Case Report Anesthetic Management of a Surgical …downloads.hindawi.com/journals/cria/2016/2434381.pdfCase Report Anesthetic Management of a Surgical Patient with Chronic Renal Tubular

Case ReportAnesthetic Management of a Surgical Patient withChronic Renal Tubular Acidosis Complicated by SubclinicalHypothyroidism

Hiroe Yoshioka Haruyuki Yamazaki Rie Yasumura Kosuke Wada and Yoshiro Kobayashi

Department of Anesthesiology National Hospital Organization Tokyo Medical Center 2-5-1 Higashigaoka Meguro-kuTokyo 152-8902 Japan

Correspondence should be addressed to Hiroe Yoshioka hiroe y 0614hotmailcojp

Received 2 April 2016 Revised 15 July 2016 Accepted 14 August 2016

Academic Editor Renato Santiago Gomez

Copyright copy 2016 Hiroe Yoshioka et alThis is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

A 53-year-old man with chronic renal tubular acidosis and subclinical hypothyroidism underwent lower leg amputationsurgery under general anesthesia Perioperative acid-base management in such patients poses many difficulties because bothpathophysiologies have the potential to complicate the interpretation of capnometry and arterial blood gas analysis datainappropriate correction of chronic metabolic acidosis may lead to postoperative respiratory deterioration We discuss themanagement of perioperative acidosis in order to achieve successful weaning frommechanical ventilation and promise a completerecovery from anesthesia

1 Introduction

Metabolic acidosis is categorized clinically as high or normalanion gap based on the presence or absence of unmeasuredanions in serum Renal tubular acidosis (RTA) is charac-terized by normal anion-gap metabolic acidosis originat-ing from excessive urinary loss of bicarbonate or defectiveurinary acidification [1] Therefore unlike high anion-gapacidoses (eg lactic acidosis or ketoacidosis) RTA must betreated with administration of sodium bicarbonate Howeverperioperative acid-base management in such cases posesmany difficulties because the total carbon dioxide (CO

2) con-

tent in blood as well as actual blood pH must be fully takeninto consideration for successful weaning from mechanicalventilation In addition thyroid function is associated withbasal metabolic rate and CO

2production thus subclinical

hypothyroidism presents specific challenges for anesthesiol-ogists

This case highlights the perioperative acid-base man-agement of a patient who has suffered from untreatedchronic RTA complicated by subclinical hypothyroidismwhile undergoing lower leg amputation surgery under gen-eral anesthesia We report this case because the anestheticmanagement of similar cases has rarely been reported in

addition there has been no prior report detailing the man-agement of perioperative acidosis which is the focal point ofthis case

2 Case Presentation

A 53-year-old man (height 167 cm weight 48 kg) whopresented difficulty in walking due to severe pain in his lowerleg was brought to our hospital by an ambulance The patienthad a prior history of chronic kidney disease arteriosclerosisobliterans and insulin-dependent diabetes mellitus Physicaland laboratory examination revealed ulcerative formationsin the left lower leg and severe metabolic acidosis (Table 1)An intravenous subsequently oral administration of sodiumbicarbonate resulted in marked improvement of the acidosisUpondetailed examination polyarteritis nodosawas stronglysuspected as the etiology of the refractory ulcer in the lowerleg simultaneously RTA type 4 was diagnosed based on aprior history of hyperkalemia and diabetes accompanying alow serum aldosterone level

For suspected pathophysiology a 10mg daily oral dose ofprednisolone had been administered for about 2 months buthis ulcerative lesions deteriorated therefore the patient was

Hindawi Publishing CorporationCase Reports in AnesthesiologyVolume 2016 Article ID 2434381 4 pageshttpdxdoiorg10115520162434381

2 Case Reports in Anesthesiology

Table 1 Perioperative blood gas analysis

On admission Preoperative Immediately after intubation PostoperativepH 7031 7345 7286 7345PaCO

2(mmHg) 136 277 344 371

HCO3

minus (mmolL) 35 148 160 198BE (mmolL) minus253 minus100 minus97 minus54AnGap (mmolL) 181 36 48 27Lactate (mgdL) 154 174 mdash mdashAnGap anion gap BE base excessHCO3minus bicarbonate PaCO2 arterial carbon dioxide partial pressure

Table 2 Preoperative laboratory test values

Test value (normal range)HGB (gdL) 71 (135ndash170)PLT (times109L) 59 (150ndash350)BUN (mgdL) 327 (80ndash220)Cre (mgdL) 26 (06ndash11)TP (gdL) 46 (63ndash82)Alb (gdL) 21 (35ndash52)Na (MmolL) 128 (138ndash146)K (MmolL) 53 (36ndash49)Cl (MmolL) 106 (99ndash109)PRA (ngmLh) 03 (02ndash27)PAC (pgmL) 13 (36ndash240)TSH (UdL) 617 (03ndash45)T3 (pgmL) 12 (20ndash45)T4 (ngdL) 11 (07ndash18)Alb albumin BUN blood urea nitrogen Cl chloride Cre creatinineHGB hemoglobin K potassium Na sodium PAC plasma aldosteroneconcentration PRA plasma renin activity TP total protein TSH thyroid-stimulating hormone T3 triiodothyronine T4 thyroxine

scheduled for lower leg amputation surgery about 3 monthsafter admission

Preoperative laboratory tests (Table 2) revealed impairedrenal function and hyperkalemia while those findings werecompatible with RTA type 4 With regard to endocrine func-tionwe suspected subclinical hypothyroidismdue to reducedplasma triiodothyronine (T3) levels and elevated thyroid-stimulating hormone (TSH) Blood gas analysis showedsevere metabolic acidosis accompanied by normal aniongap corrected for albumin and compensatory respiratoryalkalosis (Table 1) because the oral sodium bicarbonatetherapy had been discontinued 2 months before the surgeryDespite severe metabolic acidosis the history and physicalexamination did not indicate any obvious evidence of hyper-ventilation The patient had a body temperature of 364∘Cblood pressure of 12173mmHg a heart rate of 89 beats perminute (bpm) a respiratory rate of 10 breaths per minuteand an oxygen saturation level of 98 (room air) chestradiography and electrocardiogram examinations revealedno abnormalities

General anesthesia was scheduled instead of regionalanesthesia because of low platelet count Oral prednisolone(10mgday) was continued until the day of the surgery

Preoperative values of blood pressure heart rate respiratoryrate and body temperature were almost within normalranges 14291mmHg 84 bpm 10 breaths per minute and358∘C respectively Endotracheal intubation under gen-eral anesthesia was provided with intravenous inductionof 50 120583g fentanyl 70mg propofol and 40mg rocuroniumand anesthesia was maintained by 12ndash18 sevoflurane withintermittent intravenous administration of fentanyl Thetotal amount of fentanyl was 250120583g during operation Theend tidal CO

2(ETCO

2) level of the patient was 22mmHg

immediately after intubation then his minute volume wasset at 3 Lmin However the blood gas analysis revealed thatthe arterial carbon dioxide partial pressure (PaCO

2) of the

patient was within the normal range (Table 1) The frequencyof ventilation was subsequently adjusted to and maintainedat a rate of 3ndash35 Lmin in order to ensure that the PaCO

2

remained within the normal range During this time ETCO2

levels were 22ndash29mmHgThe total time of surgery was 1 h and 48min 1250mL of

crystalloid solution (normal saline and hypotonic solutionwhich contains no potassium) 280mL of red blood celltransfusion and 100mL of 84 sodium bicarbonate wereadministered during the surgery The total blood loss andurine volume were determined to be 170mL and 150mLrespectively Although the patient continued to exhibit mildsigns of metabolic acidosis upon completion of surgery(Table 1) this did not appear to impact his circulatorycondition A chest radiograph taken upon completion ofsurgery revealed a small amount of bilateral pleural effusionThe patient was given a muscle relaxant antagonist (200mgof sugammadex) after awakening and was extubated after aspontaneous breathing trial There was no appreciable eventduring the surgery except a red blood cell transfusion Nosubsequent problems related to hyperventilation or apneawere observed and the patient was sent back to his roomwithout incident

3 Discussion

RTA is classified into three types based on pathophysiologyAmong them RTA type 4 is characterized by distal tubularaldosterone resistance or aldosterone deficiency resulting inhyperkalemia and onset of metabolic acidosis [1] RTA type4 is usually asymptomatic with only mild acidosis but canbe occasionally accompanied by life-threatening electrolytedisturbances and severe decrease in bicarbonate concentra-tion In addition its clinical course tends to be prolonged

Case Reports in Anesthesiology 3

and thus complicated as with this case Therefore ratherthan actual blood pH time-dependent changes in containedCO2in the whole body should be taken into consideration

for successful weaning from mechanical ventilation whenperioperative corrective treatment is performed

Literature reviews of anesthetic management of patientswith severe acute metabolic acidosis have focused on themaintenance of adequate blood pressure and tissue perfusionHowever in chronic cases anesthesiologists should giveattention to intraoperative acid-base status in order to ensureadequate spontaneous breathing immediately after surgery

In general respiratory drive is stimulated by low pHparticularly in patients with chronic metabolic acidosisTherefore any arterial pH which is higher than preoperativevalue can be associated with a higher risk for postoperativehypoventilation to various degrees even if normal acid-basebalance without hypercapnia has been achieved at the timeof weaning from mechanical ventilation Rapid or excessivecorrection of chronic metabolic acidosis during surgery leadsto either life-threatening hypoventilation or sudden onset ofapnea [2]

With regard to correction of acidosis there is no con-clusive evidence to support bicarbonate administration tosurgical patients with chronic metabolic acidosis In contrastpatients of RTA type 4 need administration of bicarbonateat a daily rate of 15ndash2mmolkg [1] nevertheless the doseand rate of perioperative bicarbonate administration remaincontroversial in particular cases

In general severe metabolic acidosis with arterial pH lt72 is associated with higher mortality in critically ill patients[3] therefore we adjusted the ventilator settings and bicar-bonate administration to maintain arterial pH at a valuesimultaneously less than the preoperative value and higherthan 72 along with normocapnia

On the other hand the clinical picture of this case wasremarkable in the light of perioperative PaCO

2level when

compared to that of most patients with severe metabolicacidosis

Firstly although the preoperative PaCO2of the patient

was extremely low (277mmHg) which seems to be respira-tory overcompensation no obvious signs of deep breathing orhyperventilation were observed Secondly despite the adjust-ment of the minute volume in order to bring the PaCO

2level

within the normal range low minute volume was requiredfor this patient For comparison the minute volume and thePaCO

2level were assessed in other surgical patients without

metabolic acid-base disorders (Table 3) The minute volumeand the PaCO

2level exhibited by the patient in this case were

lower than the group average Based on these observationswe speculated that any underlying pathophysiologies mightlead to a decrease in PaCO

2without an increase in alveolar

ventilationSpecifically the body equilibrium of RTA patients is

known to shift to the left as follows H+ + HCO3

minus999448999471

H2CO3 999448999471 H

2O + CO

2 as such if the bicarbonate level

is not replenished the internal CO2level will be depleted

resulting in a decline in PaCO2

As another speculation subclinical hypothyroidism maypossibly lead to decreased CO

2production in the body

Table 3 Minute volume and PaCO2levels of 29 male patients (aged

48ndash90) subjected to nonlaparoscopic surgery

Mean (SD)Age (years) 740 (112)Height (cm) 1650 (52)Weight (kg) 487 (22)Minute volume (Lmin) 48 (10)PaCO

2(mmHg) 391 (50)

PaCO2 arterial carbon dioxide partial pressure

because decreased thyroid function is associated with dimin-ished basal metabolic rate thus resulting in reduced tissueCO2production [4] similarly subclinical hypothyroidism is

reported to induce a decrease in resting energy expenditure[5]

Definitely subclinical hypothyroidism and RTA type 4have the potential to complicate the reading and interpreta-tion of capnometry and PaCO

2measurements

In order to avoid postoperative respiratory deteriorationin patients with chronic metabolic acidosis anesthesiologistsshould give basic consideration to the previously docu-mented pitfalls type of anesthesia dose of opioids used incombination methods of postoperative pain managementand body temperature of the patient Besides perioperativeacid-base management on the basis of the abovementionedgoal of pH and PaCO

2will probably determine success of

weaning frommechanical ventilation andpromise a completerecovery from anesthesia in patients with RTA complicatedby subclinical hypothyroidism Given that hemodynamicstability has already been achieved in patients suffering fromlong-term preoperative exposure to RTA with low serumbicarbonate concentration the main anesthetic concernsshould include the dose and rate of bicarbonate adminis-tration tailored according to the patientrsquos usual acid-basebalance and preoperative respiratory status PaCO

2levels the

minute volume and the presence of signs of deep breathingor hyperventilation

Ethical Approval

Written informed consent from the patient was not obtainedbecause of the patientrsquos death The authors received per-mission from the Institutional Review Board of NationalHospital Organization Tokyo Medical Center to publish thiscase report

Competing Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper

References

[1] J R Soriano ldquoRenal tubular acidosis the clinical entityrdquo Journalof the American Society of Nephrology vol 13 no 8 pp 2160ndash2170 2002


[2] D Chan SThong andONg ldquoPostoperative apnoea in an adultpatient after rapid correction of metabolic acidosisrdquo OA CaseReports vol 3 no 2 article 16 2014

[3] B Jung T Rimmele C Le Goff et al ldquoSevere metabolic ormixed acidemia on intensive care unit admission incidenceprognosis and administration of buffer therapy A prospectivemultiple-center studyrdquo Critical Care vol 15 no 5 article R2382011

[4] H T Lee and M Levine ldquoAcute respiratory alkalosis associatedwith low minute ventilation in a patient with severe hypothy-roidismrdquo Canadian Journal of Anaesthesia vol 46 no 2 pp185ndash189 1999

[5] M Tagliaferri M E Berselli G Calo et al ldquoSubclinical hypo-thyroidism in obese patients relation to resting energy expendi-ture serum leptin body composition and lipid profilerdquoObesityResearch vol 9 no 3 pp 196ndash201 2001

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Table 1 Perioperative blood gas analysis

On admission Preoperative Immediately after intubation PostoperativepH 7031 7345 7286 7345PaCO

2(mmHg) 136 277 344 371

HCO3

minus (mmolL) 35 148 160 198BE (mmolL) minus253 minus100 minus97 minus54AnGap (mmolL) 181 36 48 27Lactate (mgdL) 154 174 mdash mdashAnGap anion gap BE base excessHCO3minus bicarbonate PaCO2 arterial carbon dioxide partial pressure

Table 2 Preoperative laboratory test values

Test value (normal range)HGB (gdL) 71 (135ndash170)PLT (times109L) 59 (150ndash350)BUN (mgdL) 327 (80ndash220)Cre (mgdL) 26 (06ndash11)TP (gdL) 46 (63ndash82)Alb (gdL) 21 (35ndash52)Na (MmolL) 128 (138ndash146)K (MmolL) 53 (36ndash49)Cl (MmolL) 106 (99ndash109)PRA (ngmLh) 03 (02ndash27)PAC (pgmL) 13 (36ndash240)TSH (UdL) 617 (03ndash45)T3 (pgmL) 12 (20ndash45)T4 (ngdL) 11 (07ndash18)Alb albumin BUN blood urea nitrogen Cl chloride Cre creatinineHGB hemoglobin K potassium Na sodium PAC plasma aldosteroneconcentration PRA plasma renin activity TP total protein TSH thyroid-stimulating hormone T3 triiodothyronine T4 thyroxine

scheduled for lower leg amputation surgery about 3 monthsafter admission

Preoperative laboratory tests (Table 2) revealed impairedrenal function and hyperkalemia while those findings werecompatible with RTA type 4 With regard to endocrine func-tionwe suspected subclinical hypothyroidismdue to reducedplasma triiodothyronine (T3) levels and elevated thyroid-stimulating hormone (TSH) Blood gas analysis showedsevere metabolic acidosis accompanied by normal aniongap corrected for albumin and compensatory respiratoryalkalosis (Table 1) because the oral sodium bicarbonatetherapy had been discontinued 2 months before the surgeryDespite severe metabolic acidosis the history and physicalexamination did not indicate any obvious evidence of hyper-ventilation The patient had a body temperature of 364∘Cblood pressure of 12173mmHg a heart rate of 89 beats perminute (bpm) a respiratory rate of 10 breaths per minuteand an oxygen saturation level of 98 (room air) chestradiography and electrocardiogram examinations revealedno abnormalities

General anesthesia was scheduled instead of regionalanesthesia because of low platelet count Oral prednisolone(10mgday) was continued until the day of the surgery

Preoperative values of blood pressure heart rate respiratoryrate and body temperature were almost within normalranges 14291mmHg 84 bpm 10 breaths per minute and358∘C respectively Endotracheal intubation under gen-eral anesthesia was provided with intravenous inductionof 50 120583g fentanyl 70mg propofol and 40mg rocuroniumand anesthesia was maintained by 12ndash18 sevoflurane withintermittent intravenous administration of fentanyl Thetotal amount of fentanyl was 250120583g during operation Theend tidal CO

2(ETCO

2) level of the patient was 22mmHg

immediately after intubation then his minute volume wasset at 3 Lmin However the blood gas analysis revealed thatthe arterial carbon dioxide partial pressure (PaCO

2) of the

patient was within the normal range (Table 1) The frequencyof ventilation was subsequently adjusted to and maintainedat a rate of 3ndash35 Lmin in order to ensure that the PaCO

2

remained within the normal range During this time ETCO2

levels were 22ndash29mmHgThe total time of surgery was 1 h and 48min 1250mL of

crystalloid solution (normal saline and hypotonic solutionwhich contains no potassium) 280mL of red blood celltransfusion and 100mL of 84 sodium bicarbonate wereadministered during the surgery The total blood loss andurine volume were determined to be 170mL and 150mLrespectively Although the patient continued to exhibit mildsigns of metabolic acidosis upon completion of surgery(Table 1) this did not appear to impact his circulatorycondition A chest radiograph taken upon completion ofsurgery revealed a small amount of bilateral pleural effusionThe patient was given a muscle relaxant antagonist (200mgof sugammadex) after awakening and was extubated after aspontaneous breathing trial There was no appreciable eventduring the surgery except a red blood cell transfusion Nosubsequent problems related to hyperventilation or apneawere observed and the patient was sent back to his roomwithout incident

3 Discussion

RTA is classified into three types based on pathophysiologyAmong them RTA type 4 is characterized by distal tubularaldosterone resistance or aldosterone deficiency resulting inhyperkalemia and onset of metabolic acidosis [1] RTA type4 is usually asymptomatic with only mild acidosis but canbe occasionally accompanied by life-threatening electrolytedisturbances and severe decrease in bicarbonate concentra-tion In addition its clinical course tends to be prolonged









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H2CO3 999448999471 H

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Ethical Approval


Competing Interests


References












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PPAR Research



Journal of

ObesityJournal of
























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H2CO3 999448999471 H

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Competing Interests


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PPAR Research



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ObesityJournal of


























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OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















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Documents

Case Report Anesthetic Management of a Surgical …downloads.hindawi.com/journals/cria/2016/2434381.pdfCase Report Anesthetic Management of a Surgical Patient with Chronic Renal Tubular