Hand-assisted laparoscopic living donor nephrectomy: initial Glasgow experience.

AIMS: The study presents the early results of hand-assisted laparoscopic living donor nephrectomy (HALDN) carried out in West of Scotland from June 2009 to October 2010. METHODS: The first 20 HALDN procedures carried out in our unit are presented. The outcomes reported are warm ischaemia time, operative time, delayed graft function, recipient renal function and one-month morbidity and mortality of donor and recipient. SPSS 15.0 was used for statistical analysis. RESULTS: The mean age of the donors was 44 ± 10 years, predominantly females (n = 13), median operative time 135 ± 33 min and warm ischaemia time 41 ± 16 s. The length of the incision used was 65 mm in all cases. Duration of hospital stay was 5 ± 1 days. Patient mortality was 0 and morbidity minimal with two donors developing minor wound infection and no other clinically significant postoperative morbidity. Among the recipients, 18/20 (90%) transplants worked primarily with two delayed graft functions, one due to early surgical complications in a small paediatric recipient and one due to recipient renal artery thrombosis. CONCLUSION: HALDN is safe and associated with minimal morbidity; further analysis aims to confirm excellent cosmetic results and quick return to activity compared with the standard open nephrectomy technique.

Below-target postoperative arterial blood pressure but not central venous pressure is associated with delayed graft function.

Delayed graft function (DGF) is a major issue in kidney transplantation and is associated with reduced graft and patient survival. The condition results from the summative effects of multiple injurious processes associated with transplantation with many underlying factors being nonmodifiable. Reducing cold ischemic time and machine perfusion have decreased the DGF incidence but peri-/postoperative injury resulting from suboptimal perfusion may also be critical to the development of DGF. We investigated the effect of perfusion parameters and other key variables on the incidence of DGF in 149 consecutive renal transplants. The occurrence of any recorded subtarget (70 mm Hg) mean arterial pressure (MAP) was significantly associated with DGF (perioperative P = .005; postoperative P = .002) while the occurrence of a subtarget (8 cm H(2)O) central venous pressure (CVP) among other variables was not. Routine continuous blood pressure monitoring is rare postoperatively and is shown to be more accurate than CVP in assessing renal perfusion and guiding management in the postoperative period.

Pyogenic ventriculitis following enteral bacterial translocation in a patient with small bowel obstruction.

The authors present a rare case of ventriculitis secondary to cerebro spinal fluid (CSF) colonization with Escherichia coli species in a 65-year-old woman. Passage of bacterial organisms from the lumen of the gastrointestinal tract to the bloodstream or lymphatic tissue is known as translocation. Once in the bloodstream, particular bacteria are able to cross the blood-brain barrier and migrate to CSF. Elective abdominal surgery, intestinal obstruction, colorectal cancer, ischaemic reperfusion injury and pancreatitis have all increased the risk of this phenomenon. This account highlights particular events in presentation and management of such a case, followed by a brief literature review.

Outcome of renal transplantation with and without intra-operative diuretics.

AIMS: This paper presents an e-survey of current clinical practice of use of intra-operative diuretics during renal transplantation in the United Kingdom and a study to compare outcome of renal transplants carried out with or without intra-operative diuretics in our centre. METHODS: An e-mail questionnaire to renal transplant surgeons exploring their practice of renal transplantation with or without intra-operative diuretics, the type of a diuretic/s if used and the relevant doses. An observational study comparing the outcome of renal transplant recipients, group no-diuretics (GND, n = 80) carried out from 2004 to 2008 versus group diuretics (GD n = 69) renal transplant recipients who received intra-operative diuretics over a one year period is presented. Outcome measures were incidence of delayed graft function and a comparison of graft survival in both groups. RESULTS: Forty surgeons answered from 18 transplant centres with a response rate of 67%. 13 surgeons do not use diuretics. Mannitol is used by 10/40, Furosemide 6/40 and 11 surgeons use a combination of both. In comparative study there was no significant overall difference in one year graft survival of GD versus GND (N = 65/69, 94% and 75/80, 94% respectively, p = 0.08) and the incidence of delayed graft function was also comparable (16/69, 23% and 21/80, 26% respectively, p = 0.07). The donor characteristics in both groups were comparable. CONCLUSION: The study showed variation in clinical practice on the use of intra-operative diuretics in renal transplantation and it did not demonstrate that the use of diuretics can improve renal graft survival.

Laryngopharyngeal pH measurement.

OBJECTIVES: Most emergency department (ED) intubations are to prevent gastric contents aspiration. The incidence of aspiration is unknown and intubation has complications. Balancing these risks requires an idea of the incidence of aspiration. This study assessed one technique for investigating the aspiration risk in ED patients. Cricoid pressure is used to reduce this risk and the technique may also examine this manoeuvre. METHODS: Cohorts of unconscious adult ED and elective surgical patients were recruited. The posterior pharyngeal wall pH was measured immediately before and after intubation. Pharyngeal pH was used to indicate risk of aspiration, and pH change to assess the efficacy of cricoid pressure. RESULTS: Eight ED and 48 control patients were recruited. In the ED cohort, pH ranged from 6.0 to 8.0 before intubation and 4.7 to 8.0 after intubation: a mean decrease of 0.3 (95% CI 1.5 decrease to 0.9 increase). In the control cohort pH ranged from 5.8 to 8.0 before intubation and 6.0 to 8.0 after intubation: a mean increase of 0.4 (95% CI 0.1 to 0.6 increase). CONCLUSIONS: This is a simple, cheap, and repeatable technique for assessing aspiration risk in emergency intubations. A larger study is required to assess the efficacy of cricoid pressure.

Clearing the cervical spine of paediatric trauma patients.

OBJECTIVES: To review the evidence available for clearance of the cervical spine in children under 16 years of age after trauma, and to provide guidance to enable this to be practised safely. METHODS: A comprehensive literature review was carried out, and combined with a review of standard texts and liaison with experts. RESULTS: 241 papers were identified, of which 71 papers were thought possibly relevant. These were obtained and appraised. Children in whom there is concern about possible cervical spine injury may be divided into three groups. Alert, asymptomatic children with a normal examination may be clinically cleared without need for radiology. Children with cervical spine symptoms or signs require plain radiology in the first instance. Those areas that are poorly visualised or suspicious should be discussed with a paediatric radiologist and are likely to undergo computed tomography. Children with impaired conscious level require careful evaluation. Plain radiology, if normal, can be usefully complemented by early magnetic resonance imaging to exclude ligamentous and spinal cord damage. CONCLUSIONS: There is limited evidence to guide clinicians on how to clear the paediatric cervical spine. The approach suggested is similar to adult recommendations made elsewhere, and the differences are highlighted.

Should UK emergency physicians undertake diagnostic ultrasound examinations?

From the published evidence there is no doubt that emergency physicians in America can undertake focused ultrasound examinations and that, by extrapolation, this would also be the case for UK emergency physicians. If this skill is to become part of the diagnostic armamentarium of the emergency physician, however, it needs to be demonstrated to be cost effective compared with the alternatives already available to the hospital. Trials to test for this benefit should adopt a hospital and not an emergency department perspective if the results are to influence health policy and specialty training.

Point of care testing in the accident and emergency department: a cost analysis and exploration of financial incentives to use the technology within the hospital.

OBJECTIVES: To compare the costs of current arrangements for testing emergency blood samples from patients attending an accident and emergency (A&E) department in a large teaching hospital in England with point of care testing (POCT). METHODS: Estimates were made of the fixed and variable costs of two options: a supplemental option, in which POCT was introduced to A&E only; and a replacement option, in which POCT was introduced to A&E and the intensive therapy unit (ITU), thereby entirely replacing an existing process. RESULTS: For the supplemental option, current arrangements cost 68,466 Pounds in total per year; average costs per test were 5.53 Pounds (venous in the central laboratory) and 3.60 Pounds (arterial on the ITU). Introducing POCT would increase total hospital costs by 35,929 Pounds, and average costs per test would be 5.32 Pounds (venous) and 4.28 Pounds (arterial). For the replacement option, current arrangements cost 132,630 Pounds in total, and average cost per test (for all tests) was 4.06 Pounds. Introducing POCT would make hospital savings ranging from 8332 Pounds to 20,000 Pounds, and average cost per test would be 3.78 Pounds. CONCLUSIONS: Introducing POCT results in lower average costs per test. The supplemental option will result in significantly increased costs to the hospital. The replacement option can lead to significant savings. The internal cross-charging arrangements between departments that exist in this hospital may mean that supplemental implementation of POCT could be potentially 'profitable' for the A&E department, but would result in higher expenditure for the hospital as a whole.

Bronchoscopic removal of an inhaled, sharp, foreign body: an unusual complication.

A case is reported in which an inhaled sewing needle, stuck fast in the trachea, became displaced through the tracheal wall during attempted removal via flexible bronchoscopy. The inherent risks and pitfalls of this procedure are highlighted.