Division of Anaesthesia and Intensive Care, Vardhman Mahavir Medical Faculty and Safdarjang Hospital, New Delhi, India
Division of Anaesthesia and Intensive Care, Vardhman Mahavir Medical Faculty and Safdarjang Hospital, New Delhi, India
Division of Anaesthesia and Intensive Care, Vardhman Mahavir Medical Faculty and Safdarjang Hospital, New Delhi, India
Division of Anaesthesia and Intensive Care, Vardhman Mahavir Medical Faculty and Safdarjang Hospital, New Delhi, India
Sir,
Any deviation in regular urine shade intraoperatively is alarming to the clinician. Ceaselessly noticed discoloration of urine is high-colored urine (dehydration), darkish yellow to orange (bilirubinuria), pink to red-brown (hematuria), brown (myoglobinuria), yellow (Vitamin B-complex), or orange (rifampicin). We report a case of inexperienced urine in a 45-year-old feminine affected person, 65 kg, American Society of Anesthesiologists Bodily Standing I, scheduled for laparotomy for restore of an enterocutaneous fistula. Anesthesia was induced with morphine 6 mg and propofol 100 mg, and tracheal intubation was facilitated by vecuronium 6 mg. Anesthesia was maintained with isoflurane 0.6% and nitrous oxide in oxygen (33%). The fistulous tract was delineated by the surgeon utilizing 8 ml of methylene blue 1%. Two hours after methylene blue use, a change in urine shade was noticed from regular yellow to inexperienced [Figure 1]. The intraoperative interval was uneventful. Surgical procedure lasted for five h. On the finish of surgical procedure, residual neuromuscular block was reversed (neostigmine, glycopyrrolate). The postoperative interval was unremarkable. Affected person’s urine shade turned regular 8 h postoperatively.
Methylene blue, a nonpathogenic water-soluble dye, is used intraoperatively for diagnostic assessments (fistula detection, patency of fallopian tubes, and identification of parathyroid glands). Methylene blue-induced inexperienced urine has been reported beforehand. Inexperienced urine was seen in a affected person of bladder carcinoma who was on ProSed™ DS (an oral analgesic, antiseptic, and antispasmodic medicine that accommodates methylene blue).[1] Methylene blue is metabolized within the physique to leucomethylene blue which is excreted primarily within the urine. Some are excreted unchanged within the urine. Blue urine is uncommon as a result of the blue pigments mix with urochrome (yellow pigment in urine) leading to inexperienced urine.[2] Methylene blue absorbs gentle at wavelength 550-700 nm with preferential most absorbance at 660 nm and 609 nm (shoulder peak) and might be detected in urine by spectrophotometry. The presence of those two peaks in a inexperienced urine pattern confirms the presence of methylene blue. In a affected person with regular renal perform, methylene blue seems in urine in a couple of minutes after intravenous administration and 2-6 h after oral administration.[3] It could stay detectable after 24 h.[3] In our case, inexperienced urine appeared 2 h after use of methylene blue and lasted for ≈ 10 h. Urine evaluation was regular.
Different medicines are related to inexperienced urine. Medication akin to promethazine, thymol, cimetidine, and propofol include phenol teams which can be conjugated within the liver and subsequently excreted by the kidneys as inexperienced urine.[2] Nonphenol medicines that produce inexperienced urine are metoclopramide, amitriptyline, and indomethacin. Water-soluble synthetic dyes could cause inexperienced urine.[2] Not all causes of inexperienced urine are innocuous. In sufferers with continual obstructive jaundice, the presence of biliverdin (oxidation product of bilirubin) in urine may give a inexperienced hue.[2] Urinary tract infections brought on by Pseudomonas can flip urine inexperienced resulting from pyocyanin and pyoverdin pigments produced by the bacterium.[4] Excessive discoloration might intervene with the interpretation of yellow colorimetric chemical reagent strip assessments for glucose and protein by masking or falsely enhancing constructive shade adjustments.[1]
Propofol infusion has been implicated in inflicting inexperienced urine.[5] The inexperienced shade is as a result of excretion of quinol derivatives ensuing from renal sulfo- and glucuro-conjugation of propofol.
Inexperienced urine is an uncommon intraoperative incidence. Although intriguing, it’s of little significance and requires no remedy except it’s secondary to infectious pathology. Affected person’s historical past and clinician consciousness can result in immediate recognition and restrict pointless investigations. Power accumulation of such merchandise as a part of indigenous medicines can result in potential toxicity in sufferers with compromised renal failure.
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– “b vitamin green urine”