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.