Native kidney biopsies are high-risk for bleeding complications due to the vascularity of the kidney and the inability to compress the biopsy site within a deep retroperitoneal location. Recommended parameters to minimize bleeding risk include a platelet count above 100 x 109 /L, hemoglobin above 10 g/dL, systolic blood pressure <140 mm Hg, and minimizing the number of biopsy cores. In this paper we present patient cases to discuss management of other factors pertinent to kidney biopsy planning including interruption of anticoagulation, treatment of anxiety which can elevate blood pressure, and use of Doppler. Undiagnosed chronic kidney disease can affect triaging of tissue to light, immunofluorescence and electron microscopy, as sclerosed glomeruli are difficult to visualize in fresh cores. It is recommended to have a back-up retrieval protocol in place to obtain immunofluorescence and electron microscopy results, in the event that only limited kidney tissue was acquired for light histology. A collaborative effort between nephrology, interventional radiology and pathology is essential to optimize the diagnostic yield while minimizing bleeding risk with kidney biopsies. Of paramount importance is physician judgment of whether there is an acceptable balance of benefits/risks to proceed with a kidney biopsy.

Prone positioning of patients is a routine occurrence in procedural suites and operating rooms (ORs). However, the physiological changes that occur with prone positioning are frequently underappreciated by proceduralists, surgeons, and anesthesiologists. This may be related to a sense of the routine or a lack of familiarity with physiological changes that accompany the prone position. The prone position, while aiding visualization and cannulation of the ampulla of Vater during endoscopic retrograde cholangiopancreatography (ERCP), can induce physiological changes such as reduced preload, inferior vena cava filling, and cardiac output; it can also increase intrathoracic pressure and mediastinal compression. Anesthetic agents can further impact cardiopulmonary physiology, decreasing systemic vascular resistance and reducing cardiac contractility. In addition, the transition from negative to positive pressure ventilation following endotracheal intubation can increase pulmonary artery pressures and right ventricular (RV) strain. Therefore, caution is needed with patients who have RV dysfunction, pulmonary hypertension, or preload dependency, as they may not tolerate prone positioning. We describe a case in which a 73-year-old male patient scheduled for an ERCP suffered cardiac arrest after being transitioned to the prone position. The patient was repositioned in the supine position and resuscitated. The case was completed in the supine position.

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

OBJECTIVES:To help clarify which small renal cortical neoplasms (RCNs) require surgery by using office-based, ultrasonography-guided percutaneous renal biopsy.PATIENTS AND METHODS:Biopsies were performed using facilitated ultrasound targeting (FUT) technology, which incorporates a needle guide and onscreen beam-steered technology to permit highly precise needle deployment. Patient and tumour characteristics, procedure time, complications and biopsy efficacy were documented. Wong-Baker pain levels were obtained before, during and 1 h after the procedure.RESULTS:Seven patients underwent biopsy, six for RCNs and one for medical renal disease. The mean (range) patient age was 68.5 (54-79) years, and the mean (range) tumour diameter was 2.55 (2.0-2.9) cm. Mean pain levels before, during and 1 h after the procedure were 0, 1.6 and 0.5, respectively. There were no intra- or post-procedural complications. Biopsy results were diagnostic in five of the six RCN cases and in the single case of medical renal disease.CONCLUSIONS:Our preliminary experience shows that office-based percutaneous renal biopsy using a novel transducer for FUT is safe and effective. An international multicentre study is planned to confirm these preliminary results.

Introduction: Recent advances in axial imaging have resulted in a dramatic increase in the diagnoses of renal cortical neoplasms (RCNs), but no radiographic test can reliably distinguish benign from malignant lesions.1 Routine biopsy of RCNs may help guide management and reduce the number of unnecessary surgeries. In this video, we describe a technique for office-based, ultrasound-guided percutaneous RCN biopsy (UG-PRB) using a novel facilitated ultrasound targeting technology. Materials and Methods: The patient is instructed to stop anticoagulant and antiplatelet agents before the procedure. Two hours before the procedure, the patient self-administers a low dose benzodiazepine and applies EMLA cream (lidocaine-prilocaine topical cream 2.5%2.5%) to a pre-established flank site, which is then covered with an adhesive dressing. For the procedure, the patient is draped using the sterile technique in the prone position. The tumor is identified using a novel facilitated ultrasound targeting technology (Alpha 7 system; Hitachi-Aloka Medical, Ltd., Tokyo, Japan); this device projects a virtual needle path on the ultrasound screen, as is already common for prostate biopsies. The skin is anesthetized, and then an 18-gauge biopsy needle is inserted through a needle guide on the transducer toward the RCN. The patient helps the surgeon by holding his or her breath at the appropriate time. The needle is advanced along the projected dotted line in real time to the edge of the tumor, and a core is acquired. Several cores can be acquired in this manner. Ultrasound is repeated 1 hour later to assess for hematoma, and a urine sample is obtained before the discharge home to rule out significant hematuria. Results: We performed six office-based UG-PRBs for RCNs. Five of the six (83%) biopsies resulted in a tissue diagnosis, and the mean procedure time was 15.2 minutes. There were no intra- or postprocedural complications, and patients reported minimal to no pain. Conclusion: Our preliminary experience demonstrates that office-based UG-PRB is safe and effective. The information gained from the biopsy can be used to individualize the treatment plan for each patient. No competing financial interests exist. Runtime of video: 2 mins 48 secs

BACKGROUND: In this investigation, we sought to assess the ability of pediatric attending anesthesiologists, resident anesthesiologists, and mothers to predict anxiety during induction of anesthesia in 2 to 16-yr-old children (n = 125).METHODS: Anesthesiologists and mothers provided predictions using a visual analog scale and children's anxiety was assessed using a valid behavior observation tool the Modified Yale Preoperative Anxiety Scale. All mothers were present during anesthetic induction and no child received sedative premedication. Correlational analyses were conducted.RESULTS: A total of 125 children aged 2-16 yr, their mothers, and their attending pediatric anesthesiologists and resident anesthesiologists were studied. Correlational analyses revealed significant associations between attending predictions and child anxiety at induction (r(s) = 0.38, P < 0.001). Resident anesthesiologist and mother predictions were not significantly related to children's anxiety during induction (r(s) = 0.01 and 0.001, respectively). In terms of accuracy of prediction, 47.2% of predictions made by attending anesthesiologists were within one standard deviation of the observed anxiety exhibited by the child, and 70.4%, of predictions were within two standard deviations.CONCLUSIONS: We conclude that attending anesthesiologists who practice in pediatric settings are better than mothers in predicting the anxiety of children during induction of anesthesia. Although this finding has significant clinical implications, it is unclear if it can be extended to attending anesthesiologists whose practice is not mostly pediatric anesthesia. (Anesth Analg 2009;108:1777-82)

Purpose: Computed tomography (CT)-guided percutaneous procedures are often made more difficult due to the movement of the kidney during respiration. Here we examine the use of high-frequency oscillatory ventilation (HFOV), which eliminates the movement of the kidney, potentially making cryoprobe access to the kidney simpler and possibly more efficient.Methods: We compared seven CT-guided percutaneous procedures using a single cryoprobe and either standard mechanical ventilation (MV) (n = 4) or HFOV (n = 3). The variables studied included: total time of patient intubation, operative time, overall duration of interventional radiology ( IR) suite time, change in hematocrit, narcotic use, and complications. The ease of the procedure was rated on a subjective scale from 1 to 3.Results: The total intubation time remained nearly identical at 210 minutes for HFOV and 208 minutes for MV, but surgeon procedural time decreased by 31 minutes in the HFOV group ( HFOV = 99 minutes and MV = 130 minutes) ( P = 0.40). Total IR time was 225 minutes for HFOV compared to 212 minutes for the MV group ( P = 0.63). There were no significant differences in the postoperative hematocrit, creatinine, or narcotic use between the two groups. There were no complications related to the procedure or anesthesia in either group. Both urology attending physicians and the interventional radiologist noted that the procedure seemed easier with HFOV.Conclusion: HFOV may shorten the actual procedural time required to perform cryoablation, likely due to the elimination of renal movement during the procedure, thereby facilitating targeting and access to the renal mass. In this initial experience, patients tolerated HFOV without incident, and the operating surgeons found it easier to perform the procedures.

The laryngeal mask airway (LMA) was developed in 1981 by Dr. Archie Brain in the United Kingdom, and has been available for clinical use in the United States since 1992. It represents a novel concept in airway management that allows air exchange through a specially designed mask that fits in the hypopharynx and faces the laryngeal inlet, creating an end-to-end seal. During the last decade there has been ample literature, much of it anecdotal, on the many applications of the LMA over a wide patient age range. It has also been the subject of detailed literature reviews and a book.7, 12, 39, 47 The LMA has achieved popularity at a rapid rate, and in certain regions it has become the principal means of airway management during anesthesia. The shape of the LMA mask was developed based on cadaveric studies of the adult pharynx.8 Structurally, pediatric-sized LMAs are simply scaled-down versions of the adult variety, even though newborns and infants display significant differences in airway anatomy from older children and adults. Although its application in the pediatric population has lagged behind adult use, the LMA now has established roles in routine pediatric anesthesia, management of the difficult pediatric airway, and diagnostic airway procedures. There are a number of publications addressing the use of the LMA in pediatric patients.32, 36, 46 The LMA is generally used in the spontaneously breathing patient, although it can be employed with controlled, positive pressure ventilation.25 The LMA has been used in premies as small as 1 kg in weight.11, 31