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Background and Aims: Though the role of fasting preoperative gastric ultrasound has been validated in different patient populations, namely, obese, pregnant and diabetics, it has not been explored in patients with chronic kidney disease (CKD). This prospective, observational study compared the fasting sonological assessment of gastric contents in patients with CKD versus those with normal renal function scheduled for elective surgery. Methods: After ethical approval and trial registration were obtained, preoperative gastric ultrasound was done in 115 CKD patients and 115 with normal renal function. Qualitative and quantitative assessment of residual gastric volume was done. Also, the patients were administered the Porto Alegre Dyspeptic Symptoms Questionnaire (PADYQ) to evaluate gastroparesis objectively. The researcher was not blinded to the patient groups. Data analyses were done using the Statistical Package for Social Sciences (SPSS) for Windows software (version 22.0). Results: Gastric volumes exceeding 1.5 ml/kg or particulate or solid contents were found in 57 patients with CKD and 36 patients with normal renal function (P = 0.004). The PADYQ scores were 6.54 ± 8.49 for CKD and 2.15 ± 5.71 for normal renal function (P < 0.0001) groups. CKD patients had a higher age (P < 0.001), lower body mass index (P = 0.005) and higher incidence of diabetes mellitus (P < 0.001). There were no incidents of gastric aspiration. Conclusion: Renal dysfunction contributes to delayed gastric emptying. PADYQ can also help identify those at high risk of gastroparesis. Combining the questionnaire and preoperative gastric ultrasound must be considered in these patients to ensure optimum safety.
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Introduction Pain management in patients with chronic kidney disease is challenging. Due to impaired kidney function, analgesic options are limited. Postoperative analgesia in transplant recipients is further complicated by their vulnerability to infections, titrated fluid management and optimal haemodynamics to maintain graft function. Erector spinae plane (ESP) blocks have been used successfully in a variety of surgeries. This study is a quality improvement project aiming to assess the efficacy of continuous erector spinae plane catheter analgesia in the postoperative management of kidney transplant recipients. Methods We conducted an initial audit over a period of three months. All patients who underwent kidney transplantation under general anaesthesia with erector spinae plane catheters were included. Erector spinae plane catheters were secured prior to induction, and continuous local anaesthetic infusion was maintained postoperatively. Pain scores using the numerical rating scale (NRS) were recorded at intervals in the first 24 hours postoperatively, and supplementary analgesics given were noted. Following satisfactory results from the initial audit, we implemented erector spinae plane catheters as part of multimodal analgesia in transplant patients in our centre. We re-audited all transplants done over the next year to reassess the quality of postoperative analgesia. Results Five patients were audited during the initial audit. The average NRS score ranged from 0 at rest to a maximum of 5 during mobilisation. All patients were given only paracetamol to supplement analgesia, and none required opioids. During the re-audit, data was collected on postoperative pain management in 13 subsequent transplants conducted over the next year. The NRS scores ranged from 0 at rest to 6 on mobilisation. Two patients required boluses of fentanyl 25 mcg via the catheter, and the rest reported satisfactory analgesia with paracetamol as needed. Conclusion This quality improvement project changed our centre's practice in managing postoperative pain in kidney transplantations. We switched from securing epidural catheters to erector spinae plane catheters due to better safety profile, minimal use of opioids and lesser adverse effects. We shall continue to re-audit our practices for the best outcomes.
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Organ transplantation has undergone remarkable revolution in the last two decades and offers a scope for survival amongst patients with end-stage organ failure. Along with availability of advanced surgical equipment and haemodynamic monitors, minimally invasive surgical techniques have emerged as options for surgery both amongst the donors and recipients. Newer trends in haemodynamic monitoring and expertise in ultrasound guided fascial plane blocks have changed the management in both donors and recipients. The availability of factor concentrates and point-of-care tests for coagulation have allowed optimal and restrictive fluid management of patients. Newer immunosuppressive agents are useful in minimising rejection following transplantation. Concepts on enhanced recovery after surgery have allowed early extubation, feeding and shorter hospital stay. This review gives an overview of the recent progress in anaesthesia for organ transplantation.
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Background and Aims: Cardiovascular diseases are the leading causes of morbidity and mortality in chronic kidney disease (CKD) patients. Our aim was to derive predictors of cardiac morbidity, mortality, cardiac complications and to develop/validate a scoring tool in patients with CKD undergoing non-cardiac surgery. Methods: A prospective observational multicentre study was done on 770 patients with CKD. The primary outcome ("Event") was one or more than one of sudden cardiac death, pulmonary oedema, acute coronary syndrome, arrhythmia and 30-day mortality. Secondary outcome was hypertension and hypotension. Predictors of cardiac risk were identified. A scoring tool was developed on the 2018 dataset and was validated on the 2019 dataset. Results: The overall incidence of cardiac events was 290 (37.66%) whereas the incidence of major adverse cardiac and cerebrovascular events was 15.04%. Mortality due to cardiac cause was 13 (1.68%). On multivariate regression analysis, seven perioperative variables had significant association with increased risk of events: age > 65 years (P = 0.004), metabolic equivalents (METS) ≤4 (P≤0.032), emergency surgery (P =0.032), mean arterial pressure >119 (P = 0.001), echocardiographic scoring (P = 0.054), type of anaesthesia (P ≤ 0.0001) and type of surgery (P = 0.056). Using these variables, a risk stratification tool was developed. C statistics showed favourable predictive accuracy (0.714) and the model showed good calibration. Conclusion: This risk scoring tool based on preoperative variables will help to predict the risk of events in high-risk CKD patients undergoing non-cardiac surgery. This will help in better counselling and optimisation.
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Background: Availability of cardiopulmonary resuscitation (CPR) data from India is limited in published literature and data on patients with renal disease even more so. Documented survival-to-discharge rates worldwide range from 8 to 15% in renal disease as compared to 25% in the general population. Methods: An institution-wide format for collection of cardiac arrest data was introduced in late 2015. We have analyzed all adult onsite cardiac arrests from January 2016 to December 2019. Patient characteristics and CPR parameters were both studied in detail. Primary endpoint was defined as survival to discharge. Association between patient and treatment characteristics and survival to discharge was studied. Results: Successful CPR resulting in patient discharge occurred in 28 (31.4%) out of 89 patients. A very strong association was found between mortality and prolonged CPR (p <0.00001). Events occurring out of hours (p = 0.0029), patients admitted in the intensive care unit (ICU) (p = 0.03), initiated on inotropes (p = 0.003), and patients already on a ventilator (p = 0.0018) had poorer outcomes. Sepsis as the etiology emerged as the most significant association with mortality (p = 0.0007). Patient characteristics such as age, sex, presence or absence of chronic kidney disease, type of dialysis treatment, and vintage were found to be insignificant. Conclusion: Analysis revealed survival to discharge of 31.4%. Sepsis in association with renal disease has been found to be consistent with higher risk for mortality. Other factors such as an out of hours event, admission to ICU, early intubation and inotrope initiation were associated with worse outcomes. How to cite this article: Sharma S, Raman P, Sinha M, Deo AS. Factors Affecting Outcomes of Cardiopulmonary Resuscitation in a Nephro-Urology Unit: A Retrospective Analysis. Indian J Crit Care Med 2022;26(3):322-326.
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BACKGROUND AND AIMS: An audit was conducted between July 2017 and November 2017 to assess the adequacy of American Society of Anesthesiologists (ASA) fasting guidelines on 246 patients by means of gastric ultrasonography (USG). The relevance of this audit is that many of our patients have one or more risk factors for aspiration such as diabetes mellitus, chronic kidney disease (CKD), gastro-oesophageal reflux disease (GERD), and obesity. METHODS: This audit was a prospective observational study which included all patients posted for surgery within the audit period. Patients were fasted according to ASA fasting guidelines. Their gastric content was assessed preoperatively using USG. The residual gastric volume was calculated using a validated formula. Statistical correlation between gastric volumes and the risk factors were analysed. RESULTS: Of 246 patients, 69 (28.04%) had high residual gastric volume. We found no correlation between hours of fasting and residual gastric volume (P = 0.47). We found a linear correlation between rising body mass index and residual gastric volume (P < 0.0001). Patients with GERD had 2.3 times higher risk. The CKD patient subgroup had 24 patients (30%) with high residual gastric volume. No incidents of aspiration were noted. CONCLUSION: In our audit, we found that risk factor association has a greater effect on residual gastric volume than hours of fasting. While the current fasting guidelines are adequate for healthy individuals, they are not conclusive in patients with risk factors. Ultrasound assessment of preoperative gastric volume is an effective screening tool in patients with risk factors.