Anesthesia Management For Patients With Uremia Secondary Hyperparathyroidism Undergoing Total Parathyroidectomy Combinded With Autotransplantation

OBJECTIVE:Secondary hyperparathyroidism is a common and serious complication in dialysis patients,surgery is the most safe and effective clinical treatment so far,.parathyroidectomy with a surgical rate of 2-8 per 1000 patients in Dialysis Outcomes Practice Patterns Study(DOPPS).On account of the pathophysiologic changes caused by end-stage kidney disease and hyperparathyroidism,those patients often presented with hyperkalemia and hypocalcemia,and their risk of cardiovascular complications is also significantly increased.However,the involved cases in the previous literature is generally small,and their conclusions are not consistent.Therefore,we want to investigate the perioperative hyperkalemia and hypocalcemia rates,as well as the cardiovascular complications in this population,and analyze the relevant risk factors,so as to provide clinical guide for the perioperative anesthesia management of these patients in the future.METHODS:A total of 360 patients with uremia secondary hyperparathyroidism who underwent total parathyroidectomy combined with autotransplantation in guangdong general hospital from January 2013 to November 2018 were selected as the subjects,patients were divided into two groups according to their preoperative dialysis methods,there were 44 cases in peritoneal dialysis group and 316 cases in hemodialysis group.General clinical data of all patients were collected,including age,gender,body weight,dialysis pattern and duration,preoperative hemoglobin concentration,coexistent disease,electrocardiogram,chest X-ray or chest CT scan and echocardiography and other imaging findings.The serum potassium and calcium concentrations of the patients were recorded on the morning of the operation,after the total removal of the parathyroid glands during the operation and on the evening of the operation.Calculate the incidence of perioperative hyperkalemia and hypocalcemia,and the correlation between electrolytes concentration and general clinical data of patients is analyzed by statistical software SPSS 22.0.RESULTS:1.Hyperkalemia:Intraoperative and postoperative serum potassium levels in the hemodialysis patients were significantly higher than that before the surgery,and the difference was statistically significant(P<0.05),but there was no statistically significant difference between postoperative and intraoperative serum potassium levels(P>0.05).The serum potassium levels in the peritoneal dialysis patients increased gradually before,during and after the surgery,and the differences were statistically significant(P<0.05).There were 83 patients(23.1%)with intraoperative hyperkalemia(>5.3mmol/L),and postoperatively 95 patients(30.1%)presented with hyperkalemia.The critical values for predicting intraoperative hyperkalemia in hemodialysis patients and peritoneal dialysis patients were 4.225mmol/L and 4.460mmol/L,respectively.When the blood potassium level of hemodialysis patients and peritoneal dialysis patients exceeded the critical value of 4.765mmol/L and 4.830mmol/L respectively,the risk of severe hyperkemia(>6.0 mmol/L)was significantly increased on the night of the operation.2.Correlation analysis of serum potassium level:The preoperative serum potassium level was the main relevant variable of intraoperative hyperkalemia and the hyperkalemia on the night of the operation.Preoperative hemoglobin concentration of hemodialysis patients and body weight of peritoneal dialysis patients were positively correlated with serum potassium level on the night of operation.There was no correlation between patients’ age,gender,duration of dialysis and serum potassium levels.3.Hypocalcemia:Compare with the preoperative values,the serum calcium levels of hemodialysis patients decreased successively during and after the operation,with statistically significant differences(P<0.05).In the peritoneal dialysis group,the intraoperative serum calcium levels was lower than that before the operation,and the difference was statistically significant(P<0.05),but the differences between the postoperative serum calcium levels and any of the above two values were not statistically significant(P>0.05).There were 28 patients(7.8%)with intraoperative hypocalcemia(<2.08mmol/L),and 76 patients(21.1%)with postoperative hypocalcemia.4.Correlation analysis of serum calcium level:Preoperative serum levels and gender were relevant variables of intraoperative and postoperative hypocalcemia,The age of hemodialysis patients was positively correlated with the serum calcium level,but there was no correlation between body weight,preoperative hemoglobin,duration of dialysis and serum calcium level.5.Cardiovascular complications during hospitalization:3 patients presented with transient myocardial ischemia;one patient was complicated with acute anterior interstitial myocardial infarction,and developed into left heart failure;one patient had rapid atrial fibrillation;one patient died suddenly after surgery.CONCLUSION:Preoperative serum potassium increased after parathyroidectomy with autotransplantation in patients with secondary hyperparathyroidism,whereas their serum calcemia decreased during this time.The preoperative serum potassium level could used to predict intraoperative and postoperative hyperkalemia.Postperative hyperkalemia is more likely to occur in hemodialysis patients with higher preoperative hemoglobin concentration and in heavier peritoneal dialysis patients.Low preoperative serum calcium level and men are risk factors for hypocalcemia after parathyroidectomy,and hypocalcemia is more likely to occur in younger hemodialysis patients.