Spontaneous rupture of bladder diverticulum with pseudo renal failure:A case report and literature review.

BACKGROUND: Spontaneous or non-traumatic bladder rupture is rare but can be life-threatening. Bladder rupture caused by a diverticulum is extremely rare, with only a few case reports in medical literature. CASE PRESENTATION: We report the case of a 32-year-old woman admitted to hospital complaints of abdominal pain, oliguria and ascites with no history of trauma. Laboratory tests revealed an elevated serum urea nitrogen(UN) level of 33.5 mmol/l and an elevated creatinine levels of 528 umol/l. X-ray cystography confirmed the rupture of a bladder diverticulum. Subsequent transurethral catheterization led to a prompt increase in urinary output, and serum creatinine level returned to 40 umol/l within 48 h. The patient was successfully treated with laparoscopic diverticulectomy. CONCLUSION: Clinicians should maintain a high level of suspicion for urinary bladder rupture in cases presenting with acute lower abdominal pain, urinary difficulties, and oliguria. When acute renal failure, complicated ascites, and an elevated peritoneal fluid creatinine or potassium level exceeding serum levels are observed, intraperitoneal urine leakage should be suspected without delay. This case emphasizes the importance of early diagnosis and intervention in managing this rare but serious condition.

Clinicopathological characteristics and predictors of outcome of rapidly progressive glomerulonephritis: a retrospective study.

BACKGROUND: Globally, there are regional and time-based variations in the prevalence, etiology, and prognosis of rapidly progressive glomerulonephritis (RPGN). Prognosis of RPGN is poor, with a higher risk of death and end stage renal disease (ESRD) even with immunosuppressive medications. In the Middle East and North Africa, the studies on this disease are very limited. Therefore, we determined the predictors of outcome of RPGN. METHODS: We retrospectively assessed 101 adult patients over age of 18, diagnosed with RPGN based on renal biopsy illustrating crescents in ≥ 50% of the glomeruli. Patients who had crescents in their renal biopsies that were < 50% and those who refused to consent to a renal biopsy were excluded. We categorized the patients into 3 groups based on immunohistochemistry; type I, type II and type III. Then, depending on renal loss, we divided them into ESRD and non-ESRD groups. The clinical history and physical examination were retrieved. Additionally, 24-hour urine protein, urine analysis, renal function tests, serum albumin, complete blood count, antinuclear antibodies, anti-double stranded DNA antibodies, ANCA antibodies and serum complement levels were checked. Each patient underwent a kidney biopsy for immunohistochemistry and light microscopy. The percentage of crescentic glomeruli, number of sclerosed glomeruli, tertiary lymphoid organ (TLO), neutrophil infiltration, endocapillary or mesangial hypercellularity, interstitial fibrosis with tubular atrophy (IFTA) were analyzed. Primary outcomes (remission, ESRD and mortality) and secondary outcomes were assessed. RESULTS: Type II was the most frequent cause of RPGN (47.5%), followed by type III (32.7%) and type I (19.8%). 32 patients (31.7%) died during follow up, whereas 60 patients (59.4%) developed ESRD. In 41 patients (40.6%), remission occurred. Oliguria, serum creatinine, and need for HD at presentation were significantly increased in ESRD group compared to non-ESRD group (P < 0.001 for each). Mesangial proliferation, IFTA, TLO formation, sclerotic glomeruli and fibrous crescents were also significantly increased in ESRD group in comparison to non-ESRD group (P < 0.001 for each). Glomerulosclerosis (P = 0.036), and IFTA (P = 0.008) were predictors of ESRD. Infections (P = 0.02), respiratory failure (P < 0.001), and heart failure (P = 0.004) were mortality risk factors. CONCLUSION: Type II RPGN was the most common. Infection was the most frequent secondary outcome. Oliguria, glomerulosclerosis, the requirement for hemodialysis at presentation, IFTA and TLO formation were predictors of ESRD. Respiratory failure, heart failure and infections were significant predictors of mortality.

Initial lactate levels linked to oliguria in term neonates with perinatal asphyxia.

BACKGROUND: Oliguria is a sign of impaired kidney function and has been shown to be an early predictor of adverse prognoses in patients with acute kidney injury. The relationship between urine output (UOP) and early lactate levels in neonates with perinatal asphyxia (PA) has not been extensively explored. This study aimed to investigate the link between oliguria during the first 24 h of life and early lactate levels in neonates with PA. METHODS: The medical records of 293 term neonates with asphyxia from 9216 hospitalized newborns were retrospectively analyzed, including 127 cases designated as the oliguria group and 166 cases as controls. Peripheral arterial blood gas after PA and UOP within 24 h after birth were analyzed. Logistic regression analyses and receiver operating characteristic curve analysis were conducted. RESULTS: Oliguria occurred in 43.34% of neonates with PA. The median UOP of the oliguria and control groups were 0.65 and 1.46 mL/kg/h, respectively. Elevated lactate levels after PA are an independent risk factor for oliguria in the following 24 h (p = 0.01; OR: 1.19; 95%CI: 1.04-1.35) and show a moderate discriminatory power for oliguria (AUC = 0.62). Using a cut off value of 8.15 mmol/L, the positive and negative predictive values and the specificity were 59.34%, 63.86%, and 78.30%, respectively. CONCLUSION: Neonates with elevated lactate levels after PA face a risk of oliguria in the following 24 h. Based on early elevated lactate levels after resuscitation, especially ≥ 8.15 mmol/L, meticulously monitoring UOP will allow this vulnerable population to receive early, tailored fluid management and medical intervention.

Machine-learning model for predicting oliguria in critically ill patients.

This retrospective cohort study aimed to develop and evaluate a machine-learning algorithm for predicting oliguria, a sign of acute kidney injury (AKI). To this end, electronic health record data from consecutive patients admitted to the intensive care unit (ICU) between 2010 and 2019 were used and oliguria was defined as a urine output of less than 0.5 mL/kg/h. Furthermore, a light-gradient boosting machine was used for model development. Among the 9,241 patients who participated in the study, the proportions of patients with urine output < 0.5 mL/kg/h for 6 h and with AKI during the ICU stay were 27.4% and 30.2%, respectively. The area under the curve (AUC) values provided by the prediction algorithm for the onset of oliguria at 6 h and 72 h using 28 clinically relevant variables were 0.964 (a 95% confidence interval (CI) of 0.963-0.965) and 0.916 (a 95% CI of 0.914-0.918), respectively. The Shapley additive explanation analysis for predicting oliguria at 6 h identified urine values, severity scores, serum creatinine, oxygen partial pressure, fibrinogen/fibrin degradation products, interleukin-6, and peripheral temperature as important variables. Thus, this study demonstrates that a machine-learning algorithm can accurately predict oliguria onset in ICU patients, suggesting the importance of oliguria in the early diagnosis and optimal management of AKI.

Predictors of oliguria in post-traumatic acute kidney injury.

BACKGROUND: Acute kidney injury is classified by urine output into non-oliguric and oliguric variants. Non-oliguric acute kidney injury has lower morbidity and mortality and accounts for up to 64% of acute kidney injury in hospitalized patients. However, the incidence of non-oliguric acute kidney injury in the trauma population and whether the 2 variants of acute kidney injury share the same risk factors is unknown. We hypothesized that oliguria would be present in the majority of acute kidney injury in severely injured trauma patients and that unique risk factors would predispose patients to the development of oliguria. METHODS: Patients admitted to the trauma intensive care unit and diagnosed with an acute kidney injury between 2016 to 2021 were identified. Cases were categorized based on urine output into oliguric (<400 mL per day) and non-oliguric (>400 mL per day) disease. Risk factors, management, and outcomes were compared. Logistic regression was used to identify risk factors associated with oliguria. RESULTS: A total of 227 patients met inclusion criteria. Non-oliguric acute kidney injury accounted for 74% of all cases and was associated with greater survival (78% vs 35.6%, P < .001). Using logistic regression, female sex, vasopressor use, and a greater net fluid balance at 48 hours were all predictive of oliguria (while controlling for age, race, shock index, massive transfusion, operative intervention, cardiac arrest, and nephrotoxic medication exposure). CONCLUSION: Non-oliguria accounts for the majority of post-traumatic acute kidney injury and is associated with improved survival. Specific risk factors for the development of oliguric acute kidney injury include female sex, vasopressor use, and a higher net fluid balance at 48 hours.

Tocilizumab Associated With Survival in Patients Hospitalized for COVID-19 Acute Respiratory Distress Syndrome and Low Urine Output.

BACKGROUND: Acute respiratory distress syndrome (ARDS) with oliguria is associated with increased mortality. Interleukin-6 (IL-6) plays an integral role in the pathophysiology of both disease processes. Patients who experience severe COVID-19 have demonstrated higher IL-6 levels compared to baseline, and use of tocilizumab has demonstrated efficacy in such cohorts. We set out to investigate the relationship between tocilizumab use, COVID-19 ARDS, low urine output, and mortality. METHODS: Retrospective cohort review of adult patients aged ≥ 18 years with COVID-19 and moderate or severe ARDS, admitted to the intensive care unit (ICU) of a tertiary referral center in metropolitan Detroit. Patients were analyzed based on presence of oliguria (defined as ≤ 0.7 mL/kg/h) on the day of intubation and exposure to tocilizumab while inpatient. The primary outcome was inpatient mortality. RESULTS: One hundred and twenty-eight patients were analyzed, 103 (80%) with low urine output, of whom 30 (29%) received tocilizumab. In patients with low urine output, risk factors associated with mortality on univariate analysis included Black race (P = .028), lower static compliance (P = .015), and tocilizumab administration (P = .002). Tocilizumab (odds ratio 0.245, 95% confidence interval 0.079-0.764, P = .015) was the only risk factor independently associated with survival on multivariate logistic regression analysis. CONCLUSION: In this retrospective cohort review of patients hospitalized with COVID-19 and moderate or severe ARDS, tocilizumab administration was independently associated with survival in patients with low urine output ≤ 0.7 mL/kg/h on the day of intubation. Prospective studies are needed to investigate the impact of urine output on efficacy of interleukin-targeted therapies in the management of ARDS.

Identification of an optimal threshold to define oliguria in critically ill patients: an observational study.

BACKGROUND: The relevance of current consensus threshold to define oliguria has been challenged by small observational studies. We aimed to determine the optimal threshold to define oliguria in critically-ill patients. METHODS: Cohort study including adult patients admitted within a multi-disciplinary intensive care unit between January 1st 2010 and June 15th 2020. Patients on chronic dialysis or who declined consent were excluded. We extracted hourly urinary output (UO) measurements along with patient's characteristics from electronic medical records and 90-day mortality from the Swiss national death registry. We randomly split our data into a training (80%) and a validation (20%) set. In the training set, we developed multivariable models to assess the relationship between 90-day mortality and the minimum average UO calculated over time windows of 3, 6, 12 and 24 h. Optimal thresholds were determined by visually identifying cut-off values for the minimum average UO below which predicted mortality increased substantially. We tested models' discrimination and calibration on the entire validation set as well as on a subset of patients with oliguria according to proposed thresholds. RESULTS: Among the 15,500 patients included in this analysis (training set: 12,440, validation set: 3110), 73.0% (95% CI [72.3-73.8]) presented an episode of oliguria as defined by consensus criteria (UO < 0.5 ml/kg/h for 6 h). Our models had excellent (AUC > 85% for all time windows) discrimination and calibration. The relationship between minimum average UO and predicted 90-day mortality was nonlinear with an inflexion point at 0.2 ml/kg/h for 3 and 6 h windows and 0.3 ml/kg/h for 12 and 24 h windows. Considering a threshold of < 0.2 ml/kg/h over 6 h, the proportion of patients with an episode of oliguria decreased substantially to 24.7% (95% CI [24.0-25.4]). Contrary to consensus definition, this threshold identified a population with a higher predicted 90-day mortality. CONCLUSIONS: The widely used cut-off for oliguria of 0.5 ml/kg/h over 6 h may be too conservative. A cut-off of 0.2 ml/kg/h over 3 or 6 h is supported by the data and should be considered in further definitions of oliguria.

Association between intraoperative oliguria and postoperative acute kidney injury in non-cardiac surgical patients: a systematic review and meta-analysis.

PURPOSE: This systematic review and meta-analysis aimed to evaluate the association between intraoperative oliguria and the risk of postoperative acute kidney injury (AKI) in patients undergoing non-cardiac surgery. METHODS: The MEDLINE and EMBASE databases were searched up to August 2022 for studies in adult patients undergoing non-cardiac surgery, where the association between intraoperative urine output and the risk of postoperative AKI was assessed. Both randomised and non-randomised studies were eligible for inclusion. Study selection and risk of bias assessment were independently performed by two investigators. The risk of bias was evaluated using the Newcastle-Ottawa scale. We performed meta-analysis of the reported multivariate adjusted odds ratios for the association between intraoperative oliguria (defined as urine output < 0.5 mL/kg/hr) and the risk of postoperative AKI using the inverse-variance method with random effects models. We conducted sensitivity analyses using varying definitions of oliguria as well as by pooling unadjusted odds ratios to establish the robustness of the primary meta-analysis. We also conducted subgroup analyses according to surgery type and definition of AKI to explore potential sources of clinical or methodological heterogeneity. RESULTS: Eleven studies (total 49,252 patients from 11 observational studies including a post hoc analysis of a randomised controlled trial) met the selection criteria. Seven of these studies contributed data from a total 17,148 patients to the primary meta-analysis. Intraoperative oliguria was associated with a significantly elevated risk of postoperative AKI (pooled adjusted odds ratio [OR] 1.74; 95% confidence interval [CI] 1.36-2.23, p < 0.0001, 8 studies). Sensitivity analyses supported the robustness of the primary meta-analysis. There was no evidence of any significant subgroup differences according to surgery type or definition of AKI. CONCLUSIONS: This study demonstrated a significant association between intraoperative oliguria and the risk of postoperative AKI, regardless of the definitions of oliguria or AKI used. Further prospective and multi-centre studies using standardised definitions of intraoperative oliguria are required to define the thresholds of oliguria and establish strategies to minimise the risk of AKI.

Evaluation of neonatal acute kidney injury (AKI) after emergency gastrointestinal surgery.

BACKGROUND: The overall incidence of acute kidney injury (AKI) in neonates undergoing emergency gastrointestinal surgery is yet to be determined. The study aims are to analyze our experience in emergency gastrointestinal surgery for neonates and to evaluate the incidence of AKI. METHODS: We conducted a retrospective study of neonates undergoing emergency gastrointestinal surgery between June 31, 2018 and May 10, 2022 (N = 329). The primary outcome was the overall incidence of AKI. The diagnostic AKI was based on the Modified Kidney Disease: Improving Global Outcomes (KDIGO) definition of neonatal AKI. The secondary outcomes, including the postoperative length of hospital stay (PLOS), 24-h mortality, in-hospital mortality, and total in-hospital cost, were analyzed. The risk factors associated with the development of postoperative AKI were also analyzed. RESULTS: The incidence of postoperative AKI was 9.1% (30/329). No significant differences were detected in the 24-h mortality and in-hospital mortality between the two cohorts. In the final model, patients undergoing mechanical ventilation before surgery, vasopressor support, surgical duration, intraoperative oliguria and preoperative lowest serum creatinine (SCr), were independently associated with AKI. CONCLUSION: Our study found that patients undergoing mechanical ventilation before surgery, vasopressor support, surgical duration, intraoperative oliguria and preoperative lowest SCr were independently associated with postoperative AKI in neonates who accepted emergency gastrointestinal surgeries.

Non-interventional follow-up versus fluid bolus in RESPONSE to oliguria in hemodynamically stable critically ill patients: a randomized controlled pilot trial.

BACKGROUND: Fluid bolus therapy is a common intervention to improve urine output. Data concerning the effect of a fluid bolus on oliguria originate mainly from observational studies and remain controversial regarding the actual benefit of such therapy. We compared the effect of a follow-up approach without fluid bolus to a 500 mL fluid bolus on urine output in hemodynamically stable critically ill patients with oliguria at least for 2 h (urine output < 0.5 mL/kg/h) in randomized setting. METHODS: We randomized 130 patients in 1:1 fashion to receive either (1) non-interventional follow-up (FU) for 2 h or (2) 500 mL crystalloid fluid bolus (FB) administered over 30 min. The primary outcome was the proportion of patients who doubled their urine output, defined as 2-h urine output post-randomization divided by urine output 2 h pre-randomization. The outcomes were adjusted for the stratification variables (presence of sepsis or AKI) using two-tailed regression. Obtained odds ratios were converted to risk ratios (RR) with 95% confidence intervals (CI). The between-group difference in the continuous variables was compared using mean or median regression and expressed with 95% CIs. RESULTS: Altogether 10 (15.9%) of 63 patients in the FU group and 22 (32.8%) of 67 patients in FB group doubled their urine output during the 2-h period, RR (95% CI) 0.49 (0.23-0.71), P = 0.026. Median [IQR] change in individual urine output 2 h post-randomization compared to 2 h pre-randomization was - 7 [- 19 to 17] mL in the FU group and 19[0-53] mL in the FB group, median difference (95% CI) - 23 (- 36 to - 10) mL, P = 0.001. Median [IQR] duration of oliguria in the FU group was 4 [2-8] h and in the FB group 2 [0-6] h, median difference (95%CI) 2 (0-4) h, P = 0.038. Median [IQR] cumulative fluid balance on study day was lower in the FU group compared to FB group, 678 [518-1029] mL versus 1071 [822-1505] mL, respectively, median difference (95%CI) - 387 (- 635 to - 213) mL, P < 0.001. CONCLUSIONS: Follow-up approach to oliguria compared to administering a fluid bolus of 500 mL crystalloid in oliguric patients improved urine output less frequently but lead to lower cumulative fluid balance. Trial registration clinical. TRIALS: gov, NCT02860572. Registered 9 August 2016.

Urine output and acute kidney injury following laparoscopic pancreas operations.

BACKGROUND: This study aims to assess if intraoperative urine output is associated with acute kidney injury (AKI) during laparoscopic pancreas surgery. METHODS: Medical records of adult patients who underwent laparoscopic pancreas surgery from 2010 to 2020 were reviewed to identify patients who experienced AKI (creatinine increase of 0.3 mg/dL within 72 h). Surgeries were classified as with 'vascular reconstruction' (e.g. Whipple, total pancreatectomy) versus 'without reconstruction' (e.g., distal pancreatectomy). RESULTS: Included were 365 patients (221 with and 114 without reconstruction), and 42 (11.4%) developed AKI (32 [14.5%] reconstruction and 10 [6.9%] without reconstruction (P = 0.164)). The median urine output for AKI group was 0.79 [0.43, 1.15] mL/kg/h and 0.88 [0.55, 1.53] mL/kg/h for non-AKI group, P = 0.121. Urine output between AKI and non-AKI did not vary among reconstruction cases (P = 0.383), but was lower in AKI patients without reconstruction (P = 0.047). Older age, preexisting kidney disease, higher disease burden, and intraoperative hypotension were associated with AKI. Postoperative course was more complicated for AKI patients including rates of pancreatic fistulas and mortality. CONCLUSION: Incidence of AKI increases with more extensive surgery, but is not associated with low urine output. However, low urine output was associated with AKI in patients undergoing operation without reconstruction.

Clinicopathological features and short outcomes of oliguric acute tubular injury.

PURPOSE: To explore the clinicopathological features and analyze the relevant risk factors and short-term renal outcomes of acute tubular injury (ATI) patients. MATERIALS AND METHODS: A total of 83 patients with biopsy-proven ATI were included in this retrospective cohort study. Clinical characteristic and histological feature data were collected, and renal recovery at 1 month postbiopsy was recorded. RESULTS: The severity of renal dysfunction, percentage of acute tubular lesions, interstitial inflammation and fibrosis of oliguric ATI patients were all significantly higher than those of nonoliguric patients. In the subgroup analysis of the oliguric patients, the serum creatinine and urinary microalbumin levels, severity of epithelial cell degeneration and cast formation of patients in the polyuric phase at biopsy were significantly lower than those of patients in the oliguric phase. A total of 59 patients had 1-month follow-up records, and complete renal recovery was observed in 42 patients. In the multivariate analysis, the total acute tubular injury area at biopsy was the most important independent risk factor for poor renal outcomes. CONCLUSIONS: Oliguric ATI patients had severe clinicopathological conditions. The severity of tubular lesions seriously influenced renal function recovery, demonstrating the importance of renal biopsy in assessing the prognosis of patients with kidney disease.

The role of Cushing's reflex and the vasopressin-mediated oligoanuric response to intracranial hypertension in patients with abdominal compartment syndrome.

BACKGROUND: We examined the link between increased intra-abdominal pressure, intracranial pressure, and vasopressin release as a potential mechanism. Intra-abdominal pressure, produced by abdominal-cavity insufflation with carbon dioxide (CO2) during laparoscopic abdominal procedures to facilitate visualization, is associated with various complications, including arterial hypertension and oliguria. METHODS: Mean arterial pressure, optic nerve sheath diameter, measured as a proxy for intracranial pressure, plasma vasopressin, serum and urine osmolarity, and urine output were measured 4 times during laparoscopic sleeve gastrectomy in 42 patients: before insufflation with CO2 (T0); after insufflation to 15 cm water (H2O) pressure, with 5 cm H2O positive end-expiratory pressure (T1); after positive end-expiratory pressure was raised to 10 cm H2O (T2); and after a return to the baseline state (T3). Mean values at T0 to T3 and the directional consistency of changes (increase/decrease/ unchanged) were compared among the 4 data-collection points. RESULTS: Statistically significant elevations (all P ≤ .001) were noted from T0 to T1 and from T0 to T2 in mean arterial pressure, optic nerve sheath diameter, and vasopressin, followed by decreases at T3. For optic nerve sheath diameter and vasopressin, the increases at T1 and T2 occurred in 98% and 100% of patients, ultimately exceeding normal levels in 88 and 97%, respectively. Conversely, urine output fell from T0 to T1 and T2 by 60.9 and 73.4%, decreasing in 88.1% of patients (all P < .001). Patients with class II obesity exhibited statistically greater increases in optic nerve sheath diameter and vasopressin, but statistically less impact on urine output, than patients with class III obesity. CONCLUSION: Increased mean arterial pressure, intracranial pressure, and vasopressin release appear to be intermediary steps between increased intra-abdominal pressure and oliguria. Further research is necessary to determine any causative links between these physiological changes.

An interesting presentation of invasive bladder carcinoma as pseudo renal failure.

Ascites and oliguria with an increasing serum creatinine level are often observed in patients with acute renal failure. However, these symptoms are also noted in individuals with intraperitoneal urinary leakage and can be mistaken for acute renal failure. This rise in creatinine in such patients is called pseudo renal failure and it happens by a process of reverse peritoneal dialysis. In literature, the most commonly described condition that leads to this clinical picture is following a spontaneous or missed bladder perforation. We, herein, report a case of carcinoma of the bladder that presented with features resembling acute renal failure, which later turned out to be pseudo renal failure due to intraperitoneal urinary extravasation from a forniceal rupture. The patient was managed with emergency with a percutaneous drain followed by a percutaneous nephrostomy, which led to normalization of creatinine. Cystoscopy revealed the bladder growth in an intact small capacity bladder and biopsy confirmed it as a muscle invasive squamous cell carcinoma. Due to advanced nature of his malignancy, he underwent a palliative ileal conduit diversion but he later developed chest metastasis and ultimately succumbed to the disease. Intraperitoneal urinary leakage due to forniceal rupture presenting as pseudo renal failure is a rare presentation of carcinoma bladder. Sudden onset abdominal discomfort, increasing ascites, hematuria, and oliguria with elevated renal parameters needs consideration and exclusion of this entity. The diagnostic dilemma associated with this rare presentation along with the management and prognosis in such patients of carcinoma bladder are discussed.

Intraoperative hypotension, oliguria and operation time are associated with pulmonary embolism after radical resection of head and neck cancers: a case control study.

BACKGROUND: Postoperative pulmonary embolism (PE) is a serious thrombotic complication in the patients with otolaryngologic cancers. We investigated the risk factors associated with postoperative PE after radical resection of head and neck cancers. METHODS: A total of 3512 patients underwent head and neck cancers radical resection from 2013 to 2019. A one-to-three control group without postoperative PE was selected matched by age, gender, and type of cancer. Univariate analyses were performed for the perioperative patient data including hemodynamic management factors. Conditional logistic regression was used to analyze the factors and their odds ratios. RESULTS: Postoperative PE was prevalent in 0.85% (95%CI = 0.56-1.14). Univariate analyses showed that a high ASA grade, high BMI, and smoking history may be related to postoperative PE. There was significantly difference in operation time between the two groups, especially for> 4 h [22(78.6%) vs 43(51.2%), P = .011]. The urine output was lower [1.37(0.73-2.21) ml·kg- 1·h- 1 vs 2.14(1.32-3.46) ml·kg- 1·h- 1, P = .006] and the incidence of oliguria was significantly increased (14.3% vs 1.2%, P = .004) in the PE group. Multivariable conditional logistic regression showed postoperative PE were associated with the cumulative duration for intraoperative hypotension (OR = 2.330, 95%CI = 1.428-3.801, P = .001), oliguria (OR = 14.844, 95%CI = 1.089-202.249, P = .043), and operation time > 4 h (OR = 4.801, 95%CI = 1.054-21.866, P = .043). CONCLUSIONS: The intraoperative hypotension, oliguria, and operation time > 4 h are risk factors associated with postoperative PE after radical resection of head and neck cancers. Improving intraoperative hemodynamics management to ensure adequate blood pressure and urine output may reduce the occurrence of such complications.

Mielorradiculopatia esquistossomótica: relato de caso em paciente pediátrico / Schistosomal Myeloradiculopathy: case report in a pediatric patient

A esquistossomose é uma endemia parasitária típica das Américas, Ásia e África. A Mielorradiculopatia Esquistossomótica surge como uma evolução severa da infecção por esquistossomose e, apesar de muito comum, sua prevalência em áreas endêmicas vem sendo subestimada. Objetivo: relatar caso de Mielorradiculopatia Esquistossomótica ocorrido em paciente pediátrico. Metodologia: estudo descritivo do tipo Relato de Caso retrospectivo, submetido e aprovado pelo Comitê de Ética em Pesquisa do Centro Universitário CESMAC, CAAE: 28835220.0.0000.0039, N.º do Parecer: 3.898.292. Relato de caso: paciente do sexo masculino, previamente hígido, 11 anos, iniciou quadro com história álgica aguda em membros inferiores que piorava no período da noite acompanhada de relato de febre. Quadro clínico evoluiu com lombalgia, disúria, oligúria, posterior anúria e formação de globo vesical. Evoluiu, também, com paresia de membros inferiores. A investigação realizou-se com Exame Parasitológico de Fezes positivo para esquistossomose, além de Ressonância Magnética de coluna lombo-sacra que corroboraram com a hipótese diagnóstica. Instituiu-se tratamento com Albendazol, Praziquantel e pulsoterapia com Metilprednisolona durante internação. Paciente teve alta hospitalar com melhora de quadro neurológico, em uso de prednisona 40 mg/dia. Conclusão: a MRE constitui a forma mais grave dentre as manifestações ectópicas da esquistossomose. A dificuldade do reconhecimento do quadro clínico e a limitação no acesso aos métodos complementares diagnósticos contribuem para o subdiagnóstico da enfermidade, acarretando sequelas graves para os portadores da doença e ocultando sua importância epidemiológica principalmente em pacientes pediátricos e jovens. (AU)

Schistosomiasis is a parasitic endemic typical of the Americas, Asia and Africa. Schistosomal Myeloradiculopathy is a severe evolution of schistosomiasis infection and, although very common, the prevalence in endemic areas has been underestimated. Objective: to report Schistosomal Myeloradiculopathy case in a pediatric patient. Methodology: descriptive study of the type Case Report retrospective, submitted and approved by the Research Ethics Committee of the CESMAC University Center, CAAE: 28835220.0.0000.0039, Opinion N.º: 3.898.292. Case report: a previously healthy 11-year-old boy, started with a history of acute pain in lower limbs that worsened during the night accompanied of fever. Evolved with low back pain, dysuria, oliguria, subsequent anuria, vesical globe formation and lower limbs paresis. The investigation resulted in positive stool examination for schistosomiasis and magnetic resonance imaging of lumbosacral spine that corroborated the diagnostic hypothesis. The treatment included Albendazol, Praziquantel and pulsetherapy with Methylprednisolone during hospitalization. The patient was discharged from the hospital with improved neurological status, using prednisone 40 mg/day. Conclusion: Schistosomal Myeloradiculopathy is the most severe form of the ectopic manifestations of schistosomiasis. The difficulty in recognizing the clinical condition and the limitation of access to complementary diagnostic methods contributes to the underdiagnosis of the disease, causing severe sequels for patients with disease and hiding its epidemiological importance, especially in pediatric and young patients. (AU)

Automated versus manual urine output monitoring in the intensive care unit.

Acute kidney injury (AKI) is defined by changes in serum creatinine and urine output (UO). Significant limitations exist regarding accurate ascertainment of urine output even within the intensive care unit. We sought to evaluate an automated urine output collections system and compare it to nursing measurements. We prospectively collected urine output using an electronic urine monitoring system and compared it to charted hourly UO in 44 patients after cardiac surgery at a single university hospital ICU. We calculated UO and oliguria rates and compared them to data from the sensor and from nursing charting. A total of 187 hourly UO measurements were obtained and on average, UO was reported 47 min late, with a median of 18 min, and a maximum of almost 6 h. Patients had a mean hourly UO of 76.3 ml over the observation period. Compared to manual measurements by study personnel, nurses significantly overestimated hourly UO by 19.9 ml (95% CI: 10.3; 29.5; p = < 0.001). By contrast, the mean difference between the UO measured with the sensor and by study personnel was 2.29 ml (95% CI: - 6.7; 11.3), p = 0.61. Electronic UO monitoring is significantly more accurate than nurse-performed manual measurements in actual intensive care patients. Furthermore, timely ascertainment of UO is difficult to achieve with manual technique, resulting in important delays in detecting oliguria perhaps leading to missed cases of AKI.

Intraoperative oliguria does not predict postoperative acute kidney injury in major abdominal surgery: a cohort analysis / A oligúria intraoperatória não prediz lesão renal aguda pós-operatória em grandes cirurgias abdominais: Análise de uma coorte

Abstract Background: Acute kidney injury (AKI) is a common complication in patients undergoing major abdominal surgery and is associated with considerable morbidity and mortality. Several studies investigating the association between intraoperative urine output and postoperative AKI have shown conflicting results. Here, we investigated the association of intraoperative oliguria with postoperative AKI in a cohort of patients submitted to elective major abdominal surgery. Methods: This was a single-center retrospective analysis of adult patients who underwent elective major abdominal surgery from January 2016 to December 2018. AKI was defined according to the serum creatinine criteria of the KDIGO classification. Intraoperative oliguria was defined as urine output of less than 0.5 mL/kg/h. Risk factors were evaluated using multivariate logistic regression analysis. Results: A total of 165 patients were analyzed. In the first 48 h after surgery the incidence of AKI was 19.4%. Postoperative AKI was associated with hospital mortality (p=0.011). Twenty percent of patients developed intraoperative oliguria. There was no association between preexisting comorbidities and development of intraoperative oliguria. There was no correlation between the type of anesthesia used and occurrence of intraoperative oliguria, but longer anesthesia time was associated with intraoperative oliguria (p=0.007). Higher baseline SCr (p=0.001), need of vasoactive drugs (p=0.007), and NSAIDs use (p=0.022) were associated with development of intraoperative oliguria. Intraoperative oliguria was not associated with development of postoperative AKI (p=0.772), prolonged hospital stays (p=0.176) or in-hospital mortality (p=0.820). Conclusion: In this cohort of patients we demonstrated that intraoperative oliguria does not predict postoperative AKI in major abdominal surgery.

Resumo Introdução: Lesão renal aguda (LRA) é uma complicação comum em pacientes submetidos a grandes cirurgias abdominais, e está associada a considerável morbimortalidade. Vários estudos investigando a associação entre débito urinário intraoperatório e LRA pós-operatória mostraram resultados conflitantes. Neste trabalho investigamos a associação de oligúria intraoperatória com LRA pós-operatória em uma coorte de pacientes submetidos à grandes cirurgias abdominais. Métodos: Análise retrospectiva de centro único envolvendo pacientes adultos submetidos à grandes cirurgias abdominais, de janeiro de 2016 a dezembro de 2018. A LRA foi definida segundo critérios de creatinina da KDIGO. Definimos oligúria intraoperatória como débito urinário inferior a 0,5 mL/kg/h. Fatores de risco foram avaliados por análise de regressão logística multivariada. Resultados: Analisamos 165 pacientes. Nas primeiras 48 horas após a cirurgia, a incidência de LRA foi de 19,4%. LRA pós-operatória foi associada à mortalidade hospitalar (p = 0,011). 20% dos pacientes desenvolveram oligúria intraoperatória, sem associação com comorbidades preexistentes. Não houve correlação entre o tipo de anestesia e oligúria intraoperatória; entretanto, maior tempo de anestesia esteve associado à oligúria intraoperatória (p = 0,007). Maior creatinina sérica (Cr) inicial (p = 0,001), necessidade de drogas vasoativas (p = 0,007) e uso de AINEs (p = 0,022) foram associados à oligúria intraoperatória. Oligúria intraoperatória não foi associada ao desenvolvimento de LRA no pós-operatório (p = 0,772), à permanência hospitalar prolongada (p = 0,176) ou à mortalidade intra-hospitalar (p = 0,820). Conclusão: Demonstramos que a oligúria intraoperatória não prediz LRA pós-operatória em cirurgias abdominais de grande porte.