Infrared Spectroscopy and Osmolality Analysis of
Urine: Two Simple Sensitive Methods for Early
Detection of Postoperative Anuria After
Thoracotomy
J. T. Grismer, L. T. Rozelle and R. B. Koch
Dis Chest 1966;49;467-478
DOI 10.1378/chest.49.5.467
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1966, by the American College of Chest Physicians
Infrared Spectroscopy and Osmolality Analysis of Urine:
Two Simple Sensitive Methods for Early Detection of
Postoperative Anuria After Thoracotomy
J. T. GRISMER, M.D., F.C.C.P.,* L. T. ROZELLE, PH.D.** AND R. B. KOCH, PH.D.f
Minneapolis, Minnesota
PROCEDURE
T
OBJECTWES
HE OBJECTIVE OF THIS PRELIMINARY Preoperative and renal function studies
study is to evaluate renal function included urinalysis, blood-urea-nitrogen
before, during, and after surgical stress by (BUN), 12-hour endogenous creatine
analysis of serial urine samples with double clearance (GFRcr), serum electrolytes
beam infrared spectrophotometry absorp- (Na, K, CO2, Cl)if and in selected cases,
tion spectra and osmalality determinations. intravenous pyelograms. In the operating
These tests are corrrelated with other com- room, just prior to the surgical procedure,
monly used clinical laboratory tests of renal the patient was catheterized and a urine
function. The prognostic value of the infra- and blood sample taken for osmolality de-
red (IR) spectroscopy, the osmalality de- terminations and IR spectroscopy.
terminations and the other tests are deter- Total urine was collected during the sur-
mined by comparing the patterns of renal gical procedure (if cardiopulmonary by-
function of patients who had uneventful pass was used, the urine specimens during
convalescence and of those who had car- operation were collected before, during,
diorenal complications postoperatively. and after byapss). Postoperatively, serial
Each patient had thoracotomy for dis- urine collections were recorded every two
ease of the intrathoracic viscera (Table 1). hours for 16 hours in volume and in spe-
No patient is included with known renal cific gravity and a urine specimen saved
disease by history, physical examination, or for laboratory study. A postoperative blood
routine laboratory tests. The surgical pro- specimen was drawn after the patient was
cedures, the anesthesia, the pre- and post- taken to the postanesthesia room and again
operative care, and the laboratory studies in 16 hours for serum osmolality measure-
were “standardized” in the concept that ment and IR spectroscopy. The blood-
the same groups performed their various urea-nitrogen and serum electrolytes were
specialized work. A standard method ofalso studied at 16 hours postoperatively.
renal investigation was followed preopera- An 8-hour endogenous creatinine clear-
tively, during the surgical procedure, and ance was performed postoperatively start-
postoperatively. The routine laboratory ing at midnight on the day of surgery. In
studies were performed by the standard survivors, the 12-hour endogenous creatin-
techniques of the Clinical Laboratory atme clearance and the blood-urea-nitrogen
Mt. Sinai Hospital. Repeat tests were per- level were also determined on the seventh
formed if the results were inconsistent, but postoperative day.
no test was disregarded if confirmed by During the operation and in the first
such repeat analysis. 24 hours thereafter, all patients received
5 per cent dextrose in water intravenously
*Thoracic Surgeon, St. Louis Park Medical Cen- at a calculated rate per M2BSA and the
ter.
necessary blood replacement. In addition,
**Senior Scientist, Honeywell Research Center,
(Hopkins, Minnesota). most patients undergoing “open heart” op-
fResearch Section Head, Honeywell Research erations with extracorporeal circulation re-
Center, (Hopkins, Minnesota).
Supported in part by the St. Louis Park Medical f$Na=sodium, K=potassium, CO,=carbon diox-
Research Foundation. ide content, Clchlorides.
467
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1966, by the American College of Chest Physicians
Diseases of
468 GRISMER, ROZELLE AND KOCH the Chest
CHART 1
M5 OR
PatientSex Age BSA Time Diagnosis Procedure Status
Group A-No Extracorporeal Circulation
1. L.W. F 31 1.64 150 with
RHD MS Closed commissurotomy L&W
2. M.K. F 59 1.66 165 RHDwithMS Closed commissurotomy L&W
3. R.T. M 32 1.74 240 Bronchiectasis LLL Resection LLL L&W
4. B.J. F 48 1.64 190 Pulmonary hansartoma Resection L&W
5. B.M. M 58 1.81 270 Bronchogenic carcinoma Pneumonectomy L&W
6. T.P. M 62 1.76 300 Chronic
empyema Left decortication L&W
7. A.B. M 62 1.94 220 Bronchogenic carcinoma Lobectomy Died -
Metastases
8. W.N. M 18 1.80 130 Recurrent pneumothorax Pleural scarification L&W
9. T.J. F 43 1.68 165 Mediastinal teratoma Resection L&W
10. E.E. F 56 1.64 150 Chronic lipoid pneumonia RUL-segmental resection L&W
11. R.J. F 35 1.55 180 Mediastinal teratoma Resection L&W
12. H.T. F 64 1.82 150 Mediastinal neurofibroma Resection L&W
13. O.R. M 59 2.06 180 Malignant thymoma Exploratory and biopsy Residual
Neoplasm
14. J.S. M 17 1.71 240 Bronchiectasis LLL Resection L&W
15. W.H. M 63 1.94 230 Chronic pneumonia Segmental resection L&W
Group B-Operation with Extracorporeal Circulation
16. B.G. F 3 0.68 240 CHD-VSD Repair L& W
17. V.K. F 11 1.10 300 CHD-ASD Repair L&W
18. J.W. M 23 2.07 420 RHD with MI I Starr-Edwards valve Died -
Anuria
19. W.B. M 34 1.78 300 - Inf.
CHD St. Resection L&W
20. WnB M 48 1.64 360 CHD Septum primum Repair L&W
21. lW. M 49 1.90 345 RHD-AS 1 Starr-Edwards valve Died -
in OR
22. J.A. F 53 1.50 330 RHDMI
- I Starr-Edwards valve Died -
Postop.
23. G.M. F 57 1.74 345 - MI
RHD I Starr-Edwards valve L&W
24. E.C. F 39 1.40 450 RHD A!
- I Starr-Edwards valve Died -
Postop.
25. J.W.2 F 34 1.63 480 RHD, A!, MI 2 Starr-Edwards valves L&W
26. V.B. F 55 1.62 300 RHD
MS- Open commissurotomy L&W
27. R.S. M 45 2.25 315 Coarctation without Resection coarctation L&W
collateral
28. C.F. M 51 1.98 390 Ventricular aneurysm Resection aneurysm L&W
Postmyocardial infarction
29. MG. F 37 1.52 450 CHD
- PS, Inf. St. Resection valvulotomy Died -
pneumonia
30. A.F. F 6 0.66 310 Tetralogy of Fallot Repair L&W
L & W=Living and well; CHDcongenital heart disease;
RHD=rheumatic heart disease; Inf. St.=In-
fundibular stenosis, isolated; P.S.=pulmonic valvulaar
stenosis; M.S.: M.I.=mitral valvular stenosis/in-
sufficiency; A.S.: A.I.=aortic valvular stenosis/insufficiency; ASD=atrial septal defect; VSDventric-
ular septal defect; OR Time=The time in
minutes as recorded by the anesthesiologist from the onset to
the cessation of anesthesia for the operation.
ceived bicarbonate solution and low molec- METHODS
ular weight dextran* solution in normal The Clinical Laboratory of Mount Sinai
saline during the operation. Daily weights, Hospital performed the blood and urinaly-
fluid intake and loss, and blood volumes ses by the standard methods.**
(open heart patients) were also recorded. The osmolality levels of the serum and
Other than the dextran, no diuretic drugs urine were measured by the freezing point
were administered postoperatively. Digi- **Serem sodium potassium: Bard Atomic Flame
talis preparations were continued if admin- Photometer, Assembly Products, Chesterlin,
Ohio. Blood-urea-nitrogen (BUN): AutoAna-
istered postoperatively.
lyzer; Technicore Instrument Corp., Chauncey,
*Dextran_Pharacia, Uppsala, Sweden. New York.
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1966, by the American College of Chest Physicians
Volume 49. No. 5
May ‘955 DETECTION OF POSTOPERATIVE ANURIA AFTER THORACOTOMY 469
depression method.f Calculation of the ml. The two beams are combined and inte-
renal osmolar clearance (CosmVosm/V); grated in such a way that the absorption of
Post the water in the reference cell cancels the
urine: plasma osmolality ratio (U: Posm), absorption of the “free water” in the urine
and renal concentrating operation (TCH2O= or blood in the sample cell.
Cosm-V) was possible from these and This procedure produces a spectrum of
related figures of urine flow. the infrared absorbing components of urine
The infrared absorption spectra was without being masked by the strong ab-
measured on a Perkin-Elmer Model 21sorption of water. However, absorption of
double beam infrared spectrophotometer.ff water at wave lengths less than 6.5 microns
The infrared spectrum as a part of theand greater than 10.5 microns is too in-
electromagnetic spectrum has the relation- tense even with the double beam technique
ship to visible light as depicted in Fig. to permit
1. meaningful spectra. Thus, anal-
Figure 2 compares the double beam princi- ysis of aqueous solutions (e.g. urine) can
ple used in this work with that of the more only be carried out between these two wave
familiar single beam instrument which lengths
is as indicated in Fig. I
similar to the colorimeters used in medical The major IR absorbing compounds in
laboratories. In the double beam model, normal urine have been determined1 as
the source beam is split into two separate urea, sulfates, and mono- and di-basic
beams with one passing through a cell con- phosphates. When present, as in the case of
taining the sample (blood or urine) to beintravenous addition, glucose and dextran
measured. The sample cellsi are ultrathin were observed in the IR spectra. The low-
and require a sample size of less than 0.5 est urea concentration observable by the
present IR techniques is about 200 mg.
tModel 63-31 - Advanced Instruments, Inc..
Newton Highland, Mass. Studies performed ftNorwalk, Connecticut.
courtesy of Drs. Martin and Edward Segal, lBarnes Engineering Company. Type FT -
Methodist Hospital Laboratory, Minneapolis. 0.0017”.
WAVELENGTH UNITS
A - ANGSTROM UNIT 0.1 m
#{149} #{149}
- MICRON #{149}IOOOm IOA
IOA IO4.
102A IO1A IA IOA 102A 103A Ip IO 102p. I0 1CM 10CM
LLJLYW11YJ’
4
U)
ci) II-
t&i
-j ‘ii
.)- 4
44 U)
4
Q
x > U-
z
THE ELECTROMAGNETIC SPECTRUM
FIGURE 1: The electromagnetic spectrum is the term applied to all frequencies of light, both andvisible
invisible. Infrared radiation occurs toward the longer frequency portion of the spectrum and is selective-
ly absorbed by various portions of the molecule. In this work, only a narrow band of the infrared region
(6.5 to 10.0 microns-indicated by the vertical broken lines) was useful because of overwhelmingabsorp-
tion by water beyond this region.
Downloaded from chestjournal.chestpubs.org by guest on December 26, 2011
1966, by the American College of Chest Physicians
Diseases of
GRISMER, ROZELLE AND KOCH
17#{176} the Chest
per cent (normal value about 2000 mg. per poreal circulation) had an average age of
cent per 24 hours). Thus, the method 47.1 years and the procedures required a
would detect urea concentration as low astotal anesthesia and operating time of
10 per cent of normal. The time required 197.3 minutes. In contrast, Group B pa-
for automatically scanning and recording tients (extracorporeal unit required) had
the spectrum is about 12 minutes. an average age of 36.1 years, but the total
An example of the normal
ab- operating and
time the
averaged 355.6 minutes.
normal JR spectra of urine is illustrated inFive deaths occurred in the 30 patients.
Fig. 3. A strong urea absorption peak is
Three (No. 18, 22, 24) died of cardio-
present in the normal urine, but is found torenal problems postoperatively. One (No.
be drastically diminished in the abnormal 21) died on the operating table and an-
urine of an anuric patient.
other (No. 29) died eight days postopera-
RESULTS tively of an overwhelming gram negative
Thirty patients had their renal function bacillus pneumonia and cardiac failure. All
evaluated by this protocol. By chance, an were in Group B.
almost equal distribution occurred between Twenty-seven had preoperative GFRcr
sexes and operations with and without ex- recorded (Table 2). Seven of these had
tracorporeal circulation. The pertinent
values below the limits of normal* and six
facts relative to these factors, age and
of the seven had primary cardiac disease.
length of operative procedure are repro-
Postoperatively, three of these seven pa-
duced in Table I.
tients died, two from cardio-renal failure
For this report, the patients were divided
*The normal range2 of the GFRcr: Men= 105 ±
into two groups by the type of surgical pro-
15/ml./l.73 M2BSA; Women=95I8/ml./I.73
cedure. Group A patients (non-extracor- M’BSA.
DOUBLE BEAM
SAMPLE MIRROR
CELL
CHOPPER COMBINES THE
REFERENCE MIRROR TWO LIGHT BEAMS
CELL
SINGLE BEAM
DETECTOR
MIRROR SAMPLE AREA
PRISM
I R SOURCE
DIAGRAM OF THE LIGHT PATH OF DOUBLE AND SINGLE BEAM
INFRARED SPECTROPHOTOMETERS
FIGURE 2: The double beam instrument will produce a urine spectrum free of interfering absorption due
to water. The infrared source is split into two beams: one passing through a reference cell (water) and
the other passing through the sample cell (urine). The two beams then are combined, cancelling out the
reference (water) absorption and producing only the absorption due to the desired materials (urine sol-
utes). Because there is no provision for a reference beam, the single beam instrument cannot ac- give an
curate spectrum of urine.
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1966, by the American College of Chest Physicians
Volume 49. No. 5
May 1955 DETECTION OF POSTOPERATIVE ANURIA AFTER THORACOTOMY 471
(No. 18, 24). A technical failure in the the value was above preoperative values in
extracorporeal unit contributed to the eight (five of whom had elevated 16 hour
death in patient No. 18, however. Of the levels), and had returned to preoperative
20 with normal GFRcr, two with cardiac levels in three, and remained below preop-
disease died. Patient 1W (No. 21) could erative levels in nine.
not be removed from extracorporeal circu- Eight of the 29 studied had a BUN pre-
lation because of myocardial failure after operatively over 15 mgm. per cent, and one
insertion of an aortic valvular prosthesis. over 20 mgm. per cent. Only this latter
The other (No. 22) developed the low patient died (No. 22) and this was from
output syndrome and died 16 hours after cardiac failure. The preoperative serum
insertion of a mitral valve prosthesis. creatininc (S-CR) and creatinine (GFR-
The GFRcr varied in the postoperative cr) clearance in this patient, however, was
period in the 24 patients studied (Table quite normal. The preoperative BUN levels
2). In seven, the GFRcr rose above, and were not elevated in the other four who
in 17, it fell below the preoperative value succumbed.
when recorded in 16 hours after operation. Preoperativelv, seven had S-CR levels
When recorded seven days postoperatively, above 1.0 mgm. per cent. Two of these
U,
‘5
z
4
I.-
H
z
4
I-i
H
U,
‘5
H
U,
U.
INVERTED INFRARED SPECTRA OF HUMAN URINE SAMPLES
WITH NORMAL AND ABNORMAL LEVELS OF UREA
FIGURE 3: Representative inverted tracings of infrared spectra of urine as
samples obtained from the in-
frared spectrophotometer. Absorbance differences were automatically scanned between 6.5 and mi- 10.0
crons. A reference line for 50 per cent
infrared absorption is drawn as a broken line across each tracing.
Normal urine spectrum-Note prominent absorbance peaks of urea of 6.83 Abnormal
microns. urine
spectrum-Note absence of any peak at 6.83 microns. This spectrum is indicative of a failure in renal
function.
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1966, by the American College of Chest Physicians
Diseases of
472 GRISMER, ROZELLE AND KOCH the Chest
(No. 18, 22) subsequently succumbed to critical index of the cardiorenal status than
cardiorenal problems. The GFRcr was nor- did determinations of the blood-urea-nitro-
mal in both preoperatively. gen, serum creatinine, serum electrolytes,
The S-CR and the BUN varied in re- serum osmolality, or serum JR spectra. The
sponse to the stress of the operation. The serum osmolality was necessary to calcu-
S-CR usually rose slightly. There was no late the Cosm etc., butper se was only sig-
constant pattern in the BUN. Unfortunate- nificantly abnormal in one patient (No.
ly, three of the five patients who died did 22-368 MOSM) in the immediate postop-
not have S-CR drawn at the time erative
of specimen.
death. A Cosm below 0.3 ml./min. was consid-
In the immediate postoperative period, ered indicative of renal shock. Likewise, a
analysis of the urine proved a much more TCH2O less than 0.20 during the period of
CHART 2-PREOPERATIVE AND POSTOPERATIVE RENAL FUNCTION
GFRcr 1.73 M2BSA
Per Cent
Preop. Value BUN Serum Cr
Preop. 16 Hr. 7 Day Preop. 16 Hr. 7 Day Preop. 16 Hr. 7 Day
Women
I. L.W. 94 144 106 11 10 - 0.9 0.9 0.9
2. M.K. 77* 231 96 16 21 12 - 1.3 0.9
4. B.J. 67 180 106 13 - 7 0.8 0.7 0.8
9. T.J. 77 112 111 10 3 - 0.8 0.8 0.8
10. E.E. 91 109 100 16 7 - 1.1 0.8 0.8
11. R.J. 78 98 107 - 13 - 0.8 1.1 0.8
12. H.T. 85 85 112 10 11 - 0.8 0.9 0.7
16. B.G. 104 63 78 12 10 - 0.6 0.8 0.5
17. V.K. 107 89 75 15 11 15 0.9 0.9 0.9
22. J.A. 114 DIED 24 33** 1.2 - -
23. G.M. 75 60 100 11 15 - 1.0 1.1 1.0
24. E.C. 65 DIED 15 - - 0.9 - -
25. J.W.5 95 72 89 13 14 18 0.9 1.1 0.8
26. V.B. 86 57 57 19 12 13 0.9 1.3 1.1
29. M.G. 37 92 DIED 10 23 100 0.8 1.3 -
30. A.F. 97 38 - - 14 - 0.6 0.9 -
Men
3. R.T. 110 22 55 18 8 - 1.2 1.1 0.7
5. B.M. 146 57 - 11 14 12 1.0 1.2 -
6. T.P. 119 48 73 5 31 4 0.8 1.4 0.8
7. A.B. 123 68 59 12 10 11 1.0 1.2 1.5
8. W.N. 100 126 - 17 11 - 1.0 1.1 -
13. O.R. - - - 19 - - - - -
14. J.S. 100 85 98 8 - - 1.1 1.0 1.0
15. W.H. 77 100 86 18 14 - 1.3 1.2 1.3
18. J.W. 79 ANURIA 15 33 150 1.3 3.3 12.0
19. W.B. 90 103 178 15 12 16 1.0 1.3 1.0
20. Wm.B. 70 81 114 13 23 18 1.3 1.4 1.2
21. I.W. 88 DIED 16 - - 1.0 - -
27. R.S. 92 246 128 17 13 9 1.3 1.0 1.0
28. C.F. 90* 110 100 10 18 8 - 1.1 1.1
*Assumed value of GFRcr to give relative response of GFR to stress-16 day percent
7 hr. and are rela-
tive values therefore.
**Drawn at death of patient.
GFRcr 1.73 M2BSA=Endogenous creatinine clearance as adjusted to
1.73 meter square body surface area;
Preop. =preoperative value; 16 hr. =determination approximately I 6 hours after cessation of
the surgical
procedure; 7 day=determination made on the seventh postoperative day; Per Cent Preop.=ratio ex-
pressed as per cent of value at this time to preoperative value; BUN=blood-urea-nitrogen; Serum Cr=
serum creatinine levels in mg. per cent.
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1966, by the American College of Chest Physicians
Volume 49. No. 5
May 1966 DETECTION OF POSTOPERATIVE ANURIA AFTER THORACOTOMY 473
maximum antidiuretic activity was consid- who survived the surgical procedures. Urea
ered evidence of impaired tubular function. remained evident and gradually increased
The U: Posm ratio was considered abnor- in concentration postoperatively.
mally low if it fell below 1.5 during this Of the four depicted, all had normal
same period.3 Table 3 summarizes the cal- Cosm, V-Posm, and TCH2O except patient
culated data of the 30 patients in regard toT.P. (Patient No. 6, Chart 4) Despite this
osmolar clearance Cosm, concentrating evidence of seriously impaired borderline
ability of the kidney (TCH9O), U:Posm renal function, this patient maintained
ratio, and urine volume during and imme- urine urea excretion. There was no overt
diately after the operation. The three (No. clinical evidence of his
t narrow margin of
18, 22, 24) whose deaths were directly at- renal reserve. Figure 4B depicts similar se-
tributed to cardiorenal failure are summar- rial data in three who died postoperatively.
ized separately. The period of anesthesia The urea absorption disappeared from the
and surgery prior to bypass in Group B
JR spectra in the immediate postoperative
(PRE-By) is less (average 151 minutes), period.
but comparable to the total operating time
DISCUSSION
in Group A (197 minutes).
Surgical “stress”* results renal
in artery
Chart 4 depicts the value and outcome vasoconstriction, the degree and result of
of the ten patients in whom one of more the vasoconstriction being proportional to
abnormal osmolar values in the urine were the degree and duration of the stress. The
calculated during or following the surgical vasoconstriction is related to the adrenalin
procedure. The remaining 20 patients and the noradrenalin levels in the blood.
maintained urine values considered to be In addition, the stimulus of stress results in
“normal.” Of these 20 patients, one (No. release of other hormones among which are
29) subsequently succumbed to an over- the antidiuretic hormone and aldoste-
whelming infection. rones. The net result is the commonly
Aliquot portions of these serial urine seen “postoperative oliguria” which is not
samples from the various surgical phases of usually considered to be indicative of renal
these 30 patients were also analyzed by JR parenchymal injury.
spectroscopy. The different patterns of the *stress has been used as an inclusive term de-
relative urea concentrations in urine are signating all of the emotional and physical fac-
tors inherent in the anesthesia and the trauma
graphically depicted in Fig. 4A in four of surgical procedures.
CHART 3
Cosm Tcss,,o
2 0 2
Group A. .66 - - - 1.25 1.32 .29 - - - .75 .84
Group B. - .86 .38 2.07 1.44 1.34 - .43 .14 .59 .58 .66
Died (No. 18, 22, 24) - .31 .12 .25 .36 .23 - .13 .00 .06 .00 .00
U: P Urine ml./min.
Group A. 1.9 - - - 2.4 2.8 .35 - - - .52 .49
Group B. - 1.7 1.7 1.3 1.9 2.3 - .54 .22 1.37 .81 .62
Died (No. 18, 22, 24) - 1.9 1.4 1.3 1.0 1.0 - .18 .11 .33 .36 .24
OR=Total anesthesia and operating period; PRE= anesthesia and operating period prior to extracorpo-
real circulation; ByP=anesthesia and operating period during extracorporeal circulation; POSTanes-
thesia and operating period following extracorporeal circulation ;U/2the twofirst hour period after re-
turn of the patient to the post-anesthesia recovery
room; U/4=the second two hour period; Cosm=os-
molar clearance expressed as milliosmols fo solute excreted in urine per minute; TCSe,O=concentration
ability of the kidney expressed as amount of “solute-free water” removed from the e. urine
urine i.
flow
is less than the Cosm by the amount of solute-free water substracted to concentrate isosmotic urine;
U: Posm=the ratio of osmolality of the urine to the osmolality of the plasma.
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1966, by the American College of Chest Physicians
Diseases ot
GRISMER, ROZELLE AND KOCH
474 the Chest
The “physiologic oliguria” produces urine sodium content. The specific gravity and
with characteristic findings.’8 There is a fall osmolality levels rise and the free water
in urine volume excretion, an increase inclearance (CH20) becomes a negative fig-
the total urea content and a decrease in
ure; (TCH2O) therefore becomes a positive
6 10 14
TIME AFTER SURGERY (HOURS)
RELATIVE UREA CONCENTRATION CURVES OF PATIENTS SURVIVING SURGERY
16.0
z
0
I-
z
UJ
0
z
0
0
d
Ui
Ui
>
-J
Ui
CON- PRE BY POST 2 6 10 4 Is
TROL BY PASS BY TIME AFTER SURGERY (HOURS)
PASS PASS
RELATIVE UREA CONCENTRATION CURVES OF PATIENTS NOT SURVIVING SURGERY
FIGURE 4: (A) Patients surviving surgery. (B) Patients not surviving surgery. These curves represent
the urea Concentration in urine samples of patients analyzed before, during, and after operation. The rel-
ative urea concentration was calculated from the absorbance of urea in the infrared spectra these
of urine
samples corrected forurine volume. In surviving patients, the urea concentration decreased during sur-
gery, but increased to operative levels during the patient’s recovery. In nonsurviving patients the urea
does not increase the
to operative levels, but remains undetectable on the infrared spectrum.
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1966, by the American College of Chest Physicians
Volume 49. No. 5
May 1966 DETECTION OF POSTOPERATIVE ANURIA AFTER THORACOTOMY 475
figure as it is the opposite of CH2O. Potas- though the sodium level “paradoxically”
sium levels also rise. The urine volume is rises. The osmolarity falls and the urine
obligatory in that it is related to total so-becomes isothenuric. The physician must
lute excreted. The concentrating ability ofdifferentiate the “pathologic oliguria” from
the kidney is reflected in the urea/solute the “physiologic oliguria” at the earliest
ratio of the urine, being maximum as this
moment. Such early differentiation is im-
ratio approaches 0.35 and less at lower
portant in order to initiate the proper pro-
ratios.’
gram of therapy, as well as to analyze fac-
Postoperative oliguria may also indicate
tors precipitating the renal difficulty.5’#{176}’2
developing renal i nsu ffi ci en c
y.’’’#{176} This
The confirmation of early renal insuffi-
“pathologic oliguria” may be subtly pres-
ent for hours”’2 before the classic signs of ciency is basically by laboratory means.
renal shutdown become clinically evident. Various tests have been devised to establish
There is evidence that renal insufficiency this diagnosis. The most practical methods
may exist and yet despite low total solutes applicable to clinical medicine are: (1)
the urines have a specific the urine
gravity volume
of (in reality a clinical test)
1.010 to 1.020 range.”1’ The urine volume (2) urine specific gravity (unfortunately
can be similar to that in physiologic oh- unreliable, especially if there is a solute di-
guria”’4 However, the failing kidney ex- uresis) ;h5 (3) urine area and/or creatinine
cretes less total solutes including urea al- content;’” (4) urine sodium content; (5)
CHART 4
Cosm TcH,O
OR or Post OR or POST
Patient PRE b ByP By U+2 U+4 PRE by ByP by U+2 U+4
2* M.K. .30 .72 .52 .10 .34 .31
3* R.T. .24 1.56 1.45 .13 1.04 1.01
5* B.M. 94 2.00 1.43 .16 1.00 .81
6 T.P. .27 .27 .21 .06 .02 .02
18 J.W. .51 .21 .50 .31 .22 .19 .00 .06 .00 .00
21 I.W. 1.06 .08 .11 .03 ..
22 J.A. .38 .12 .02 .16 .25 .19 .00 .00 .00 .00
24 E.C. .04 .02 .22 .62 .02 .01 .11 .00 .
25 J.W.2 .33 .85 .69 .79 .11 .24 .23 .33
28 C.F. .37 .06 .70 1.91 1.84 .16 .00 .16 .81 .92
*Group A patients. Other patients in
Group B.
See Chart 3for code to abbreviations.
U :Posm Urine Vol.
OR POST OR POST
Patient PRE By ByP By U/2 U/4 PRE By ByP By U/2 U/4
Status
2* M.K. 1.5 2.0 2.5 .20 .41 .38 1 & w
3* R.T. 2.2 3.0 3.3 .11 .52 .44 &1 w
5* B.M. 1.2 2.0 2.3 .78 1.00 .62 1 & w
6* T.P. 1.3 1.1 1.1 .21 .25 .19 1 & w
18 J.W. 1.6 1.0 0.9 1.0 1.0 .32 .21 .56 .31 .22 death-
anuria
21 I.W. 1.2 1.7 .95 .05 . died in
surgery
22 J.A. 2.0 1.0 1.0 1.0 1.0 .19
.12 .02 .16 .25 died hrs. 24
post surg.
24 E.C. 2.2 2.2 2.0 1.0 .02 .01 .11 .62 died post
surg.
25 J.W., 1.5 1.7 1.4 1.5 1.9.22 .61 .46 .46 1 & w
28 C.F. 1.7 1.0 1.3 1.7 2.0 .22 .06 .54 1.16 .92 1 & w
*Group A patients. Other patients in Group B.
See Chart 3 for code to abbreviations.
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1966, by the American College of Chest Physicians
Diseases of
476 GRISMER, ROZELLE AND KOCH the Chest
urine hydrogen-ion excretion ;‘“ (6) urine modalities is logical and definitive. Fortun-
osmolality;” (7) urine blood ratio of cre- atelv, in the measured urine volumes, total
atinine, urea or osmolahity, and (8) phe- solutes are easily determined by osmometry.
nohsulfonphthalein excretion. More compli- Likewise, of the solutes, the urine urea
cated excretion tests (inulin, para-amino- content has been implicated as a sensitive
hippurate) are usually not available nor index of tubular cell function.’ The auth-
practical except in the research centers. ors’ experience with double beam JR spec-
Unfortunately, only a few of the above tra indicated that this method accurately
tests lend themselves to serial determina- determines significant urea levels in the
tions. The presently available laboratory urine.’
methods for determining urea, creatinine, This pilot study was devised, therefore, to
and sodium are relatively time-consuming. evaluate the efficacy of these two methods
Serial tests every one to two hours are not in serial determinations of renal function.
practical either from expense or time in the The experimental data accumulated
usual hospital. Single “spot” checks of the from these patients indicate that double-
various blood and urine levels are helpful, beam infrared spectroscopy and osmolality
but unfortunately do not accurately portray determinations provide rapid, accurate
the dynamic pattern of the kidney func- techniques for serial quantitative measure-
tion. The phenolsulfonphthalein test is rel- ment of the urea and total solutes, respec-
atively simple, but it is not suitable to fre- tively, in urine samples. The urine osmolar-
quent serial determinations. ity levels indicate the total amount of the
The most important aspect of the kid- solutes, but does not indicate the concentra-
ney function is water and solute excretion. tions of the individual compounds. The IR
Therefore, analysis of urine for these two spectra allow direct calculation of the urea
PRE SURGERY SURGERY POST SURGERY
PRE POST (AVERAGE
1000 BY BY BY OF I8HRS)
PASS PASS PASS
U)
-I
0
5O0
-J
-J
0
cIZ 4
WO
3
2 7
I-UJ
I
C
REPRESENTATIVE VALUES OF URINE MILLIOSMOLAR AND RELATIVE UREA
CONCENTRATIONS IN SURVIVING PATIENTS
FIGURE 5: The osmolalities andrelative urea concentrations both decrease after administration of
anesthetic, but increase again after surgery. he relative
T urea concentration was calculated from the urea
absorption from the infrared urine spectrum. this In figure, neither the milliosmolar values nor the urea
values were corrected for urine volumes. This allows direct comparison between the two quantities.
Downloaded from chestjournal.chestpubs.org by guest on December 26, 2011
1966, by the American College of Chest Physicians
Volume 49, No. 5
May 1966 DETECTION OF POSTOPERATIVE ANURIA AFTER THORACOTOMY 477
concentrations, am important constituent centrations by IR spectra are depicted of a
of the total solutes. representative patient who had no cardio-
This study further indicates that devel- renal complications after a corrective open
oping renal insufficiency (pre-natal or par- heart procedure. Although there was a de-
enchymal in origin) is immediately reflect- crease in both components immediately aft-
ed in the urine content of urea and total er extracorporeal circulation, the osmolahity
solutes. Within four hours postoperatively, and urea levels quickly returned to more
the status of the cardiorenal system is evi- normal values.
dent. Although this present study er
p se Figure 6 is representative of the urine
could not determine the etiology of the re- milhiosmolar and relative urea concentra-
nal dysfunction (i. e. prenatal or paren- tions before, during, and after corrective
chymal), the data served as a guidepost toopen heart surgery of a patient who did
the clinical evaluation and allowed appro- not survive. The extracorporeal perfusion
priate therapy. Similarly, such a study can was inadequate for technical reasons. The
he further refined or expanded to include patient developed postoperative renal in-
evaluation of the treatment of the under- sufllciencv. The heart repair was adequate
lying renal problem and to note the effect and cardiac output normal. Despite an
on renal function of solute diuretics, drugs, “adequate” postoperative urine volume,
etc. the immediate decrease in urine osmolalitv
The value of serial IR spectra and os-and loss of urea in the IR spectra was evi-
molalitv determinations before, during and dent during the postbvpass period in the
after the operative procedure are well em- first two postoperative specimens. The
phasized by Figs. 5 and 6. In Fig. 5, theurine volume did not decrease to “anuric”
urine milliosmolar and relative urea con- levels until 14 hours after the operation.
PRE SURGERY SURGERY POST SURGERY
In (AVERAGE
-J PRE POST
0 BY BY BY OF 18 HRS)
U)
PASS PASS PASS
0
-J
-J 500
0
H
4
Ui0 Z
3
Wi.. 0
>2U)
,1x04 I
_jz
IaJO...
0- 0
REPRESENTATIVE VALUES OF URINE MILLIOSMOLAR AND RELATIVE UREA
CONCENTRATIONS IN NONSURVIVING PATIENTS
FIGURE 6: The osmolalities relative
and urea concentrations both decreased after administration of an-
esthetic as in the surviving patients. (Fig
5). However, the relative urea concentration becomes virtually
undetectable during surgery and does not undergo a postoperative increase. During surgery and postop-
eratively. the milliosmolar value remains at around 300.
Downloaded from chestjournal.chestpubs.org by guest on December 26, 2011
1966, by the American College of Chest Physicians
Diseases of
478 GRISMER, ROZELLE AND KOCH the Chest
The authors believe, therefore, that this bei solchen, die einen cardio-pulmonalen Kurz-
schlu erfordern.
type of study has better defined the normal
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For reprints, please write Dr. Grismer, 4959 Excel-
Ablauf chirurgischer Eingriffe, kommt, besonders sior Boulevard, Minneapolis.
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1966, by the American College of Chest Physicians
Infrared Spectroscopy and Osmolality Analysis of Urine: Two Simple
Sensitive Methods for Early Detection of Postoperative Anuria After
Thoracotomy
J. T. Grismer, L. T. Rozelle and R. B. Koch
Dis Chest 1966;49; 467-478
DOI 10.1378/chest.49.5.467
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