Severe hemodynamic instability in a patient with suspected hepatoadrenal syndrome during liver transplantation -A case report-
A 67-year-old female patient with adrenal insufficiency in drug-induced hepatic failure previously had a cancer on the left breast, which had been treated by modified radical mastectomy followed by an unknown regimen of adjuvant chemotherapy. Thereafter, she had experienced jaundice with mental change and had been diagnosed with drug-induced liver failure. Despite supportive care, her stuporous mental status did not return, making her a candidate for liver transplantation. Although she was semicomatose, her vital signs were stable and there was no evidence of sepsis. Laboratory analysis revealed unexplained hyponatremia of 121-124 mmol/L and K+ concentration of 4.8-5.4 mmol/L (). A rapid adrenocorticotropic hormone (ACTH) stimulation test was performed to diagnose adrenal insufficiency. Her preoperative random total cortisol concentration was 9.0 µg/dl (adrenal insufficiency: < 10 µg/dl). Thirty minutes after stimulation with 250 µg synacthen, her delta cortisol concentration was 4.9 µg/dl (adrenal insufficiency: < 9 µg/dl). The concentrations of all the other hormones were within the normal ranges. Based on guidelines for the diagnosis of corticosteroid insufficiency in critically ill patients [], she was diagnosed with adrenal insufficiency. The patient was started on hydrocortisone therapy (50 mg, tid) preoperatively, and it was maintained during liver transplantation.\nAnesthesia was induced with thiopental sodium, fentanyl, vecuronium, and sevoflurane. Hemodynamic data were recorded in real time during surgery using an online personal computer interfaced with a signal processing software (Windaq, DATAQ instrument, Akron, OH). Thirty minutes after surgical incision, the patient's mean arterial blood pressure (ABP) started to fluctuate and decreased to less than 60 mmHg without significant blood loss. Because intermittent bolus administration of ephedrine was not effective, she was infused continuously with dopamine (5-10 µg/kg/min), dobutamine (5 µg/kg/min) and norepinephrine (0.15-0.2 µg/kg/min), starting from the pre-anhepatic phase of liver transplantation (). However, her ABP fluctuated markedly (). Before graft reperfusion, she was administered 172.5 mg of methylprednisolone (3 mg/kg) for immunosuppression. Immediately after reperfusion, she was administered 40 µg of an epinephrine bolus due to severe hypotension. However, although she was supported by increasing dose of inotropics and vasopressors after graft reperfusion, her ABP continued to fluctuate until the end of the operation. Blood components transfused during operation were shown in .\nAlthough she was maintained on hydrocortisone postoperatively, inotropics could not be tapered and hemodynamic instability continued (). On postoperative day 9, the patient developed atrial fibrillation, and a chest radiograph showed pneumonic infiltration. On postoperative day 11, the patient died due to pneumonia and septic shock.