Urine Protein Separation by Geometrical Electrophoresis after Anaesthesia with Sevoflurane
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Abstract:
Protein determination in urine above the normal values after low-flow anaesthesia with Sevoflurane has led us to study its nature and significance. Proteinuria after anaesthesia is caused by Sevoflurane degradation by carbon dioxide absorbers and the increased amount of fluorine ions in kidneys. Compound A resulting from Sevoflurane degradation by carbon dioxide absorbers causes renal toxicity in animals with tubular necrosis, clinically evidenced by proteinuria and glycosuria. Materials and method: We observed 62 patients in the Intensive Care Unit who were anesthetised with Sevoflurane for different surgical interventions on medium and long term. Thus, we analyzed 186 urine samples from the anesthetized patients by spectrophotometry at 600 nm and by electrophoresis. Urine samples were taken from patients, preoperatively and at 24 and 72 hours postoperatively and were analyzed without having been previously preserved in order to remove any possible errors. The patients who were accepted in the study had an anaesthetic risk ASA I-III, according to the classification of the American Society of Anaesthesiology, without a known renal pathology, with normal blood urea nitrogen and serum creatinine level in the preoperative period. The proteinuria was analyzed in a specialized laboratory of Mures County Hospital with a Konelab 30i autoanalyzer by spectrophotometry at 600 nm. Protein electrophoresis was performed in the laboratory of the Department of Pathophysiology within the University of Medicine and Pharmacy of Târgu Mures. Urinary protein levels were statistically analyzed, by applying the ANOVA test. The obtained data were statistically analyzed by calculating the p value which was considered statistically significant at a value less than 0,05. Results: A number of 61 patients were included in the study, with an average age of 59 years old, a mean BMI=23 and a sex ratio F/M=29/32 with an anaesthetic risk, ASA I/II/III=1/22/38, according to the classification of the American Society of Anaesthesiology. The anaesthetic characteristics were the following: an average duration of anaesthesia of 200 minutes (between 80 and 300 minutes) and a minimal alveolar concentration (MAC) of 1.8 (1.4 to 2.2). Discussion: This study is a prospective, observational one, in which we demonstrate the presence of proteinuria with statistical significance (p<0.0001) after anaesthesia with Sevoflurane, data that we partially found in literature. Compund A, incriminated as triggering glomular toxicity after anaesthesia with Sevoflurane has to reach a level of 800 ppm (parts per million) in order to be toxic to the kidneys. The literature also mentions the appearance of albuminuria after Desfluran anaesthesia although the degradation of this anaesthetic agent by carbon dioxide absorbers does not produce the compound A.Keywords:
Blood urea nitrogen
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Objective To investigate the effects of minimal-flow sevoflurane anesthesia combined with a new CO2 adsorbent Amsorb Plus calcium lime on the hepatic and renal functions in patients.Methods Seventytow ASA Ⅰ or Ⅱ patients,aged 20-60 yr,scheduled for gastrointestinal surgery under general anesthesia,were randomized into 2 groups (n =36 each):middle-flow anesthesia group (group G1 ) and minimal-flow anesthesia group (group G2 ).Amsorb Plus calcium lime was added into the CO2 absorption canister and the core temperature of the calcium lime was continuously monitored and recorded.The patients were tracheal intubated after anesthesia induction and mechanically ventilated.The initial sevoflurane concentration was set at 4％ and the fresh gas flow of oxygen was set at 4 L/min.After the end-tidal concentration of sevoflurane reached 2.6％,the fresh gas flow of oxygen was adjusted to 2 L/min in group G1 or 0.5 L/min in group G2.The end-tidal concentration of sevoflurane was maintained at 2.4％-2.8％ during operation.Venous blood samples were taken 24 h before and 24 h after operation for determination of the serum concentrations of total bilirubin (TBIL),direct bilirubin (DBIL),blood urea nitrogen (BUN) and creatinire (Cr) and activities of alanine aminotransferase (ALT) and aspartate aminotransferase (AST).Urine samples were obtained at 24 h before and after operation to detect the concentration of glucose and protein.The urine glucose and protein positive patients were recorded.Results There was no significant difference in the core temperature of calcium lime at different time points between the two groups ( P ＞ 0.05 ).Compared with that at 24 h before operation,AST activity,TBIL and DBIL concentrations were significantly increased,BUN concentration was significantly decreased,but no significant change was found in the Cr concentration and the number of urine glucose and protein positive patients at 24 h after operation in group G1,and DBIL concentration was significantly increased,while BUN concentration was significantly decreased at 24 h after operation in group G2 ( P ＜ 0.05 ).There was no significant difference in the parameters of hepatic and renal functions between the two groups ( P ＞ 0.05).Conclusion The combination of minimal-flow sevoflurane anesthesia and Amsorb Plus calcium lime exerts no effect on the hepatic and renal functions,the effect is similar to that of middle-flow anesthesia,and it can be safely used in patients.
Key words:
Anesthetics,inhalation; Anesthesia,inhalation; Liver function tests; Kidney function tests
Blood urea nitrogen
Soda lime
Fresh gas flow
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Background Cirrhotic patients are prone to developing renal dysfunction after anaesthesia and surgery. However, no consensus has been reached whether sevoflurane could have adverse effects on renal function in cirrhotic patients. We hypothesised that the use of sevoflurane for general anaesthesia would lead to post‐operative renal dysfunction in cirrhotic patients undergoing liver resection. Methods A total of 200 patients undergoing liver resection were randomly assigned to a propofol or sevoflurane group. The influence of sevoflurane or propofol on renal function was evaluated by the maximal change, the difference between the pre‐operative baseline and the highest values of serum creatinine and blood urea nitrogen measured at day 1, 3 and 6 post‐operatively. Results The maximal change in serum creatinine after liver resection was −4.52 (5.78) μmol/l and −3.37 (7.34) μmol/l with P = 0.398, and that in blood urea nitrogen was 0.41 (1.49) mmol/l and 0.93 (1.54) mmol/l with P = 0.098 between the sevoflurane group ( n = 52) and the propofol group ( n = 50), respectively. Conclusions Sevoflurane does not seem to impair post‐operative renal function in cirrhotic patients undergoing liver resection.
Blood urea nitrogen
Liver function
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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.
Urine output
Oliguria
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In the study we analysed the variation of serum magnesium (Mg) concentrations during perioperative period in twenty male and twenty female patients that were subjected to cholecystectomy under general anaesthesia. Five serum blood samples were collected at intervals: 1 h preoperative (S1), 3 min after the introduction in anaesthesia and intubation (S2), 1h (S3), 8h (S4) and 24h (S5) after the beginning of operation. The concentration of Mg in serum samples was determined by atomic absorption spectrophotometry. The mean value (± SD) serum Mg concentrations obtained were: S1:13.77 ± 5.60, S2:12.64 ± 3.78, S3:11.70 ± 5.18, S4:12.32 ± 4.73, S5:10.86 ± 3.76 μg/ml. Our results demonstrate a reduction of Mg concentrations between S2 and S3 in relation with S1. Increased Mg is observed in S4. In S5, there is a reduction of Mg concentrations in relation with S1. ANOVA and t-test were used for statistic analysis. It has been observed that the fluctuation of Mg concentrations depends on gender. The determination of Mg changes in blood serum perioperatively, shows the importance of Mg monitoring and significance in avoiding the complications because of its fluctuation.
Serum concentration
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Urine norepinephrine concentration and excretion were measured before, during, and after mitral or aortic valve replacement in four groups of patients anesthetized with 1 to 3 mg/kg of morphine plus oxygen or 0.5 to 1.5 percent halothane and oxygen. All patients were similarly premedicated 90 minutes before operation. A bladder catheter was implanted at the time of premedication and urine collected from then until anesthesia was begun. Urine was also collected during induction of anesthesia, from the first incision until bypass, during bypass, after bypass, and for 2 hours in the recovery room. Urine was analyzed for norepinephrine via the fluorometric method of Viktora. Urine output of patients undergoing the same procedure were similar during all study periods irrespective of anesthetic. Mean preoperative urine norepinephrine concentrations and excretions of all groups were also similar. Urine norepinephrine concentrations and excretions in patients receiving halothane were unchanged until the postoperative period, when they became significantly increased. Patients given morphine anesthesia had marked increases in urine norepinephrine concentrations and excretions during induction, at all times intraoperatively, and postoperatively. These data suggest that morphine anesthesia increases norepinephrine blood levels in patients with valvular heart disease undergoing surgical correction.
Mitral valve replacement
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Aim: The aim of this study was to investigate the acute effects of halothane administration on postoperative liver function tests in elective surgical patient requiring general anaesthesia at our institution.
Methods: Sixty patients scheduled for elective surgeries under general anaesthesia were enrolled using convenience sampling method. The patients had no history of recent alcohol intake or general anaesthesia in the previous 6 months. There was no hepatic, cardiac or renal disease. Anaesthesia was maintained within 0.75% - 1.5% halothane in 100% oxygen. Three different blood samples were collected from each patient before anaesthesia, 24 hours and 48 hours post-surgery. The plasma level of total bilirubin (TBil), albumin (Alb) and total protein (Tpro) as well as plasma activities of aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), and gamma glutamyltransferase (GGT) were determined.
Analysis of variance (ANOVA) was used to compare the differences in the mean levels of the three groups of blood samples followed by a post-hoc test using the least significant difference (LSD) method for significant ANOVA results. P-values less than 0.05 were considered statistically significant.
Results: The age range of the patients who were scheduled for elective surgical procedures was between 41 and 72 years. Significant elevations were observed in AST and ALT at 24 (33.27±0.52, 34±0.49) and 48 hours (39.73±0.49, 41.28±0.48) post anaesthesia compared to pre-anaesthesia values (27.2±0.52, 29.93±0.52). There were no significant changes in either the activities of GGT and ALP, or Tbil, Alb and Tpro.
Conclusion: Halothane and/or its metabolites could cause a mild increase in liver enzymes suggestive of sub-clinical liver cell alteration which buttresses the fact that halothane anaesthesia is still a safe agent in patients without pre-existing liver disease.
Liver function
Elective surgery
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Background Acute kidney injury (AKI) after radical nephrectomy is a serious complication that increases morbidity and mortality rates. Early detection and prevention of this complication are very important. A novel biomarker named neutrophil gelatinase-associated lipocalin (NGAL) can play an important role in early diagnosis of AKI. Recent studies have been published on the favorable effects of dexmedetomidine on renal functions. Objective The aim was to evaluate the possible renal protective effects of dexmedetomidine regarding urine output, creatinine clearance, serum cystatine C, NGAL in patients undergoing radical nephrectomy. Patients and methods A randomized double-blind, placebo-controlled study was conducted on 30 adult patients scheduled for radical nephrectomy. The patients were randomly allocated into two equal groups. Dexmedetomidine group (D group) received dexmedetomidine 0.8 µg/kg intravenously over 10 min as a loading dose, and then it was infused at a rate of 0.4 µg/kg/h. Placebo group (P group) received normal saline instead of dexmedetomidine in the same volume (ml) and rate (ml/h). In both groups, fentanyl (0.5 µg/kg) boluses were given if blood pressure or heart rate (HR) showed 20% increase from the baseline reading to control the hemodynamics. Vital signs [HR and mean arterial blood pressure (MABP)] were recorded before induction, after induction, after intubation, intraoperatively every 10 min till the end of surgery, and postoperatively every 2 h during the first 24 h. Urine output was assessed intraoperatively every 1 h and postoperatively every 4 h in the first 48 h. Serum creatinine, urinary creatinine, and creatinine clearance were assessed 24 h before surgery, 24 h after urinary catheter insertion after induction of anesthesia, and 24–48 h postoperatively. Cystatine C and NGAL were assessed after induction of anesthesia and after 24 h and 48 h postoperatively. Sedation was assessed during the first 5, 15, 30, and 60 min in the recovery room by the investigator using a five-point sedation scale. Postoperative pain was assessed using the visual analog scale, based on 0–10 points, every hour in the first 4 h postoperatively and then every 4 h in the first postoperative day. Results There was a significant decrease in HR and MABP in the dexmedetomidine group compared with placebo group. Urine output showed significant difference between the two groups in all studied periods except for the first hour. Urine output was higher in dexmedetomidine group, and seven patients in the placebo group needed lasix. Serum creatinine values, creatinine clearance, and cystatine C showed no statistically significant difference between the two groups in the three studied periods. NGAL values were similar after induction but were significantly different between the two groups after 24 and 48 h, with values higher in the placebo group. Sedation was different between the two groups in all studied periods except after 5 min. Patients in dexmedetomidine group were more sedated compared with the placebo group. Dexmedetomidine had postoperative analgesic effect represented by low visual analog scale score. Conclusion Dexmedetomidine proved to be effective in the prophylaxis of postoperative AKI after radical nephrectomy in terms of NGAL values but did not affect renal functions in terms of serum creatinine, creatinine clearance, and cystatine C. Dexmedetomidine in the used dose did not have adverse effects on MABP and HR. In addition to renal protection, dexmedetomidine proved to have sedative and analgesic properties.
Dexmedetomidine
Mean arterial pressure
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Objective To investigate the effect of norepinephrine infusion at 0.03-0.3 μg·kg-1 ·min-1 on renal function in patients undergoing kidney transplantation. Methods Thirty-two ASA Ⅲ or Ⅳ patients aged 22-64 yr weighing 44-88 kg undergoing kidney transplantation were studied. Dialysis was performed within 36 h before operation. Blood pressure was fairly stable. Combined spinal-epidural anesthesia (CSEA) was performed. Spinal anesthesia was performed at L2,3 interspace and hyperbaric 0.5% bupivacaine 10-15 mg was injected into the subarachnoid space. The upper level of sensory block measured by pin-prick reached T6. Epidural catheter was placed at T11,12 interspace and 1% ropivacaine was given intermittently. The patients were randomly allocated into preoperative baseline level (increase or decrease amplitude ＜ 10% of baseline level) by dopamine or norepinephrine infusion during operation. Venous blood samples and urine samples were obtained at the end of operation and 12 h after operation for determination of serum concentrations of cystatin C and β2-microglobulin and urine α1- and β2-microglobulin concentrations. Urine was collected and the volume was recorded. Meanwhile the consumption of furosemide administration during the 12 h after operation was recorded. Results The two groups were comparable with respect to age, M/F sex ratio, body weight, the volume of urine and fluid infused, and the consumption of furosemide. There was no significant difference in serum cystatin C and β2-microgiobulin and urine α1- and β2-microglobulin concentratious, urine volume and consumption of furosemide administration between the transplantation without adverse effect on kidney allograft function.
Key words:
Norepinephrinc; Kidney transplantation; Kidney function tests
Ropivacaine
Urine specific gravity
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To explore the clinical effects of alprostadil injection on acute kidney injury (AKI) after cardiac surgical procedures by a prospective randomized controlled trial.A total of 63 AKI-patients after cardiac surgical procedures were randomly divided into the control group (n = 31) and the study group (n = 32). All patients received routine therapy while patients in the study group were additionally given alprostadil injection (10 µg i.v. once every 12 hours) for 7 days. A 11-year-old patient weighing 29 kg was given half of the conventional dose. During the period of control treatment (7 days), 1 patient in the control group and 2 patients in the study group were excluded because of hemodialysis or peritoneal dialysis. Urine volume, urine β-N-acetylglucosaminidase, urine α(1)-microglobulin, urine β(2)-microglobulin, serum creatinine and blood urea nitrogen were measured before and after the control treatment. And the ICU stay duration and the percentage of dialysis after the control treatment were calculated. Adverse reactions of alprostadil injection were observed simultaneously in the study group.After the treatment, urine volume in the study group was obviously more than that in the control group [(65.9 ± 3.1) ml/h vs (58.8 ± 4.5) ml/h, P < 0.05] while urine β-N-acetylglucosaminidase, urine α(1)-microglobulin, urine β(2)-microglobulin, serum creatinine and blood urea nitrogen in the study group were obviously lower than those in the control group (all P < 0.05). The ICU stay duration in the study group was obviously less than that in the control group [(12 ± 5) d vs (17 ± 5) d, P < 0.05]. But there was no significant difference in the percentage of dialysis after the control treatment between two groups (3.3% vs 6.7%, P > 0.05). And no serious adverse reaction was reported in the study group.On the basis of routine therapy, alprostadil injection may promote the recovery of renal function in AKI-patients after cardiac surgical procedures.
Beta-2 microglobulin
Blood urea nitrogen
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