Residents' Abstracts Presented at the WARC, 2000
Ahmed | Chao | Falabella | Hadap | Lessler | Shah | Shahangian | Yumul
Use of midazolam in misdiagnosed ectopic pregnancy
Ahmed K, MD, Patel RV, MD, Bhasin, PS MD.
Department of Anesthesiology, LAC-USC Medical Center, USC Keck School of Medicine, Los Angeles, CA 90033
Incidence of ectopic pregnancy is 16 per 1000 reported pregnancies in the USA.1 In routine anesthesia, common practice is to premedicate patients with midazolam (benzodiazepine) to alleviate anxiety, followed by fentanyl, induction agents and succinylcholine for general anesthesia. This practice may cause post-operative concerns. Benzodiazepines are known to cause birth defect if given during first trimester of pregnancy2. In most ectopic pregnancies, we anticipate that the pregnancy will be terminated during surgery, and hence the use of routine anesthetic medications. Sometimes diagnosis is wrong. Whenever midazolam is given to patients with misdiagnosed ectopic pregnancy, there is a chance of teratogenic effects to the newborn.
Methods:
A database containing records of patients who were admitted with diagnosis of tubal pregnancy, ectopic pregnancy and extrauterine pregnancy during the periods of 1/93 to 3/99 were reviewed. 661 patients were identified to have above diagnosis with the help of ultrasound. Intraoperative confirmation of misdiagnosed ectopic pregnancy was established. Misdiagnosis included intrauterine pregnancy, salphingitis and tubovarian mass. The anesthesia did include use of midazolam as preoperative medication.
Results:
Out of total 661 patients, 18 patients (2.7 %) were misdiagnosed, of which 13 patients (1.95 %) had intrauterine pregnancy. Eight patients out of these 13 had D&C, 5 patients were allowed to continue pregnancy to term. These were 5 patients who were exposed to midazolam during 1st trimester of pregnancy and are the focus of discussion.
Total Cases (661) Correct Diagnosis = 643 Misdiagnosis Cases = 18 (2.7%) Intrauterine Pregnancy = 13 (1.95%) Other than intrauterine = 5 - D&C = 8 - No D&C = 5 Discussion:
Those 5 patients who continued to term pregnancy, were exposed to midazolam in first trimester, thus exposed to possibility of teratogenic effects in the newborn. Because of increased use of fertility drugs ectopic and multiple pregnancy incidence is on the rise. So we may be faced with frequent encounter in future if we continue to have increased incidence of ectopic pregnancy. We recommend that whenever pre-operative diagnosis is ectopic pregnancy, benzodiazepines (midazolam) be excluded from premedication.
References:
1. Goldner TE, Lawson HW, Xia Z, Atrash HK, Surveillance for ectopic pregnancy-United States, 1970-989. MMNR CDC Surveillance Summary 1993; 42: (SS6): 73-85
2. McElhatton PR, The effects of benzodiazepine use during pregnancy and lactation. Reproductive Toxicology. 8(6):461-75, 1994 Nov-Dec
Subdural Hematomas and Cerebral Infarct after Dural Puncture during the Administration of Labor Epidural Analgesia
Fu Chao, MD, Matthew Srikureia, DO Thomas Nguyen, MD, Sean Lavine, MD
University of Southern California School of Medicine, Los Angeles, CaliforniaAbstract:
Intracranial hemorrhage following dural puncture in patients without preexisting intracranial diseases is an exceptionally rare complication. We report a case of bilateral subdural hematomas, and cerebral infarct after inadvertent lumbar puncture in an obstetric patient. A healthy 18-year-old woman had inadvertent dural puncture at L2-L3 level with an 18G Tuohy needle during labor epidural analgesia attempt. On the postpartum day (PPD) one the patent complained of positional headache, nausea and vomiting. She was treated conservatively with bed rest, fluids, caffeine, and analgesia. Since the patient was able to ambulate and her symptoms were improving, she was discharged on PPD 3. On PPD 17 the patient returned to the hospital complaining of non-positional headache, nausea, vomiting, foul lochia, fever, and low abdominal pain. She was readmitted with the diagnosis of postpartum endometritis. On PPD 20, in addition to persistent headache, she developed photophobia. The neurologist concurred with the diagnosis of postdural puncture headache (PDPH) and recommended symptomatic management. On PPD 24, the patient was found obtunded but responsive to verbal commands. Her pupils were 4 mm dilated bilaterally and reeacted sluggishly to light. She had left gaze paresi, left facial palsy, and left upper extremity weakness. Computerized tomography showed a large right chronic subdural hematoma with evidence of rebleeding, a small left subdural hematoma, and midline structures shifted to the left. She underwent an emergent craniotomy for evacuation of the right subdural hematoma. Three days after craniotomy, magnetic resonance imaging (MRI) showed evidence of acute infarct in the right temporoparietal lobe and no significant change in the left subdural hematoma. However, eight days later, the follow-up head MRI showed enlargement of left subdural hematoma and fluid collection. Patient underwent a bum hde craniotomy for evacuation of left subdural hematoma and fluid collection. She did well and was discharged home 5 days after her last operation with some left-sided fine motor weakness and gait instability. There are two phases in the development of subdural hematoma after dural puncture. The first phase is common to all patients who develop PDPH and is characterized by a strong headache hours or days after the dural puncture. The headache is worse in the upright position apparently associated with the loss of CSF. However, it responds to analgeia, rest, caffeine and hydration, and improves or disappears after a certain period of time. In the second phase, unique to those patients who will develop subdural bleeds, the headache tends to be more severe and to persist even in the recumbent position, ana to be associated with other symptoms including vomiting, blurred vision, drowsiness, and disorientation. In summary, atypical or persistent headache after dural puncture could be the presenting symptom of subdural hematomas, which require prompt neurosurgical evaluation.
Hydrothorax during Laparoscopic Splenectomy
Andres Falabella, MD, Fu Chao, MD, Thomas Nguyen, MD
University of Southern California School of Medicine, Los Angeles, CaliforniaAbstract:
Hydrothorax has not been previously described as a complication of laparoscopic surgery. We report a case of hydrothorax developed during the course of laparoscopic splenectomy. A 72-yr-old, 71 kg man with splenomegaly was scheduled to undergo a laparoscopic splenectomy. His EKG, complete blood count, electrolytes, PT, PTT and chest x-ray were Wthin normal limits. Computerized tomography of the abdomen showed marked splenomegaly suggesting splenic lymphoma. After preoxygenation, general anesthesia induction was performed intravenously with thiopental, rocuronium, fentanyl and midazolam. Anesthesia was maintained with isoflurane, fentanyl, rocuronium and oxygen. The patient was placed in the supine position with a mild elevation of the left side. Carbon dioxide (CO2) pneumoperitoneum was created with a pressure controlled insulator to an intraabdominal pressure of 15 mm Hg. Once the hilum of the spleen was clamped, the surgeons alerted us of the possibility of a pneumothorax due to possible trauma to the diaphragm, but no changes in the patient's vital signs or peak airway pressure were noted. When surgery was finished, muscular paralysis was reversed with neostigmine and glycopyrrolate. When patient was breathing spontaneously, his oxygen saturation decreased from 99% to 90%, and his end tidal C02 increased to 60 mm Hg. After he was placed back on mechanical ventilation, physical examination revealed markedly diminished breath sounds and dullness on percussion of the left chest. A chest x-ray showed marked left pleural effusion with no pneumothorax. A chest tube was placed and two liters of irrigation fluid were drained. The patient was successfully extubated few minutes later. The chest tube was removed on the second postoperatJive day and the patient was discharged home on the fourth postoperative day. Pneumothorax is a recognized complication of laparoscopic surgery. There are several possible routes by which carbon dioxide may tract its way from the peritoneal cavity to the pleural cavity: the presence of a congenital diaphragmatic defect (patent pleuroperitoneal canal), mediastinal pleural disrupted by the pressure in pneumomediastinum, and surgical trauma to the diaphragm. Our patient had a large hydrothorax but no pneumothorax. He probably had a diaphragmatic tear that happened while there was a large amount of irrigation fluid collection covering that tom area of the diaphragm. This fluid collection could enter the pleural cavity and could also act as seal impeding CO2 to enter the pleural cavity.
Acute Normovolemic Hemodilution: Reduction of transfusion requirements during liver resection.
Hadap V. MD, Bhasin PS. MD, Patel RV. MD, Jabbour N. MD, Selby R. MD, Genyk Y. MD
Department of Anesthesiology, LAC-USC Medical Center, Los Angeles, CA
BACKGROUND: Allogeneic blood transfusion during liver resection for malignancies has been associated with an increased incidence of tumor recurrence and decreased survival in some series. Acute normovolemic hemodilution (ANH) has been utilized in cardiac, orthopedic, and major general surgery procedures to reduce the use of banked blood products. We therefore sought to determine the safety and efficacy of ANH during liver resection in an adult popubtion.
METHODS: Twenty consecutive patients undergoing major liver resection with ANH were compared with 20 age- and disease-matched controls. The diseases included hepatoma (5 in each group), carcinoid (1 versus 0) and other (4 versus 2); and the procedures included total (right or left) hepatic lobectomy (7 versus 6), partial lobectomy (2 versus 3) and trisegmentectomy (2 versus 1).
RESULTS: There was no significant difference in operating time or estimated blood loss between the two groups. There was no perioperative morbidity related to ANH. The use of ANH resulted in a 80% reduction in mean packed red blood cells transfusion during liver resection. Only 17% of patients undergoing ANH required packed red cells transfusion, whereas 87% of historical control patients required allogenic transfusion.
CONCLUSION: The use of ANH reduces the need for homologous transfusion during liver resection. ANH is a safe technique during liver resection and is not associated with perioperative morbidity.
Migration of Intrathecal Catheter into Subdural Space Post Implantation of a Programmable Subcutaneous Pump
Paul A. Lessler, M.D. and Jack Berger, M.D., Ph.D.
Department of Anesthesiology and Pain Medicine University of Southern California, Keck School of Medicine
The migration of epidural and intrathecal catheters is not unusual. It is found in 0.82% of epidural catheter attempts. (1) Often times, these catheters either erode or become dislodged into new areas. More often, an epidural catheter will erode into the subdural intrathecal space. It is highly unusual and previously unreported, that an intrathecal catheter would migrate out into the subdural space. (2) However, in this case a Medtronic intrathecal one?piece catheter was placed into the intrathecal space and secured in place. After two months, when the pain control became ineffective, it was determined that the tip of the catheter had relocated into the subdural space.
Report of a Case
A 48-year-old female presented with chronic pain in the rectum, pelvis and lower abdomen, with radiation to her legs. The patient's symptoms began in January 1975, starting with decreasing bowel function and resulting in a total colectomy and ileorectostomy in 1995. The patient subsequently developed multiple fistulae. This necessitated a temporary ileostomy in October 1995. Soon after this procedure, she began developing severe rectal pain, which radiated into her pelvis, lower abdomen and down her legs.
The patient underwent a series of interventional procedures for her pain, including sympathetic blocks, caudal blocks and hypogastric phenol blocks, without any significant relief. Neurological evaluation revealed damage to the sacral nerve plexus. The patient was placed on multiple medication trials including, Depakote, Neurontin, Percocet, methadone, Duragesic and intravenous lidocaine without any substantial relief
The patient described the pain in the rectum like that of a "hot poker" which travels to her lower abdomen and pelvis and then down both her legs, anteriorly and posteriorly. Her Visual Analogue Pain Score ranged from 7-10/10 and was never lower.
The patient was admitted to the University Hospital for a trial of continuous epidural analgesia in September 1991 This was successful using a combination of Ropivocaine, Clonodine and Hydromorphone. The following month, the patient had and insertion of a one-piece spinal catheter through a #15 Touhy needle at L 4-5, using a right paramedian approach. The catheter was inserted to 10 cm without resistance and the location of the tip of the catheter was confirmed at the L 1 level using fluoroscopy and myelogram. Cerebrospinal fluid was freely dripping frm the catheter before it was attached to the implanted Medtronic pump. The catheter was secured in place using a 3?0 silk suture purse string. The patient initially had excellent pain control for the first two months following the implantation of the pump and catheter. However, at the end of November 1999, the patient lost pain control and had a seroma formation in the posterior wound. Radiological examination, by accessing the accessory port and injecting Isoview 200, indicated that the catheter had migrated into the subdural space. (See Figure 1.) The patient was readmitted for outpatient surgery and the catheter was replaced in the intrathecal space. The patient is currently receiving adequate pain control and has resumed activities that she was unable to participate in for over a year.
Discussion:
We have described a patient who initially had adequate pain control after implantation of an intrathecal catheter and a Medronics pump. This is an established and acceptable procedure in controlling chronic opioid responsive pain. Anatomically, the subdural space is a potential space. The dura and the arachnoid are separated by a thin film of lymph. (Fig. 2) (9) The canalization and subsequent injection of local anesthetic, when doing a spinal, usually results in a total or high spinal anesthetic. (3) Gershon reported a case where an epidural was placed for labor and delivery and found that large volumes of local anesthetics were required for sensory anesthesia during a g cesarean section. The poKon of this catheter was confirmed radiologically to be in the subdural space. Gershon concluded that a high percentage of epidural catheters may.be in the epidural space and undiagnosed. Thus, he refives some of the possible dangers of subdural catheter placement. (4) Endine and Yucle report intrathecal catheter dislodgment in 4.5% of patients. (5) The rate of catheter dislodgment and migration was 20% with tunneling and 22% without tunneling. These authors warn against potential hazards of drugs inadvertently delivered to the subdural space. They state that opioids accidentally given in this manner may cause a progressive respiratory depression. This depression has a longer effect than an equivalent intrathecal injection. In their study they reported the migration of 7 intrathecal catheters in 148 patients having epidurals. (5)The protocol for determining the migration of the intrathecal catheter is to first give a bolus of drug and determine the response. This is not practical in implanted pump patients. The second procedure for this problem in to do x-ray studies and thirdly, a CT scan, if necessary. (6)(10)(11)
According to Nanmerin (7) the most common complication of intrathecal delivery systems is the migration or misplacement of the catheter into the epidural space. An extensive search of the literature does not produce any other report. Recently, a patient was found to have an intrathecal catheter, which was inserted for Baclofen delivery, migrate into the epidural space. The catheter was originally very effective and stopped working after approximately six months. Imagining with contrast showed the characteristic "railroad track pattern" indicating that the catheter had migrated into the subdural space. Serial NMI's proved the catheter position. The catheter was reinserted and the patient was improved. (8)
We have tried to examine the mechanics of this complication. It is possible that when the catheter was originally inserted it was inserted into the subdural space and eventually pushed through into the intrathecal space at the time of insertion. It is also possible that after some time the catheter can retract back down into the subdural space where it becomes ineffective. Another possibility is that the catheter is properly inserted into the intrathecal space, but eventually will erode into the subdural space and become ineffective.
It is the author's conclusion that this complication, although rare, must be considered in the differential diagnosis of malfunctioning intrathecal catheter delivery systems for pain management.
References & Bibliography
(1) Forrester, DJ, Murkherji, S. K., Mayer, D. C., Spielman, F.J. Dilute Infusion for
Labor, Obscure Subdural Catheter, and Life Threatening Block at Cesarean Delivery.
Anesthesia & Analgesia 1999; 89: 1267
(2) Bredtmann F, Scholtz A. Subdural Location of a Catheter. A Complication of
Peridural Anesthesia Regional Anaesthesie 1989: 12(5): 102?5
(3) Jack' s Book: 163
(4) Gershon, R.Y. Surgical Anaesthesia for Caesarean Section with a Subdural Catheter
Canadian Journal ofAnaesthesia 1996; 43: 1068-71
(5) Erdine S., Yucel, A. Complications of Drug Delivery Systems Pain Reviews 1995; 2:
227-242
(6) Gianino, J.M., York, M.M., Paice, J.A. Mechanical System Complications
Intrathecal Drug Therapy for Spasticity cumUddi 1996; 155-171
(7) Nanmerin
(8) Mekhail, N. Pain Management Center, Cleveland Clinic Foundation, Cleveland, OH
(9) Netter, F.H., Atlas of Human Anatomy Ciba-Geigy Medical Education 1989; 155
(10) Naumann, C, Erdine, S, Koulousakis, A, Van Buyten, J.P., Schuchard, M. Drug
Adverse Events and System Complications of Intrathecal Opioid Delivery for Pain:
Origins, Detection, Manifestations, and Management Neuromodulation 1999; 2: 92-107
(11) Mack, P.F., Gurvitch, D.L., Gadalls, F. Transient Paraplegia After Epidural
Anesthesia in a Parturient .Anesthesia Analgesia 2000, 90: 114-115
INITIAL EXPERIENCE WITH THE VIDEO INTUBATION SYSTEM
P. Shah, MD, J.Szenohradszkyy, MD, Ph.D., R. Chorn, B.Sc., MBChB, FRCPC, R. Patel, MD, M. Mikhail, MD, E. Strum, MD, R.L. Katz, MD
Department of Anesthesiology, Keck School of Medicine, University of Southern California, Los Angeles
AIM: To use the flexible video intubating scope for oral and transnasal intubation, and to check the position of a double lumen tube and laryngeal mask airway. To teach anesthesia residents fiberoptic intubation using this system both in normal and in difficult airway settings. To demonstrate the value of this technique and to gain acceptance from anesthesiologists, surgeons and operating room personnel.
METHODS: After obtaining IRB approval and informed verbal consent, 50 adult patients (age 20-81 years, 32 female, 19 male) undergoing elective surgery at USC University Hospital were studied. We used a 3.7 mm E.D. scope. With the exception of 2 cases, oro-tracheal fiberoptic assisted intubation was performed under general anesthesia. Each patient received 0.2-0.4 mg glycopyrrolate I.V. 20-30 min prior to induction of anesthesia. After muscle relaxation, the oropharynx was suctioned, and the tongue was gently pulled up prior to advancement of the fiberoptic scope into the oral cavity. The time from placement of the scope in the mouth until the trachea was reached was measured In one patient with a difficult airway, "awake intubation" was performed in another patient, the position of a laryngeal mask airway was checked. In 39 patients, the fiberoptic scope as placed and the trachea was intubated transorally. In 9 patients, double lumen tube position was checked. The tube placements and positions were recorded on video tape.
RESULTS: In 39 patients the fiberoptic scope was placed in the trachea via the oral cavity. The mean time spent for the placement was 135 sec (range 8-900 sec, median 60 sec). In one patient, a bronchus tumor in the left lower lobe was visualized, and in another patient a mucus secreting WRwr was detected in the right lower lobe. In 9 patients the tracheal and endobronchial position of a double lumen tube was checked, requiring correction in 6 cases. One patient required a transnasal intubation, and in another patient the position of an LMA was confirmed, which was in central position (Brimacombe Berry #4). Some photographs, taken from the video tape, illustrate the sequence of introduction of the fiberscope into the trachea.
CONCLUSION: The magnified view on the TV screen makes assessment of the anatomy easy and the insertion of the tracheal tube faster, with less tissue trauma. The system is a very useful tool for educating anesthesia residents. The airway manipulation can be observed simultaneously with the staff member, making the learning process easier and more satisfactory. The video recording capability enables repeated review and analysis of the entire intubation procedure. An advantageous feature of this system is the small cart, swivel arm and TV monitor, which take up little space in the OR. It could be the intubating instrument of the future for anesthesiologists, similar to gastroenterologists, gynecologists and surgeons who routinely do procedures using video.
Supraventricular Tachycardia and Myocardial Ischemia after Epinephrine Overdose In a Teenage Patient
Shahangian S, MD and Joseph MM, MD
Department of Anesthesiology, LAC-USC Medical Center, Los Angeles, CAAccidental overdose of epinephrine is an uncommon event fewer than 40 cases have been reported in the last 50 years.There is one case report of epinephrine toxicity on cardiovascular system of a child by epinephrine overdose prehospital causing ventricular dysrhythmia and myocardial ischemia. We are presentinga case of accidental overdose of Epinephrine administered subcutaneously to reduce the vascularity in the Surgical field for repair of branches of facial nerve. A 19 year old, 67.3 kg and 154 cm thall man who was scheduled for repair of facial nerve injury, inflicted by stab wound to the face. His past medical and surgical history was insignificant He was a non-smoker and drank 6 pack of beer on weekends. After pre-medication, with 10 ing of Metoclopromide and l mg of Midazalom, he was taken to the operating room and placed on monitors i.e. pulse oximeter, EKG and blood pressure cuff. Anesthetic induction was started intravenous Fentanyl 100 mcg, Thiopental 375 mg and an RAE endotracheal tube was inserted with ease and secured at 21 cm from teeth. Breath sounds were bilateral and equal. Anesthesia was maintained with 2% Isoflurane and Oxygen.
At 11:10 the surgical resident infiltrated the surgical site with presumably 1% Lidocaine with 1/100,000 Epinephrine. Five minutes later the heart rate rose from 86 to 177 beats/min. Blood pressure was 103/74 mmHg at the time of infiltration soon after that Blood Pressure could not be measured, as it was out of limits of measurement of the automatic blood pressure cuff. After intravenous injection of 10 mg of Esmolol blood pressure was 120/86 mmHg but supraventricular tachycardia,with the rate of 180 to 210 beats/min continued requiring another 10 mg of Esmolol, before conversion to normal sinus rhythm of around 60 beats/min. At that time it was noticed that instead of Lidocaine with Epinephrine, 5 vials of 1 ml of 1/1000 Epinephrine (for a total dose of 5 mg Epinephrine) was infiltrated. The rise in heart rate was abrupt and happened 5 minutes after subcutaneous injection. Heart rate was 83 beats/min at time of infiltration and for the six minutes afterwards was: 78, 84, 84, 74, 177, and 188. EKG showed supraventricular tachycardia that persisted for 8 minutes with significant generalized ST segment depression.
A Nitroglycerine (400 mcg/ml) infusion started at rate of 2-7 ug/Kg/min at 13:40 titrated to maintain systolic Blood Pressure between 100-140 mmHg and after consultation with cardiologist it was decided to postpone the surgery. Right radial artery was catheterized. with size 20, 2 inch long angiocath under aseptic conditions for continuous monitoring of blood pressure. Blood was sent for cardiac enzyme assessment i.e. Troponin level. Although there was no more surgical stimulation despite normal sinus rhythm of mostly 63 to 79 beats/min, blood pressure was fluctuating between 76/28 and 138/68 mmHg. When systolic arterial blood pressure was in 70's the hypotension was treated with total of 5mg of Ephedrine intravenously. Anesthesia was discontinued at 14:55 and the patient was extubated uneventfully and transferred to PACU. Patient did not complain of any chest pain, Cardiac enzymes were negative and EKG was normal and he subsequently underwent surgery after a few days without any complications.
References:
1.Karch SB :Coronary Artery Spasm induced by intravenous epinephrine overdose,Am J Emerg Med 1989:7:485-488
2.Davis CO,Wax PM:Prehospital epinephrine overdose in a child resulting in ventricular dysrythmias and myocardial ischemia: Pediatric Emergency Care: 1999,15(2):116-8
TRAUMATIC AORTIC TRANSECTION IN A 2 ½-YEAR OLD ABUSED GIRL
R. Yumul, MDa, PhD, Z. Steffens, MDa, H. Ocampo, MDb, G. Hinika, MDb, C. Johnson, MDa, S. Steen, ScD, MDa
Department of Anesthesiologya, Department of Surgeryb, Level I Trauma Center, Martin Luther King, Jr./Drew University, Los Angeles, CA 90059This is a case report of a 2½-year old African-American female who was admitted to the Level I Trauma Center of Martin Luther King, Jr./Drew University Medical Center in severe shock, bleeding from scalp laceration, lethargy, GCS 6 (E4, M1, V1) from questionable blunt trauma was noted.
On admission, vital signs were BP 67/41, PR 120-150, RR 20-32, temperature 35° with an O2 SAT of 90% and Hemoglobin of 6.0.
Physical examination was significant in that the abdomen was distended and tense, and the lower extremities were bluish and cold with no palpable pulses below the femoral vessels. She was immediately intubated and 2 large IVs were inserted in the upper extremities. The systolic blood pressure hovered between the 50s and 60s with a heart rate circa 150 per minute. Following a CT scan with standard monitoring to rule out intra-abdominal pathology as well as head injury, it was noted that the head CT scan was normal. However, the patient was noticed to have free fluid intra-abdominally with what appeared to be a shattered right kidney and a massive retroperitoneal hematoma. There was questionable aortic injury versus questionable splenic injury as well as questionable liver injury.
The child was immediately taken from the CAT scan and rushed to the operating suite where standard monitoring was applied and central and arterial lines were placed. The patient was transfused with cross-matched blood (1 Unit of packed red blood cells).
The patient received general anesthesia for an exploratory laparotomy, at which time the aorta was noted to be completely transected infrarenally with a right renal artery laceration. During this 6-hour procedure, aortic cross-clamp time was 12 hours with an estimated blood loss of 2500 cc and a urine output of 20 cc.
Post-operatively, the course was uneventful and angiography with CT scan demonstrated good perfusion of both kidneys. The patient was discharged home 21 days later with no sequelae.