measure the time to spontaneous resolution of severe chronic otitis media with effusion (glue ear) in children and study the effects of adenoidectomy, adenotonsillectomy, and ventilation tubes (grommets). DESIGN--Randomised controlled study over 12 years. SETTING--Paediatric otorhinolaryngology clinics and in-patient unit. SUBJECTS--228 children aged 2-9 years with pronounced hearing loss from glue ear and persistent bilateral middle ear effusions confirmed on three occasions over three months. INTERVENTIONS--Children were randomly allocated to adenotonsillectomy, adenoidectomy, or neither procedure. In all groups a Shepard type ventilation tube was inserted in one randomly chosen ear. Follow up was annually for five years and then less often for up to seven years four months. For analysis the two operated groups were combined. MAIN OUTCOME MEASURES--Otoscopic clearance of fluid, change in tympanogram, and improvement in mean audiometric hearing threshold. RESULTS--Survival analysis showed appreciable otoscopic and tympanometric resolution of fluid with ventilation tubes alone and adenoidectomy alone compared with no surgery. Further improvement was seen after combination of both treatments. Mean audiometric hearing thresholds improved with fluid resolution. Resolution was delayed in younger children and in those whose parents smoked, irrespective of treatment. Whereas a single insertion of a Shepard tube resolved the glue for a mean (SD) period of 9.5 (5.2) months, the effect of adenoidectomy was sustained throughout follow up. CONCLUSIONS--Treatment of glue ear considerably shortened the time to fluid resolution, combined adenoidectomy and tube insertion being better than either procedure alone. Resolution was longer in younger children and those whose parent(s) smoked, irrespective of treatment.     

Lyophilization of rumen fluid for use in culture media

The supernatant from centrifugation at 1,000 x g of strained rumen fluid was lyophilized, and the residue and sublimate fractions were used to replace fresh rumen fluid in a complete roll tube medium for enumeration of total rumen bacteria. Most of the growth-supporting nutrients in fresh rumen fluid were found in the residue fraction. With one exception, no significant differences were found in total bacterial numbers either by roll tube or most-probable-number procedures when lyophilized rumen fluid residue was substituted for fresh rumen fluid. Lyophilized rumen fluid residue was stable for at least 5 months at room temperature. Rumen fluid supernatant from centrifugation at 1,000 x g had a mean density of 1.005 +/- 0.03 g/ml and contained 1.56% +/- 0.30% dry matter. On the basis of these values, 15.68 mg of lyophilized rumen fluid residue is equivalent to 1 ml of rumen fluid supernatant from centrifugation at 1,000 x g.     

Lyophilization of rumen fluid for use in culture media.

The supernatant from centrifugation at 1,000 x g of strained rumen fluid was lyophilized, and the residue and sublimate fractions were used to replace fresh rumen fluid in a complete roll tube medium for enumeration of total rumen bacteria. Most of the growth-supporting nutrients in fresh rumen fluid were found in the residue fraction. With one exception, no significant differences were found in total bacterial numbers either by roll tube or most-probable-number procedures when lyophilized rumen fluid residue was substituted for fresh rumen fluid. Lyophilized rumen fluid residue was stable for at least 5 months at room temperature. Rumen fluid supernatant from centrifugation at 1,000 x g had a mean density of 1.005 +/- 0.03 g/ml and contained 1.56% +/- 0.30% dry matter. On the basis of these values, 15.68 mg of lyophilized rumen fluid residue is equivalent to 1 ml of rumen fluid supernatant from centrifugation at 1,000 x g.     

Pre-Dialysis Systolic Blood Pressure-Variability Is Independently Associated with All-Cause Mortality in Incident Haemodialysis Patients

Systolic blood pressure variability is an independent risk factor for mortality and cardiovascular events. Standard measures of blood pressure predict outcome poorly in haemodialysis patients. We investigated whether systolic blood pressure variability was associated with mortality in incident haemodialysis patients. We performed a longitudinal observational study of patients commencing haemodialysis between 2005 and 2011 in East Anglia, UK, excluding patients with cardiovascular events within 6 months of starting haemodialysis. The main exposure was variability independent of the mean (VIM) of systolic blood pressure from short-gap, pre-dialysis blood pressure readings between 3 and 6 months after commencing haemodialysis, and the outcome was all-cause mortality. Of 203 patients, 37 (18.2%) patients died during a mean follow-up of 2.0 (SD 1.3) years. The age and sex-adjusted hazard ratio (HR) for mortality was 1.09 (95% confidence interval (CI) 1.02–1.17) for a one-unit increase of VIM. This was not altered by adjustment for diabetes, prior cardiovascular disease and mean systolic blood pressure (HR 1.09, 95% CI 1.02–1.16). Patients with VIM of systolic blood pressure above the median were 2.4 (95% CI 1.17–4.74) times more likely to die during follow-up than those below the median. Results were similar for all measures of blood pressure variability and further adjustment for type of dialysis access, use of antihypertensives and absolute or variability of fluid intake did not alter these findings. Diastolic blood pressure variability showed no association with all cause mortality. Our study shows that variability of systolic blood pressure is a strong and independent predictor of all-cause mortality in incident haemodialysis patients. Further research is needed to understand the mechanism as this may form a therapeutic target or focus for management.     

Neurotensin-like immunoreactivity (NTLI) concentration in the cerebrospinal fluid of children and its alteration in a febrile aseptic meningitis

Neurotensin-like immunoreactivity (NTLI) concentrations in the cerebrospinal fluid (CSF) of normal children and patients with febrile aseptic meningitis, aged 7 months to 15 years, were studied. The NTLI concentrations in CSF of 27 children with normal CSF findings were 160.1 +/- 54.6 pg/ml (mean +/- S.D.). The NTLI concentration in CSF of 26 patients in an acute phase of aseptic meningitis was 110.6 +/- 51.1 pg/ml which was significantly (P less than 0.01) lower than the controls. These patients had a mean temperature of 101.4 +/- 1.5 degrees F which remained elevated for an average of 3.5 days. The NTLI concentrations in CSF of 23 patients in a recovery phase (after blood and CSF findings became normal with no fever) were 166.5 +/- 57.8 pg/ml, which did not differ significantly from the normal. There were no statistical correlations between the NTLI concentration in CSF and the protein concentration or total cell count in CSF. These results suggest that NTLI concentration changes during a febrile aseptic meningitis and that it may be associated with thermoregulation.     

Early rheumatoid arthritis is characterized by a distinct and transient synovial fluid cytokine profile of T cell and stromal cell origin

Pathological processes involved in the initiation of rheumatoid synovitis remain unclear. We undertook the present study to identify immune and stromal processes that are present soon after the clinical onset of rheumatoid arthritis (RA) by assessing a panel of T cell, macrophage, and stromal cell related cytokines and chemokines in the synovial fluid of patients with early synovitis. Synovial fluid was aspirated from inflamed joints of patients with inflammatory arthritis of duration 3 months or less, whose outcomes were subsequently determined by follow up. For comparison, synovial fluid was aspirated from patients with acute crystal arthritis, established RA and osteoarthritis. Rheumatoid factor activity was blocked in the synovial fluid samples, and a panel of 23 cytokines and chemokines measured using a multiplex based system. Patients with early inflammatory arthritis who subsequently developed RA had a distinct but transient synovial fluid cytokine profile. The levels of a range of T cell, macrophage and stromal cell related cytokines (e.g. IL-2, IL-4, IL-13, IL-17, IL-15, basic fibroblast growth factor and epidermal growth factor) were significantly elevated in these patients within 3 months after symptom onset, as compared with early arthritis patients who did not develop RA. In addition, this profile was no longer present in established RA. In contrast, patients with non-rheumatoid persistent synovitis exhibited elevated levels of interferon-γ at initiation. Early synovitis destined to develop into RA is thus characterized by a distinct and transient synovial fluid cytokine profile. The cytokines present in the early rheumatoid lesion suggest that this response is likely to influence the microenvironment required for persistent RA.     

Treatment of resistant ascites by continuous ultrafiltration--reinfusion of ascitic fluid.

Eight patients with diuretic-resistant ascites due to cirrhosis were treated by reinfusion of concentrated ascitic fluid. In 11 procedures, with a mean duration of 21.9 hours, weight loss averaged 14.8 kg. Complications during reinfusion included septicemia in 1 procedure, left-sided heart failure in 5, pyrexia in 7 and coagulation abnormalities in 10. Ascites recurred within 2 months after reinfusion in all but one patient. Although this technique is an efficient and inexpensive method of treatment of ascites, it does not appear indicated in patients with cirrhosis and resistant ascites in view of the possibly serious complications associated with reinfusion and the poor long-term results.