PMC8062170_01
Preoperative images of computed tomography showing a massively enlarged polycystic liver that occupied the abdominal space and compressed the diaphragm and abdominal wall. (a) Coronal section. (b) Axial section.
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Preoperative computed tomography revealed remarkable abdominal distension caused by an enlarged polycystic liver (Figure 1).
Overview of the anesthetic chart. The dosages of drugs are shown in the upper part. Serial changes in QTc interval (QTc), Ca2+, cardiac index (CI), hemodynamics, and body temperature (BT) are shown in the middle part. Approximate amounts of blood loss and transfusion (mL/hr) are shown in the bottom part. Time indicates time after the start of surgery. The double circles indicate the start and end of the surgery. HR, heart rate; bpm, beats per minute; BP, blood pressure; FFP, fresh frozen plasma; RBC, red blood cell concentrates; PC, platelet concentrates.
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Soon after the start of surgery, massive bleeding of more than 4,000 mL/hr occurred (Figure 2). T wave and prolongation of QTc interval (557 msec) occurred (Figures 2 and 3). At that time, we visually noticed that the QT interval was shortened in response to bolus calcium administration, and we therefore displayed the QTc interval on a bedside monitor (CSM-1000 series Life Scope G, Nihon Kohden, Tokyo, Japan) and used the change of real-time QTc interval as a supportive indicator for calcium correction (maximum rate: 120 mEq/hr) combined with blood gas analysis. The hepatectomy was performed without veno-veno bypass 4.5 hours after the start of surgery and the bleeding rate at that time was 15,000 mL/hr (Figure 2). The excised polycystic liver weighed 10.0 kg. After portal reperfusion, the bleeding rate gradually decreased and the hemodynamic variables and electrolyte disturbance improved (Figures 2 and 3; Table 1).
Changes in the electrocardiogram due to electrolyte abnormalities. Upper part: one hour after the start of surgery. Middle part: five hours after the start of surgery. Bottom part: nine hours after the start of surgery. The unit of K+ is mEq/L, the unit of Ca2+ is mg/dL, and the unit of QTc is msec.
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T wave and prolongation of QTc interval (557 msec) occurred (Figures 2 and 3). At that time, we visually noticed that the QT interval was shortened in response to bolus calcium administration, and we therefore displayed the QTc interval on a bedside monitor (CSM-1000 series Life Scope G, Nihon Kohden, After portal reperfusion, the bleeding rate gradually decreased and the hemodynamic variables and electrolyte disturbance improved (Figures 2 and 3; Table 1).
Correlation between Ca2+ and QTc interval. R2 indicates coefficient of determination.
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Postoperative analysis of the relationship between QTc interval and Ca2+ during surgery showed a strong negative correlation (Figure 4).