Marijuana Use Associated with Decreased Mortality in Trauma Patients.

BACKGROUND: The incidence of trauma patients with a positive marijuana screen (pMS) is increasing but the effects of marijuana on outcomes have varied in previous studies. A recent statewide analysis demonstrated decreased mortality for intensive care unit (ICU) trauma patients with pMS. Thus, we hypothesized a pMS to be associated with a decreased risk of mortality for all trauma patients. METHODS: The 2017 Trauma Quality Improvement Program (TQIP) database was queried for adult (≥18 years-old) pMS patients, who were compared to patients negative for all drugs and alcohol (nDS). Patients not drug tested or testing positive for drug(s)/alcohol other than marijuana were excluded. Multivariable logistic regression was used to evaluate risk of mortality after controlling for known predictors of mortality including age, sex, injury severity, vital signs, and comorbidities. Additional subgroup analyses were performed for ICU patients and younger adults (<40 years-old). RESULTS: From 141 737 tested patients, 23 310 (16.4%) had an isolated pMS. Patients with pMS were younger (P < .001) but had a similar median injury severity score (ISS) (9, P = .42) compared to nDS patients. On multivariable analysis the associated risk of mortality was lower for pMS (OR .79, .71-.87, P < .001) compared to nDS patients. Subgroups analyses also demonstrated decreased associated risk of mortality for ICU and younger patients (both P < .05). DISCUSSION: Patients with a pMS had decreased associated risk of mortality compared to nDS patients, including subgroups of ICU and younger patients. These findings require corroboration with future prospective clinical study and basic science evaluation to ascertain the exact pathophysiologic basis and thereby target potential interventions.

Safety and feasibility of urological procedures in Jehovah's Witness patients.

OBJECTIVES: To describe the safety and feasibility of urological transfusion-free surgeries in Jehovah's Witness patients. METHODS: An institutional review board-approved, retrospective review of Jehovah's Witness patients who underwent urological transfusion-free surgeries between 2003 and 2019 was carried out. Surgeries were stratified into low, intermediate and high risk based on complexity, invasiveness and bleeding potential. Patient demographics, perioperative data and clinical outcomes are reported. RESULTS: A total of 161 Jehovah's Witness patients (median age 63.4 years) underwent 171 transfusion-free surgeries, including 57 (33.3%) in low-, 82 (47.9%) in intermediate- and 32 (18.8%) in high-risk categories. The mean estimated blood loss increased with risk category at 48 mL (range 10-50 mL), 150 mL (range 50-200 mL) and 388 mL (range 137-500 mL), respectively (P < 0.001). Implementing blood augmentation and conservation techniques increased with each risk category (3.5% vs 29% vs 69%, respectively; P < 0.001). Average length of stay increased concordantly at 1.6 days (range 0-12 days), 2.9 days (range 1-13 days) and 5.6 days (range 2-12 days), respectively (P ≤ 0.001). However, there was no increase in complication rates and readmission rates attributed to bleeding among the risk categories at 30 days (P = 0.9 and 0.4, respectively) and 90 days (P = 0.7 and 0.7, respectively). CONCLUSIONS: Transfusion free urological surgery can be safely carried out on Jehovah's Witness patients using contemporary perioperative optimization. Additionally, these techniques can be expanded for use in the general patient population to avoid short- and long-term consequences of perioperative blood transfusion.

Sedation with ketamine and fentanyl combination improves patient outcomes in intensive care units.

Psychological manifestations such as depression and suicidal ideation are commonly caused by poorly controlled pain, anxiety, and sleep deprivation in intensive care unit (ICU) patients. We are concerned that previous analgesic and sedative techniques administered as single-medication approaches are outdated and inadequate. It is imperative that ICU practitioners are knowledgeable in multimodal approaches to pain and sedation in high acuity settings. We have shown that appropriate combinations of ketamine and fentanyl are effective, and if further supplementation is needed, we utilize additional pharmacological agents in low doses and regional techniques that ultimately lower the overall opioid consumption. We acknowledge that a variety of medication supplementations tailored to the patient's clinical needs and nature of surgery improves a patient's outcome in ICU and overall quality of life.

Perioperative Outcome of Suprarenal Resection of Vena Cava Without Reconstruction in Urologic Malignancies: A Case Series and Review of the Literature.

OBJECTIVE: To describe the feasibility and perioperative outcome of suprarenal resection of inferior vena cava (IVC) in urologic neoplasms without reconstruction. METHODS: We retrospectively reviewed the patients who underwent suprarenal resection of IVC without reconstruction for urologic neoplasms in our institution between September 2010 and October 2019. Patients' demographic, clinical, radiologic, and 90-day perioperative complications were recorded. RESULTS: Twenty-eight (79% male) patients with a median age of 59 (25-75) years were included in the study. Twenty-five (89%) of patients had renal cell carcinoma, 1 had renal leiomyosarcoma, and 2 had metastatic testicular teratoma. Twenty-two patients had Mayo level 3 thrombus, 3 had level 2, and 3 had level 4. The mean radiologic thrombus length was 12.6 cm. Eleven patients had radiologic bland thrombosis in the infrarenal IVC. Twenty-seven patients underwent open, and 1 robotic surgery. The median operating time was 411 (range 240-808) minutes, median blood loss was 3750 cc, and all but 1 patient received perioperative transfusion (median 11 units of packed red blood cells). Median hospital stay was 5 (3-50) days. Ninety-day complication rate was 35% (Clavien-Dindo grade I/II and III/IV were 21% and 14%, respectively). Four patients (14%) developed transient nondisabling leg edema. The 90-day mortality rate was 7%. CONCLUSION: Suprarenal inferior vena cava resection without reconstruction is feasible, yet high-risk operation that should be performed in experienced centers in selected patients with urologic malignancies.

Robotic Level III Inferior Vena Cava Tumor Thrombectomy: Initial Series.

PURPOSE: Level III inferior vena cava tumor thrombectomy for renal cancer is one of the most challenging open urologic oncology surgeries. We present the initial series of completely intracorporeal robotic level III inferior vena cava tumor thrombectomy. MATERIALS AND METHODS: Nine patients underwent robotic level III inferior vena cava thrombectomy and 7 patients underwent level II thrombectomy. The entire operation (high intrahepatic inferior vena cava control, caval exclusion, tumor thrombectomy, inferior vena cava repair, radical nephrectomy, retroperitoneal lymphadenectomy) was performed exclusively robotically. To minimize the chances of intraoperative inferior vena cava thrombus embolization, an "inferior vena cava-first, kidney-last" robotic technique was developed. Data were accrued prospectively. RESULTS: All 16 robotic procedures were successful, without open conversion or mortality. For level III cases (9), median primary kidney (right 6, left 3) cancer size was 8.5 cm (range 5.3 to 10.8) and inferior vena cava thrombus length was 5.7 cm (range 4 to 7). Median operative time was 4.9 hours (range 4.5 to 6.3), estimated blood loss was 375 cc (range 200 to 7,000) and hospital stay was 4.5 days. All surgical margins were negative. There were no intraoperative complications and 1 postoperative complication (Clavien 3b). At a median 7 months of followup (range 1 to 18) all patients are alive. Compared to level II thrombi the level III cohort trended toward greater inferior vena cava thrombus length (3.3 vs 5.7 cm), operative time (4.5 vs 4.9 hours) and blood loss (290 vs 375 cc). CONCLUSIONS: With appropriate patient selection, surgical planning and robotic experience, completely intracorporeal robotic level III inferior vena cava thrombectomy is feasible and can be performed efficiently. Larger experience, longer followup and comparison with open surgery are needed to confirm these initial outcomes.

Level III-IV inferior vena caval thrombectomy without cardiopulmonary bypass: long-term experience with intrapericardial control.

PURPOSE: Inferior vena cava tumor thrombectomy requires experienced surgical teams due to complex hemodynamic considerations. The teams often use vascular bypass techniques that introduce additional risk. Inferior vena caval control in the pericardium obviates the need for cardiopulmonary bypass. We reviewed our experience with intrapericardial control during inferior vena caval tumor thrombectomy to evaluate perioperative outcomes and determine factors associated with overall survival. MATERIALS AND METHODS: We retrospectively reviewed the records of 87 patients who underwent nephrectomy with inferior vena caval tumor thrombectomy using intrapericardial inferior vena caval control from 1978 to 2012. This technique was performed in all 43 and 35 cases of intrahepatic and supradiaphragmatic thrombi, respectively, and in 9 select cases of intra-atrial thrombi. Patient demographics, operative variables and postoperative outcomes were examined. Multivariate regression analysis was used to determine associations between clinical variables and overall survival. RESULTS: Mortality 30 days perioperatively was 9.2% and the incidence of high grade complications was 19.5%. Median survival was 3.1 and 2.5 years in patients with pT3bN0 and pT3cN0, respectively. Extended regional lymphadenectomy, which was performed in all cases, revealed nodal metastasis in 38%. On multivariate analysis ECOG greater than 2 and pT3c stage were associated with worse survival. Histological grade, perinephric fat invasion and lymph node involvement were not associated with worse survival. CONCLUSIONS: Intrapericardial control of the inferior vena cava enables a single surgical team to safely perform tumor thrombectomy for intrahepatic and supradiaphragmatic thrombi, eliminating the risk and morbidity related to cardiopulmonary bypass. Although supradiaphragmatic extent and ECOG greater than 2 are associated with worse survival, complete resection with lymphadenectomy can allow for long-term survival in patients with locally advanced disease.

The use of regional cerebral oximetry monitoring during controlled hypotension: a case series.

Regional cerebral oximetry monitoring was used to guide nitroglycerin infusion and IV fluid administration during controlled hypotension in order to optimize each individual patient's mean arterial pressure in a series of 20 consecutive patients who underwent major open urological or abdominal surgery. Although controlled hypotension offers a definite benefit in patients undergoing complex surgery where blood loss will be elevated or would severely compromise the surgical field, it is not without risk as low arterial pressure may compromise tissue perfusion and promote ischemia. In this case series, despite an average mean arterial pressure decrease of 19.5 % (p < 0.001), cerebral oximetry values increased by an average of 22.7 % (p < 0.001) after the nitroglycerin infusion had been initiated (220 mcg/min average). Patients received an average of 3.15L crystalloid and 437 ml albumin in fluid resuscitation.

Zero ischemia anatomical partial nephrectomy: a novel approach.

PURPOSE: We present a novel concept of zero ischemia anatomical robotic and laparoscopic partial nephrectomy. MATERIALS AND METHODS: Our technique primarily involves anatomical vascular microdissection and preemptive control of tumor specific, tertiary or higher order renal arterial branch(es) using neurosurgical aneurysm micro-bulldog clamps. In 58 consecutive patients the majority (70%) had anatomically complex tumors including central (67%), hilar (26%), completely intrarenal (23%), pT1b (18%) and solitary kidney (7%). Data were prospectively collected and analyzed from an institutional review board approved database. RESULTS: Of 58 cases undergoing zero ischemia robotic (15) or laparoscopic (43) partial nephrectomy, 57 (98%) were completed without hilar clamping. Mean tumor size was 3.2 cm, mean ± SD R.E.N.A.L. score 7.0 ± 1.9, C-index 2.9 ± 2.4, operative time 4.4 hours, blood loss 206 cc and hospital stay 3.9 days. There were no intraoperative complications. Postoperative complications (22.8%) were low grade (Clavien grade 1 to 2) in 19.3% and high grade (Clavien grade 3 to 5) in 3.5%. All patients had negative cancer surgical margins (100%). Mean absolute and percent change in preoperative vs 4-month postoperative serum creatinine (0.2 mg/dl, 18%), estimated glomerular filtration rate (-11.4 ml/minute/1.73 m(2), 13%), and ipsilateral kidney function on radionuclide scanning at 6 months (-10%) correlated with mean percent kidney excised intraoperatively (18%). Although 21% of patients received a perioperative blood transfusion, no patient had acute or delayed renal hemorrhage, or lost a kidney. CONCLUSIONS: The concept of zero ischemia robotic and laparoscopic partial nephrectomy is presented. This anatomical vascular microdissection of the artery first and then tumor allows even complex tumors to be excised without hilar clamping. Global surgical renal ischemia is unnecessary for the majority of patients undergoing robotic and laparoscopic partial nephrectomy at our institution.

Anatomic renal artery branch microdissection to facilitate zero-ischemia partial nephrectomy.

BACKGROUND: Robot-assisted and laparoscopic partial nephrectomies (PNs) for medial tumors are technically challenging even with the hilum clamped and, until now, were impossible to perform with the hilum unclamped. OBJECTIVE: Evaluate whether targeted vascular microdissection (VMD) of renal artery branches allows zero-ischemia PN to be performed even for challenging medial tumors. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort evaluation of 44 patients with renal masses who underwent robot-assisted or laparoscopic zero-ischemia PN either with anatomic VMD (group 1; n=22) or without anatomic VMD (group 2; n=22) performed by a single surgeon from April 2010 to January 2011. INTERVENTION: Zero-ischemia PN with VMD incorporates four maneuvers: (1) preoperative computed tomographic reconstruction of renal arterial branch anatomy, (2) anatomic dissection of targeted, tumor-specific tertiary or higher-order renal arterial branches, (3) neurosurgical aneurysm microsurgical bulldog clamp(s) for superselective tumor devascularization, and (4) transient, controlled reduction of blood pressure, if necessary. MEASUREMENTS: Baseline, perioperative, and postoperative data were collected prospectively. RESULTS AND LIMITATIONS: Group 1 tumors were larger (4.3 vs 2.6 cm; p=0.011), were more often hilar (41% vs 9%; p=0.09), were medial (59% and 23%; p=0.017), were closer to the hilum (1.46 vs 3.26 cm; p=0.0002), and had a lower C index score (2.1 vs 3.9; p=0.004) and higher RENAL nephrometry scores (7.7 vs 6.2; p=0.013). Despite greater complexity, no group 1 tumor required hilar clamping, and perioperative outcomes were similar to those of group 2: operating room time (4.7 and 4.1h), median blood loss (200 and 100ml), surgical margins for cancer (all negative), major complications (0% and 9%), and minor complications (18% and 14%). The median serum creatinine level was similar 2 mo postoperatively (1.2 and 1.3mg/dl). The study was limited by the relatively small sample size. CONCLUSIONS: Anatomic targeted dissection and superselective control of tumor-specific renal arterial branches facilitate zero-ischemia PN. Even challenging medial and hilar tumors can be excised without hilar clamping. Global surgical renal ischemia has been eliminated for most patients undergoing PN at our institution.

Innovations in laparoscopic and robotic partial nephrectomy: a novel 'zero ischemia' technique.

PURPOSE OF REVIEW: To describe a novel 'zero ischemia' technique for laparoscopic and robotic partial nephrectomy. RECENT FINDINGS: Laparoscopic partial nephrectomy has been performed in 15 patients without the need for warm ischemia by utilizing pharmalogically induced hypotension. This consecutive series includes complex tumors in patients with multiple comorbidities. Herein we describe our current practice, initial results, and several practical considerations associated with the application of this novel technique. SUMMARY: Initial results with our 'zero ischemia' technique have been encouraging. Evaluation of long-term outcomes is ongoing.

"Zero ischemia" partial nephrectomy: novel laparoscopic and robotic technique.

BACKGROUND: Ischemic injury impacts renal function outcomes following partial nephrectomy. Efforts to minimize, better yet, eliminate renal ischemia are imperative. OBJECTIVE: Describe a novel technique of "zero ischemia" laparoscopic (LPN) and robotic-assisted (RAPN) partial nephrectomy. DESIGN, SETTING, AND PARTICIPANTS: Data were prospectively collected into an institutional review board-approved database. Fifteen consecutive patients underwent zero ischemia procedures: LPN (n=12), RAPN (n=3). Included were all candidates for LPN or RAPN, irrespective of tumor complexity, including tumors that were central (n=9; 60%), hilar (n=1), in solitary kidney (n=1), in patients with chronic kidney disease grade 3 or greater (n=3). Anesthesia-related monitoring included pulmonary artery catheter (ie, Swan-Ganz), transesophageal echocardiography, cerebral oximetry, electroencephalographic bispectral index, mixed venous oxygen measurements, and vigorous hydration/diuresis. Pharmacologically induced hypotension was carefully timed to correspond with excision of the deepest aspect of the tumor. Renal parenchymal reconstruction was completed under normotension, ensuring complete hemostasis. MEASUREMENTS: Intraoperative and early postoperative data were collected prospectively. RESULTS AND LIMITATIONS: All cases were successfully completed without hilar clamping. Ischemia time was zero in all cases. Median tumor size was 2.5 cm (range: 1-4); operative time was 3 h (range: 1.3-6); blood loss was 150 ml (range: 20-400); and hospital stay was 3 d (range: 2-19). Nadir mean arterial pressure ranged from 52-65 mm Hg (median: 60), typically for 1-5 min. No patient had intraoperative transfusion or complication, acute or delayed renal hemorrhage, or hypotension-related sequelae. Postoperative complications (n=5) included urine retention (n=1), septicemia from presumed prostatitis (n=1), atrial fibrillation (n=1), urine leak (n=2). Pathology confirmed renal cell carcinoma in 13 patients (87%), all with negative margins. Median pre- and postoperative serum creatinine (0.9 mg/dl and 0.95 mg/dl, respectively) and estimated glomerular filtration rate (eGFR) (75.3 and 72.9, respectively) were comparable. Median absolute and percent change in discharge serum creatinine and eGFR were 0 and 0%, respectively. CONCLUSIONS: A novel zero ischemia technique for RAPN and LPN for substantial renal tumors is presented. The initial experience is encouraging.