Gross Examination of left kidney:Solid cystic mass which
was occupied the lower and inter polar region.
On the day of surgery consent taken ,blood & blood products booked, ASA
standard monitors attached. Premedicated with Inj Glycopyrrolate
(0.004mg/kg),Inj Midazolam (0.02mg/kg),preoxygenated with 100%
O2,Inj.Fentanyl 20mcg was given and induced with Inj Propofol
(2mg/kg),Inj.Vecuronium 1 mg given and after three minute intubation was
done orally with size 4.5 uncuffed endotracheal tube. After checking air
entry,tube was fixed and inj.Vecuronium 0.5mg for maintenance was
given.Ryles tube 10french & right internal jugular vein 5french 8 cm
central line was secured.
Patient was maintained on O2:AIR(50:50) , isoflurane at 0.8. In left
lateral position epidural catheter was secured at L1-L2 level and
Inj.Ropivacaine 0.2% infusion started to maintain blood pressure and
intra operative analgesia. Intraoperative blood loss due to lot of
adhesions and pressure symptoms causing fluctuations of BP and CVP and
was managed with PRBC 8-10ml/kg and fluids.Vitals BP was maintanined
between 90-100/60-70mmhg intraoperatively. After visualizing the
mass,nephrectomy was performed.Blood loss 200 ml,urine output-40ml,total
IV fluids-410ml,inj.Dexa1mg &inj.PCM 15mg/kg was given.
After surgery baby started taking spontaneous attempts and BP started
rising and initially treated with Inj.Xylocard 1mg/kg & Inj.Labetalol
0.2mg/kg. Due to persistent high BP inj.Labetalol 0.5mg/kg/hr started,
shifted to PICU, mechanically ventilated for better control of BP and
extubated on post op day1.Intraoperatively hypertension could not be
appretiated due to epidural infusion and blood loss.
Postoperatively inj.Labetalol continued for 3 days and discharged after
10 days of hospitalization with T.Amlodipine 2.5 mg OD, T.Minipress
2.5mg BD and T.Labetalol (1-3mg/kg)BD
Discussion :
Wilms Tumour is a highly malignant embryonal neoplasm. It may involve
one or both kidneys. Usually the tumor is unilateral but in 5% cases it
may be bilateral. Disease occur in about 1 out of 2-2.5 lakh
children2.
HT is known to be associated with several childhood cancers at
diagnosis,such as WT, neuroblastoma, brain tumors, and pheochromocytoma.
It could be due to renin secretion by the tumor or secondary to
mechanical mass effect causing renal vascular compression or thrombosis.
Hormonal secretion of glucocorticoids or catecholamines, treatment with
steroid chemotherapy, and increased intracranial pressure could be other
causes of HT3.
In children with WT, HT results from increased renin production
secondary to intra-renal vascular compression. Alternatively, renin may
also be produced by tumor cells. Increased plasma renin concentration
has been reported in approximately 80% of hypertensive WT children at
diagnosis, and relapse was observed in 3 out of 4 patients with
increased plasma prorenin/renin concentrations. Renin production is
controlled by the renin–angiotensin system, which plays a decisive role
in maintaining BP homeostasis.
It could be due to increased renin secretion in response to renal
ischemia produced by the pressure of the tumor on the hilar or
intrarenal vessel4. Moreover, the tumor itself could
directly be responsible for HT by producing renin itself. In addition,
as the Brenner–Barker hypothesis noted, there is a significant
reduction of nephrons with the development of renal HT and progressive
renal failure. Approximately 20–55% of children with WT reportedly
present with HT at diagnosis
Anesthetic management can be challenging in children with HT, diagnosed
in the pre-operative period. HT could be severe enough to cause
encephalopathy and cardiovascular compromise. Secondary
hyperaldosteronism and hypokalemia could manifest itself as chronic HT
significant intraoperative bleeding could result from improperly
controlled HT. Pre-operative recognition of HT and appropriate pre- and
perioperative treatment is mandatory for safe surgical treatment.
Angiotensin-converting enzyme inhibitors are the drugs of
choice5. One could add a short-acting beta-antagonist
to control HT in severe cases. Babies should be evaluated preoperatively
and prophylactic treatment of borderline BP in WT can be considered to
prevent post op complications.