S 393
15. Renal - Posters 143
272 DEVELOPMENT OF ACUTE RENAL FAILURE IN POLYTRAUMATIZED PATIENTS
ORAL ACYCLOVIR-INDUCED ACUTE RENAL FAILURE G.Katikos, Ch. Forulis, A. Kiriakidou OBJECTIVE: Acute renal failure (ARF) after orally administration of Acyclovir. DESIGN: A case report. SETTING: General hospital I.T.U. PATIENT: Male, 60 years old, with free desease anamnesis, he took 3x200mg acyclovir for 3 days per os for cutaneous herpes simplex infection. MEASUREMENTS AND RESULTS: 2 days long hoarseness, the 4th day stupor, intense metabolic acidosis (PH 6,99, BE -24,9), afebrile. Plasma-urea (PU) level 36,1mmol/L, -creatinine (PCr) 1264pmol/L, -K 8mmol/L. No oliguria, urinary specific gravity 1010. Computer tomography of Brain and Abdomen normal. The day after: PU 79,9mmoVL, PCr 1502 VmoVL, relation U urine/plasma 2,16(<3), Cr urine/plasma 2,57 (<20), Na' urine 99,4mmol/L (>40), renal failure indicator 38 (>1). Pump assisted continous venovenous hemofiltration for the next 36 hours. Spectacular improvement. After 2 days PU 15,8mmoVL, PCr 168 smoVL, K' 4,9mmoVL. CONCLUSION: The first, in international bibliography, case of ARF is described after pure oral administration of acyclovir. No relation with pre-existing renal failure or dehydration of patient. No relation with drug-dose. Urinary sediment normal, no oliguria. Quick recovery (2 days for neurological, 8 days for renal). State of consciousness coma drowsiness normal state
Serum creatinine Diuresis (m1/24h) Qunol/L) 1500 7000 6000 1250 1005000 4000 750 3000 500 2000 250 1000 100 123456789
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A
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Changes in creatinine concentration, diuresis and neurological status during and after treatment with acyclovir.
N. Andelic , O. Cosic, K. Todorovic, M. Risovic, M. Colic, T.
Randelovid
There is a high risk of development of renal failure in polytraumatized patients. Numerous factors may lead to renal failure among which the most frequent include hypovolemia, rabdomyelysis and release of nephrotoxic substances. The aim of the study was to determine the incidence of development of acute renal failure in polytraumatized patients. During our study there were 54 polytraumatized patients analysed, of both sexes, mean age 42 years. The patients were divided into 2 groups according to the Injury Severity Score (ISS). The first group consisted of 25 patients with ISS higher than 30, and the second group of 29 patietlts with ISS lower than 30. In all the patients there were continuously determined serum urea, creatinine and electrolyte levels, diuresis by the hour, mean arterial preassure, minute volume and heart index. Arterial gas analyses were also determined. Based on the parameters followed, it was found that the development of acute renal failure occurred in Group I in 8 patients (32%), and Group II in 4 patients (13,7%). Out of 8 patients from the first group, despite the resuscitation measures applied, 5 patients required the application of hemodialysis. Out of the second group only one patient needed hemodialysis. It may be concluded that the patients with higher ISS have a greater incidence of acute renal failure and that it is manifested in a more sever form in those patients. Emergency Center, Clinical Center of Serbia, 11000 Belgrade, Yugoslavia
Intensive Care Unit, General hospital, Volos 38221, GR.
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ELEVATED INTRA ABDOMINAL PRESSURE AFTER MAJOR ABDOMINAL SURGERY DOES NOT PREDICT IMPAIRED RENAL FUNCTION
SPLANCHNIC HOMEOSTASIS DURING ENDOTOXIN CHALLENGE IN THE PIG AS ASSESSED BY MICRODIALYSIS AND TONOMETRY
JGH van den Brand MC van Meeteren, YEA van Riet, Chr van der Werken.
OBJECTIVES: A combination of elevated intra abdominal pressure (IAP) and decreased renal function (RF) has been described. Patients with elevated IAP are known to become oliguric or anuric. A relationship has never been clearly demonstrated, This study's objective was to determine whether raised IAP influences RF in a negative way DESIGN: a prospective study on the surgical Intensive Care Unit (ICU) SUBJECTS: All patients admitted to the surgical ICU after receiving major abdominal surgery, complicated by extensive bleeding or after abdominal gauze packing. METHODS: In patients LAP was recorded intermittently during the first 24 postopera Rive hours using an indirect transuredual method'. If relaparotomy was performed IAP was monitored another 24 hours. Pressures were related to urine production and renal function (RF). IAP higher than 18 nun Hg was considered elevated. Oliguria was defined as less than 30 ml nrineproduction per hour and RF was regarded impaired if the value of serumcreatinine exceeded 130 cmol/L with preoperative normal values. RESULTS AND STATISTICAL ANALYSIS: 44 series of measurements were done on 32 patients after vascular (19), traumatic (7) and gastrointestinal (6) operations. After the first operation the median maximal IAP was 23,5 nun Hg, after relaparotomy it dropped to 18,0 mm Hg. <30
530
total
<530
2130
total
I">IB nun H1
3
24
27
IAP > 18 mnns H=
11
16
27
1":518 mm Ht
3
14
17
LAP 518 non Hg
9
8
17
total
6
38
44
total
20
24
44
Urine(MIJU)
Creatinine (pmoYL)
The prevalence of oliguria in the total included patientpopulation was 6/44 = 14 % With elevated IAP it was 3/27 = 11 %. The likelihood-ratio for this testresult is 0,8 (n.s.). The total prevalence of impaired RF was 24/44 = 54%, in the elevated IAPgroup this was 16/27 = 59 %. The likelihood-ratio here is 1,2 (n.s.). CONCLUSION: Elevated intra abdominal pressure as such does not predict impaired renal function. Therefore registration of intra-abdominal pressure after major abdominal surgery is not indicated. 1 I Kron et at: The measurement of iMra-abdominal pressure as a criterion for abdominal reexploration Ann Sorg 1984;199:28-30
Surgical Intensive Care Unit, University Hospital Utrecht, 3508 GA Utrecht, The Netherlands.
A Oldner , M Goiny. U Ungerstedt, A Sollevi OBJECTIVES: To evaluate microdialysis of the liver and small intestine as a monitor of splanchnic metabolic deterioration in endotoxin shock. Tonometry of the small intestine was used as a reference. DESIGN: Prospective trial. SUBJECTS: Thirteen landrace pigs. METHODS: After surgical preparation, including insertion of microdialysis probes (in liver, ileum wall and a foreleg artery), a tonometer in the ileum and a PA-catheter, eight animals received an IV infusion of E. Coli endotoxin (20 µg kg h 1 for two hours). Five animals served as controls. The experiment was terminated five hours after onset of endotoxin infusion. RESULTS: Measurements of hemodynamic parameters and tonometry (presented as calculated pHi) were made every half hour. Dialysates from the microdialysis probes was collected with the same interval and later analysed for lactate and hypoxanthine. All parameters were stable in the control group with the exception of liver lactate that had a tendency to gradual declination. Three hours after onset of endotoxin challenge there were significant differences between endotoxin and control groups in intestinal lactate and hypoxanthine as well as liver lactate, in addition to mucosal acidosis obtained by tonometry. Lactate elevation in blood was first seen at four hours, while there was no significant hypoxanthine elevation in arterial blood over five hours. Hence, data obtained from the splanchnic region became significantly different early compared to data obtained from arterial blood. CONCLUSIONS: This study demonstrates an advantage of regional monitoring of susceptible organs in the course of endotoxin shock. Microdialysis of liver and small intestine as well as intestinal tonometry are sensitive tools for detection of splanchnic metabolic deterioration in this condition. Dept of Anesthesiology & Intensive Care, Karolinska Hospital 5-171 76 Stockholm, SWEDEN
S 394 844
663 Acute renal insufficience caused by war injuresour experiences Lukic Zoran 2 Jovanovic Branimir;Jovanovic Krsto 2 Butorajac Josip?Hrvacevic Ratko2,Doki6 Gorica;Tomovic Mirjana 3 2 Clinic of Anestesiology and Intensive Therapy-Mili tary Medical Academy Belgrade-Yugoslavia 3 Department of Neurology-MMA Belgrade-Yugoslavia Themes of our work are risk factors in moment and frequency of appereance,as well as type and final state of patientes with acute renal insufficience (ARI)caused by war injures.ARI was recognised as co mplication of war injures in World War II with leta lity 69-91 %.First try was hemodialise therapy in Corean war with letality 53- 69%.In retrospective study we analised 51 patients with ARI caused by war injures.That number was 1,3%of all, patients with war injures treated in Military Medical Academy in period from october 1991 till february 1994.ARI diagnosis was concluded by anamnesis,clinical state, laboratory results,and diuresis.All injured patients from our experimental group were treated by the principals of first urgency treatment inclouded adecvate volume expander therapy. In that group we had 25,4%polytraumatised patientes,21,6%patientes with thoracoabdominal trauma.All other patientes were monotraumatised,but most serious clinical state had patientes with abdominal trauma.Haemorrhagical shock was the main reasol of ARI in 56,8%.Massive transfusion in treatment of patients with war injures never caused ARI.We could nt analised hypotension as relevant cause.We also could nt analise influence of potentially nefrotoxic drugs because of dominant influence of other factors.Maine cause of ARI in complicated cases was sepsis in 25,5%cases.Letality in our group was 33,3%,but higher letality was in group with oliguric form of ARI.Quick evacuation from first battle line to hirurgical stations(in 30-45 min.),intensive volume expander therapy,and urgent surgical treatment of war injures made 'a number of cases with• ARI lower,during the war on theritory of the form Yugoslavia. Hemodialise therapy in right moment lowed number of letality cases in group of war injured patientes with ARI. -
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666 THE INFLUENCE OF ACE INHIBITING DRUG CAPTOPRIL ON RENAL FUNCTION IN OPEN-HEART SURGERY V.Ivancan , I.Rude2, Z.Baudoin, D.Anic, A.Nikoli6, D.Zani6-Matanic Impaired renal function is well-known symptom after an open-heart surgery. Some authors quote that almost 30% of patients develop transitory acute renal failure (ARF) during the early postoperative course, while 3% of patients require haemodialysis but have poor prognosis. In this article the authors present the influence of ACE-inhibiting drug captopril in patients undergoing open-heart surgery. In this study we observed thirty-eight patients undergoing open-heart surgery. All patients were randomised into two groups: Group 1 received captopril and Group 2 received placedo. We observed mean arterial prassure, systemic vascular resistance, central venus pressure and diuresis during the first 24 hours after the surgery. All the aquired data are presented as mean value ± standard deviation, calculated, according the Student's t-test, and p values less than 0.05 were considered statistically significant. Urinary output in the first six hours was high in both groups, but in the group 1 it was significantly higher than in the second group (5.2±2.2 mL/kg/h VS 4.2±1.3 mL/kg/h; p<0.01). In the period from 6th till 12th hour postoperatively, urinary output was satisfactory in both groups, and there was no need for additional supportive medication to maintain renal function. In the period from 12th to 24th hour, there was no statistically significant difference in the urinary output between the groups, but in order to maintain the diuresis at the rate of I mL/kg/h in the group 1, four patients (22%) required additional stimulation with furosemid (3x20 mg i.v./24h), while in the group 2 seven patients (35%) required furosemid therapy, and four of those seven patients required additional inotrope therapy (dopamine 3pg/kg/min). In this study the authors have observed protective effect of ACE-inhibiting drug captopril and its protective role on kidney function in patients undergoing open-heart surgery. The administration of captopril does not exclude transitory renal failure, but surely decreases its incidence. Department of Anesthesiology, Department of Surgery, Clinical Hospital Centre Zagreb - Rebro, Kis`paticeva 12, 10000 Zagreb, Croatia.
CONTINUOUS VENO-VENOUS RAEMOFILTRATION (CVVHF) IN CRITICAL CARE. D Daq a, M Herrera, LR Del Fresno, JM Garcia, R Toro, M Lebr n, A Poullet, JL Carpintero.
Objetive : To determinate the efficacy of continuous veno-venous haemofiltration (CVVHF) in patients admitted at the ICU and to detect possible complications of its use. Design: Proscpective observational. Setting : Two ICUs in third level Hospitals with 12 and 42 beds. Patients : we have studied 60 patients admitted at the ICUs from 1993 through 1994 and recieving CVVHF. Results : A specific data base was designed to collect data of interest. The median age was 65 years, 70.6 % were males. The median stay at ICU was 16 days and mortality rate was 81.7%. Main diagnosis on admission were sepsis 38.3%; acute pancreatitis 21.7%; cardiac surgery 16.7%; multiple trauma 11.7% and congestive heart failure 6.7%. Mean APACHE II score on admission was 17.1±6.4. Fifty six patients (93.3%) had acute renal failure at the beginning of CVVHF and all of them presented with at least one organ in failure. Eleven patients survived and were discharged from ICU (18.3%). CVVHF was mantained for a median of 91 hours per patient. The mean ultrafiltrate volume was 876±430 mL/h, and 1.8±1 filters were used per patient. The mena heparin dose was 714±214 U/h. BUN levels decreases from 67.6±25.8 mg/dL at the beginning of the procedure to 57.6±16.8 mg/dL at the end (p=0.001). Creatinine levels also decreased from 4.1±2.2 mg/dL to 3±1.5 mg/dL (p<0.001). Conclusion : CVVHF is an easy to use, safe and effective technique for treatment of critically ill patients, and it is associated with a low morbidity and perhaps an encouraging survival rate in specific pathologies. Therefore, we considered CVVHF as the renal replacement therapy of choice in critically ill patients. Intensive Care Unit. H.U. Virgen de la Victoria. Milaga 29010 Spain.
