Laproscopic kidneys

[Arch Guillotti]

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Do any of you all do anything special for these cases? Normally I will place a second large bore IV and an aline and a type and cross x 2.

I was in the lounge and overheard one of the surgeons talking to another about these cases and he stated that the cases scared the crap out of him because of the issues involved in maintaining hemostasis (that is, if you lose control and hit something you aren't supposed to, venous usually, your view is hosed and their is a high chance you will have to convert to an open case). So while rare, these cases can turn into a full scale resuscitation.

Do you type and cross all of these cases, and if so, do you have the blood in the room?

 

[SleepIsGood]

That's all we do as well. I believe it is prudent to use an A line. I have an attending at our institution who adamantly is against an A line for this. But I'm with you.

 

[jwk]

We do laparascopic nephrectomies all the time with an 18ga IV, standard monitors, and no a-line. I understand the preference for a bigger or 2nd IV, but why would you routinely need an a-line?

 

[jennyboo]

18-gauge IV, standard monitors. No blood in the room (but a good sample in the bank).

Most of the lap nephrectomies I've seen at my institution are living donors with recipient in the OR next door. As such, they're usually healthy ASA I - II patients. Also because the kidney is going to someone else they're asking us to give large amounts of crystalloid (like a liter an hour) plus mannitol and furosemide to flush the organ so the patient ends up being far from hypovolemic at any given point during the procedure.

 

[SleepIsGood]

We do laparascopic nephrectomies all the time with an 18ga IV, standard monitors, and no a-line. I understand the preference for a bigger or 2nd IV, but why would you routinely need an a-line?

There's the potential for a tremendous amount of bleeing. The vessels you are working with are quite large and bleeding can be deleterious. It's not like a lap chole where the surgeon accidentally nicks the cystic artery. Accidentally nicking the renal artery/vein or even aorta can cause WIDE swings in BP.

I'd want a beat to beat determination of BP in these cases.

 

[coprolalia]

I was doing a lap hemi-nephrectomy where I was glad for the 2nd big IV and having the blood up and in the fridge. When they pulled the bulldog off the artery, they lost control of everything... view, patient's BP, etc., etc.

It was one of three times (so far) during my residency that I was scared so sh*tless that the patient was going to die on my watch, that I was shaking. I called for help, and got two other attendings and two techs in the room, and all we did was push blood, epi, and bicarb for a solid 10 minutes. The guy's BP was like 40/20 for at least 5 minutes. Needless to say, they ended-up taking the whole kidney.

At least two good IVs and have the blood close by. A-line is probably wise too, especially if the patient has any cardiopulm co-morbidities. That's my advice. These things can turn on a dime and you can go from smooth sailing to all hell breaking loose in a matter of seconds, especially if there is a uro resident that hasn't done many of them up to that point.

-copro

 

[huktonfonix]

2 good IVs and any additional monitoring to be based on the same criteria I would use for any other patient. I would place an aline only if I think I would have needed it for the patient anyway (as previously mentioned significant cardiac disease, need for frequent blood sampling, issues with NIBP monitoring). For an otherwise healthy ASA 1 donor lap nephrectomy, an aline isnt gonna tell me much. If the patient is bleeding severely, then I know his BP is low and that I need to resuscitate. An NIBP cycled rapidly with clinical data pulse ox, ETCO2) should be fine unless the case REALLY goes to crap in which case you need a cordis and a good surgeon anyway, not an aline.. However, the aline is a fairly low risk procedure so I cant really fault anyone for wanting it, I just dont personally see the need for it in most of these cases.

 

[Planktonmd]

This is one of those surgeries where your degree of preparation depends on the skill of your surgeons and on how many of these cases they have under their belts.
With a good and experienced surgeon you will be OK with a good peripheral IV and you really don't need an A line.
With a surgeon that does this surgery only occasionally or if residents are operating I would want at least 2 large bore IV's but most likely a central line + large peripheral IV.
An A line would depend on the pre-existing health status of the patient but not really necessary.

 

[SleepIsGood]

2 good IVs and any additional monitoring to be based on the same criteria I would use for any other patient. I would place an aline only if I think I would have needed it for the patient anyway (as previously mentioned significant cardiac disease, need for frequent blood sampling, issues with NIBP monitoring). For an otherwise healthy ASA 1 donor lap nephrectomy, an aline isnt gonna tell me much. If the patient is bleeding severely, then I know his BP is low and that I need to resuscitate. An NIBP cycled rapidly with clinical data pulse ox, ETCO2) should be fine unless the case REALLY goes to crap in which case you need a cordis and a good surgeon anyway, not an aline.. However, the aline is a fairly low risk procedure so I cant really fault anyone for wanting it, I just dont personally see the need for it in most of these cases.

Hey Hukton

I agree with your post to some extent. Here's my question though. What's the harm in putting an A line? Like you said the complications are VERY low. Yes, there's a chance someone might get a thrombosis or damage to the radial artery. But from my limited experience, I've seen that even when the radial artery is punctured, MULTIPLE times d/t multiple attempts....not much happens.

Once one is good at them, one can usually start these on the first shot and it becomes as difficult as putting in a regular ol IV.

I just think that with an Aline you can monitor BP better and get ABGs,etc. When something REALLY goes wrong as someone mentioned above...it's really difficult to start an Aline...usually the pt is airplaned over and is in a very odd position.....

I guess either way can be argued.

 

[jwk]

Hey Hukton

I agree with your post to some extent. Here's my question though. What's the harm in putting an A line? Like you said the complications are VERY low. Yes, there's a chance someone might get a thrombosis or damage to the radial artery. But from my limited experience, I've seen that even when the radial artery is punctured, MULTIPLE times d/t multiple attempts....not much happens.

Once one is good at them, one can usually start these on the first shot and it becomes as difficult as putting in a regular ol IV.

I just think that with an Aline you can monitor BP better and get ABGs,etc. When something REALLY goes wrong as someone mentioned above...it's really difficult to start an Aline...usually the pt is airplaned over and is in a very odd position.....

I guess either way can be argued.

Ah, the joys of academia. 🙂 An A-line just isn't necessary for a nephrectomy, unless as huk indicated, there is some underlying reason for having it. ABG's on a nephrectomy? LOL. It just doesn't happen in private practice. And although morbiditiy from an a-line is low, it's still there and certainly not as innocuous as an IV.

 

[Arch Guillotti]

What Plank said.

The case I did was a little different from a standard run of the mill donor nephrectomy on a younger patient. This lady was in her 70's and had a collecting duct tumor that required a nephroureterectomy so dissection was more difficult and everything was inflamed/scar tissue, etc. I did not think an aline was absolutely necessary for the case but I put one in anyway. I knew that I would not be finishing the case and that if I handed it off to someone else w/out an aline I would incur all sorts of grief. Turns out they did get into some trouble and the aline helped out.