The relevance between graft preservation solutions and QTc interval during living donor kidney transplantation and rat cardiomyocytes sampling.

BACKGROUND: The purpose of the retrospective study was to identify the impacts of different solutions on the electrocardiogram and cardiovascular changes. Moreover, the differences between these solutions were analyzed by examining their impacts on rat ventricular cardiomyocytes. METHODS: Eighty renal transplant patients were evaluated retrospectively. The patients were divided into two groups: Group UW (n =40) used the University of Wisconsin solution, and Group HTK (n =40) used the Histidine-Tryptophan-Ketoglutarate solution. Electrocardiograms of the subjects were obtained three times at different periods; during the pre-perfusion, intraoperative kidney reperfusion, and postperfusion phase at the end of the surgery. Any Electrocardiogram or cardiovascular alterations were noted and analyzed. Adult male Wistar rats were used for in vitro experiments. Myocyte contractility, action potentials, and membrane current were recorded in enzymatically isolated ventricular myocytes. RESULTS: Sinus bradycardia was detected in 19 patients of Group UW, while there was short-term asystole in eight patients. However, no cardiac changes were observed in Group HTK patients. In both Groups, reperfusion and postperfusion corrected QT (QTc) intervals were different from pre-perfusion QTc intervals. Group UW patients' reperfusion and postperfusion QTc's values were higher than those of the Group HTK patients. In rat myocytes, prominent asystole episodes were observed at specific concentrations of the UW solution compared to the HTK solution. The UW solution depolarized the resting membrane potential significantly and decreased the peak value of action potential, whereas the HTK solution did not elicit a significant change in those parameters. Accordingly, the UW solution elicited a significant inward current at -70 mV, while the HTK solution activated only a modest current, which may not change the membrane potential. CONCLUSION: Prolongation of QTc intervals was detected with reperfusion in both groups according to electrocardiography analysis. However, the QTc interval was observed to be longer in cases using the UW solution and required intervention intraoperatively. HIPPOKRATIA 2021, 25 (1):22-30.

Homocysteine levels after nitrous oxide anesthesia for living-related donor renal transplantation: a randomized, controlled, double-blind study.

BACKGROUND: Nitrous oxide anesthesia increases postoperative homocysteine concentrations. Renal transplantation candidates present with higher homocysteine levels than patients with no renal disease. We designed this study to investigate if homocysteine levels are higher in subjects receiving nitrous oxide for renal transplantation compared with subjects undergoing nitrous oxide free anesthesia. METHODS: Data from 59 patients scheduled for living-related donor renal transplantation surgery were analyzed in this randomized, controlled, blinded, parallel-group, longitudinal trial. Patients were assigned to receive general anesthesia with (flowmeter was set at 2 L/min nitrous oxide and 1 L/min oxygen) or without nitrous oxide (2 L/min air and 1 L/min oxygen). We evaluated levels of total homocysteine and known determinants, including creatinine, folate, vitamin B12, albumin, and lipids. We evaluated factor V and von Willebrand factor (vWF) to determine endothelial dysfunction and creatinine kinase myocardial band (CKMB)-mass, troponin T to show myocardial ischemia preoperatively in the holding area (T1), after discontinuation of anesthetic gases (T2), and 24 hours after induction (T3). RESULTS: Compared with baseline, homocysteine concentrations significantly decreased both in the nitrous oxide (22.3 ± 16.3 vs 11.8 ± 9.9; P < .00001) and nitrous oxide-free groups (21.5 ± 15.3 vs 8.0 ± 5.7; P < .0001) at postoperative hour 24. The nitrous oxide group had significantly higher mean plasma homocysteine concentrations than the nitrous oxide-free group (P = .021). The actual homocysteine difference between groups was 3.8 µmol/L. CONCLUSION: This study shows that homocysteine levels markedly decrease within 24 hours after living-related donor kidney transplantation. Patients receiving nitrous oxide have a lesser reduction, but this finding is unlikely to have a clinical relevance.

Comparison of open and retroperitonoscopic donor nephrectomy in terms of lipid and protein peroxidation responses.

BACKGROUND: This study was designed to compare donors who underwent open (ODN) versus retroperitonoscopic nephrectomy (RDN) in terms of intra-operative oxidative stress and recipients graft function in the early postoperative period. METHODS: Among 40 patients who underwent donor nephrectomy, 23 were operated via an open method and 17 via retroperitonoscopic method. To analyze oxidative stress, we measured plasma levels of malondialdehyde (MDA), protein carbonyl, and protein sulfhydryl moieties in donor venous blood before induction of anesthesia and postoperatively at 0, 6, and 24 hours. The influence of oxidative stress on graft function was evaluated by means of the postoperative 5th day recipient creatinine and estimated glomerular filtration rate (eGFR) Modification of Diet in Renal Disease Formula (MDRD) to evaluate delayed graft function (DGF) status. RESULTS: ODN patients showed significantly higher 24-hour mean levels of MDA, (6,139 ± 1,854 vs 4,813 ± 1,771 nmol/L; P = .01), protein carbonyl (366 ± 64 vs 311 ± 62 µmol/L; P = .01) and protein sulfhydryl (468 ± 110 vs 386 ± 75 µmol/L; P = .01) moieties compared with those RDN patients. However, ODN and RDN recipients were similar in terms of 5th day mean creatinine and eGFR (1.1 ± 0.3 vs 1.4 ± 0.8 mg/dL and 69.15 ± 12.24 vs 56.31 ± 25.2, respectively) and DGF status (4.4% [1/23] vs 5.9% [1/17], respectively). CONCLUSIONS: Although ODN donors were more prone to intra-operative oxidative stress than RDN donors, based on significantly higher levels of oxidative stress markers, this difference seems to not significantly influence recipients early graft function.

Combination of epidural anesthesia and general anesthesia attenuates stress response to renal transplantation surgery.

Choice of the anesthestic technique can reduce or even eliminate stress responses to surgery and decrease the incidence of complications. Our aim was to compare a combination of epidural anesthesia+general anesthesia with general anesthesia alone as regards perioperative insulin resistance and inflammatory activation among renal transplant recipients. Forty-six nondiabetic patients undergoing renal transplantation were prospectively randomized to the epidural anesthesia + general anesthesia group (n = 21), or general anesthesia alone group (n = 25). Plasma levels of glucose, insulin, interleukin (IL)-6, tumour necrosis factor (TNF)-α, resistin, and adiponectin were measured at baseline (T1), end of surgery (T2), postoperative first hour (T3), postoperative second hour (T4) and postoperative 24th hour (T5). Homeostasis model assessment-estimated insulin resistance (HOMA-IR) scores were calculated at every time point that the blood samples were collected. Glucose levels (P < .001) and insulin levels at the end of surgery (P = .048) and at postoperative first hour (P = .005) and HOMA-IR levels at the end of surgery (P = .012) and at postoperative first hour (P = .010) showed significantly higher values among the general anesthesia alone group when compared with the epidural+general anesthesia group. TNF-α levels at postoperative 2nd and at 24th hour (P = .005 and P = .004, respectively) and IL-6 levels at postoperative 1st and 2nd hours (P = .002 and P = .045, respectively) were significantly higher in the general anesthesia alone group when compared with the epidural+general anesthesia group. The TNF-α levels were significantly less at all time points when compared with baseline only in the epidural+general anesthesia group (T1, 33.36 vs 37.25; T2, 18.45 vs 76.52; T3, 15.18 vs 78.27; T4, 10.75 vs 66.64; T5, 2.98 vs 36.32) Hospital stays were significantly shorter among the epidural+general anesthesia group (P = .022). We showed partly attenuated surgical stress responses among patients undergoing renal transplantation using general anesthesia combined with epidural anesthesia compared with general anesthesia alone.

The first (double) hand transplantation in Turkey.

In September 2010, a bilateral hand allotransplantation was performed on a 28-year-old man who had suffered amputations at the level of 1/3 of the proximal forearm on the right and 1/3 of the distal forearm on the left 2 years previously. This was the first hand transplantation case in Turkey. Preoperative organization, legal difficulties, technical aspects of the operation, and immunosuppressive regimen are detailed herein. The early results of the first composite tissue allograft (CTA) transplantation are also reported. The results were encouraging for all future types of CTA transplantation, including hand and face. Following the early promising outcome of the first case of hand transplantation in Turkey, we have accelerated preparation of regulations for CTA transplantation, including hand and face allotransplantation.

Neurological complications after liver transplantation.

This was a single-centre, prospective study to assess the frequency of neurological complications and their impact on prolonged hospitalization in 137 liver transplant patients presenting between September 1997 and June 2010. Neurological complications were seen in 22 (16%) patients during their postoperative stay in the intensive care unit. Complications included new-onset, recurrent headache (five patients), generalized seizures (four patients), dysarthria (two patients), delirium with agitation (three patients), persistent flapping tremor (two patients), alteration in level of consciousness (three patients), central pontine myelinolysis (one patient), myopathy (one patient) and visual hallucinations (one patient). Seizures were associated with immunosuppressive drug toxicity (tacrolimus). Myopathy presenting as quadriplegia was diagnosed by muscle biopsy. The patient with central pontine myelinolysis lived in a persistent vegetative state for 2 years and died of pneumonia. In conclusion, neurological complications are frequently encountered after liver transplantation, and are an important cause of severe morbidity and prolonged intensive care unit and hospital stay.

Spinal analgesia for the postoperative period in renal donors.

BACKGROUND: To provide postoperative analgesia by spinal anesthesia, we compared the quality of analgesia and side effects of two doses of morphine added to ropivacaine in kidney donors. MATERIALS AND METHODS: Thirty renal donors underwent nephrectomy under standard general anesthesia. After the operation, the patients were randomly allocated into two groups of intrathecal doses for spinal anesthesia: the 0.5 group (n = 15) received a total volume of 4 mL including 0.5 mg morphine, 10 mg ropivacaine, and 0.9% NaCl, and the 0.3 group (n = 15), a total volume of 4 mL including 0.3 mg morphine, 10 mg ropivacaine, and 0.9% NaCl. After extubation, an intravenous (IV) morphine protocol was initiated by a patient-controlled analgesia pump to provide sufficient spinal analgesia. RESULTS: In the 0.3 group, the IV morphine consumption was significantly higher, namely, 14.60 +/- 7.57 times versus 4.60 +/- 10.14 times for the 0.5 group (P = .005). The total amount of morphine was 7.80 +/- 5.40 mg in the 0.5 group and 13.53 +/- 5.30 mg in the 0.3 group (P < .05). Postoperative side effects of nausea and vomiting were higher among the 0.3 group (P < .05). CONCLUSIONS: In the 0.5 group, the quality of analgesia was better than in the 0.3 group. The need for IV morphine was less in the 0.5 group. Also, side effects like nausea and vomiting were less, so better analgesia in the postoperative period was obtained with the 0.5 mg morphine solution.

Correlation of peripheral venous pressure and central venous pressure in kidney recipients.

BACKGROUND AND OBJECTIVE: Previous studies in adults have demonstrated a clinically useful correlation between central venous pressure (CVP) and peripheral venous pressure (PVP). The current study prospectively compared CVP measurements from a central versus a peripheral catheter in kidney recipients during renal transplantation. METHODS: With ethics committee approval and informed consent, 30 consecutive kidney recipients were included in the study. We excluded patients who had significant valvular disease or clinically apparent left ventricular failure. For each of 30 patients, CVP and PVP were measured on five different occasions. The pressure tubing of the transducer system was connected to the distal lumen of the central or to the peripheral venous catheter for measurements following induction of anesthesia, after induction, 1 hour after induction, reperfusion of the kidney, and the end of the operation, yielding 150 hemodynamic data points. Each hemodynamic measurement included heart rate, mean arterial pressure, mean CVP, and mean PVP determined at end-expiration. RESULTS: The mean PVP was 13.5 +/- 1.8 mm Hg and the mean CVP was 11.0 +/- 1.5 mm Hg during surgery. The mean difference was 2.5 +/- 0.5 (P < .01). Repeated-measures analysis of variance indicated a highly significant relationship between PVP and CVP (P < .01) with a Pearson correlation coefficient of 0.97. CONCLUSION: Under the conditions of this study, PVP showed a consistently high agreement with CVP in the perioperative period among patients without significant cardiac dysfunction.

Comparison of two different techniques for brachial plexus block: infraclavicular versus axillary technique.

BACKGROUND: Brachial plexus block via the axillary approach is problematic in patients with limited arm mobility. In such cases, the infraclavicular approach may be a valuable alternative. The purpose of our study was to compare axillary and infraclavicular techniques for brachial plexus block in patients undergoing arm or forearm surgery. METHODS: After institutional approval and informed consent were obtained, 30 patients (ASA physical status I or II) scheduled for forearm and hand surgery under brachial plexus anesthesia were included in the study. Patients were randomly allocated into two groups. Brachial plexus block was performed via the axillary approach in the Group A patients and via the infraclavicular approach in the Group I patients using a peripheral nerve stimulator. All blocks were performed with a total dose of 40 ml 0.375% bupivacaine. RESULTS: In each nerve territory (radial, ulnar, median, and musculocutaneous), the mean values of the degree and the duration of the sensory block and motor block were not significantly different between the two groups (P > 0.05). Inadvertent vessel puncture was significantly more frequent in the axillary approach (P < 0.05). CONCLUSION: Brachial plexus block performed via the infraclavicular approach is as safe and effective as the axillary approach. Infraclavicular approach may be preferred to the axillary approach when the upper arm mobility is impaired or not desired.

A randomized study comparing combined spinal epidural or general anesthesia for renal transplant surgery.

INTRODUCTION: The appropriate anesthesia for renal transplantation requires minimal toxicity for patients and for the transplanted organ, as well as sufficient pain relief and maintenance of vital functions. The aim of this study was to determine how the anesthetic technique influences the outcome in patients after renal transplantation in terms of preoperative and intraoperative hemodynamic changes and blood gas changes. METHODS: Fifty adult patients undergoing renal transplantation were randomly divided into two groups receiving standardized general anesthesia or combined spinal and epidural anesthesia. RESULTS: Demographically both groups were similar. Total anesthesia time (202 +/- 53 vs 186 +/- 37 minutes) and surgical time (191 +/- 52 vs 162 +/- 31 minutes) did not differ between the groups. The heart rate and systolic blood pressure values of the groups as measured before induction and 5, 15, 20, 30, as well as 60 minutes thereafter did not differ between the groups. Neither the frequency of bradycardia (four vs two) nor of hypotension (six vs four) during anesthesia differed between regional versus general anesthesia groups. CONCLUSION: Regional is an important alternative to general anesthesia during renal transplantation surgery in adult patients.

Intrathecal fentanyl added to hyperbaric ropivacaine for transurethral resection of the prostate.

BACKGROUND: Our purpose was to evaluate the effect of intrathecal fentanyl 25 microg added to 18 mg of 6 mg ml(-1) hyperbaric ropivacaine on the characteristics of subarachnoid block and postoperative pain relief in patients undergoing TURP surgery. METHODS: The patients were randomly assigned into two groups: Group S (saline group, n=16) received 3 ml of 18 mg hyperbaric ropivacaine + 0.5 ml saline--in total, a 3.5-ml volume intrathecally; and Group F (fentanyl group, n=15) received 3 ml of 18 mg hyperbaric ropivacaine + 0.5 ml of 25 microg fentanyl--in total, a 3.5-ml volume intrathecally. In both groups the onset and recovery times of the sensory block, degree and recovery times of the motor block and side-effects were recorded and statistically compared. RESULTS: There was no significant difference between the groups in achieving the highest level of sensory block, and in the times taken to reach the peak level. Regression to L1 was significantly prolonged in the fentanyl group compared with the saline group (P=0.004). Times to the first feeling of pain and the first analgesic requirement were significantly prolonged in the fentanyl group compared with the saline group (P=0.011 and P=0.016, respectively). The frequency of pruritus was significantly higher in the fentanyl group compared with the saline group (P=0.022). CONCLUSION: Addition of fentanyl 25 microg to hyperbaric ropivacaine 18 mg for spinal anesthesia in patients undergoing TURP may significantly improve the quality and prolong the duration of analgesia, without causing a substantial increase in the frequency of major side-effects.