Torsade de pointes in liver transplantation recipient after induction of general anesthesia: a case report
A 53-year old male (height 173.6 cm, weight 75.6 kg) was scheduled for emergency cadaveric donor liver transplantation due to hepatitis B virus-related liver cirrhosis and hepatocellular carcinoma. Microvascular angina was diagnosed 2 years earlier with atypical chest pain. Coronary angiography at that time showed no significant stenotic findings. The patient was diagnosed with atrial fibrillation at the same time, and he was started on nicorandile, molsidomine, isosorbide dinitrate, digoxin, furosemide, and spironolactone. An anticoagulant was excluded due to bleeding tendencies. Furthermore, the patient had liver cirrhosis-related diabetes mellitus, portal hypertensive gastropathy, and esophageal varix.\nECG was performed just before surgery and showed atrial fibrillation with a normal heart rate (). The calculated QTc interval was 455 ms. The patient had mild mitral regurgitation and tricuspid regurgitation, but no regional wall motion abnormality was seen on preoperative echocardiography. The calculated left ventricular ejection fraction was 68%, and the mean pulmonary arterial pressure was 24 mmHg. The PT INR was 1.38, total bilirubin was 2.2 mg/dl, platelet count was 48,000 /µl, and albumin was 2.5 g/dl. Other blood test findings were within normal limits.\nWithout preoperative medication, the patient entered the operating room and his vital signs were measured immediately. His blood pressure (BP) was 117/73 mmHg, heart rate (HR) was 80 beats/min, and his pulse oximetry oxygen saturation (SpO2) was 99%. After preoxygenation with a mask by applying 100% O2 at 6 L/min for a few minutes, palonsetron 0.075 mg, lidocaine 40 mg, and propofol 120 mg were administered intravenously. After the patient lost consciousness, manual assisted ventilation was performed with 100% O2 at 6 L/min and 5 vol% sevoflurane; in addition, rocuronium 50 mg was injected. With full relaxation, the patient's trachea was intubated using a cuffed 7.5 mm endotracheal tube without difficulty. The radial and femoral arteries were cannulated, followed by continuous arterial blood pressure monitoring. A central venous catheter (AVA HF; Edwards Lifesciences, Irvine, CA, USA) was placed at the right internal jugular vein with no resistance or difficulty. A pulmonary artery catheter (Swan-Ganz CCOmbo; Edwards Lifesciences, Irvine, CA, USA) was inserted and pulmonary artery pressure monitoring was started. By ECG, no clinically significant change occurred during insertion of the pulmonary artery catheter. The catheter's position was checked with a chest X-ray. Anesthesia was maintained with 0.7 L/min O2, 1.3 L/min air, and 1.5-4.0 vol% sevoflurane. Initial arterial blood gas analysis (ABGA) revealed normal electrolyte levels and adequate oxygenation. ECG showed atrial fibrillation, but no clinically significant abnormal change was observed.\nAt 50 minutes after the patient's arrival, the surgeon started to prepare for surgery. At that time, sudden-onset large QRS tachycardia () appeared, and the femoral and radial arterial waves became flat. The end tidal CO2 (ETCO2) pressure dropped rapidly, from 35 to 13 mmHg. Epinephrine 100 µg and calcium chloride 300 mg were administered twice. One of the surgeons started cardiac compression immediately, and mechanical ventilation was continued with 100% O2. Epinephrine 1 mg was injected intravenously. During CPR, defibrillation was performed four times using 150-200 J, and epinephrine 1 mg was administered intravenously every 3-5 minutes. Amiodarone 300 mg mixed with 100 ml of normal saline was administered. Additionally, magnesium sulfate 2 g and lidocaine 70 mg were injected intravenously. Calcium chloride, regular insulin, and sodium bicarbonate were also administered after checking ABGA (). During CPR, a bloody secretion started to come out of the endotracheal tube, and the peak inspiratory pressure increased. We repeatedly suctioned the endotracheal tube, and alveolar recruitment via manual bagging was attempted a few times.\nAfter 30 minutes of CPR and the last defibrillation, large QRS tachycardia disappeared and ECG revealed a normal sinus rhythm. Simultaneously, the femoral and radial arterial waves recovered to normal wave forms. The patient's systolic BP was 80-85 mmHg, his HR was 40-45 beats/min, and ETCO2 was 17-19 mmHg. After the return of spontaneous circulation, we loaded 50 µg/kg milrinone intravenously and started continuous infusion of milrinone at 0.5 µg/kg/min and epinephrine at 0.1 µg/kg/min. Regular insulin, sodium bicarbonate, and vasopressin were also administered. The patient's temperature was 34.7℃, and both pupils were dilated without a light reflex.\nA few minutes later, the patient's SpO2 increased to 100%, and ETCO2 increased to 28 mmHg. The patient's vital signs stabilized at a HR of 80-85 beats/min, systolic BP over 100 mmHg, and mean BP over 80 mmHg. Without proceeding with the operation, the patient was transferred to the intensive care unit (ICU). The total exposure time to anesthesia was about 110 minutes. 1 L of crystalloid and 400 ml of colloid were infused, and the patient's urine output was 30 ml during anesthesia. On arrival at the ICU, the patient's BP was 98/62/76 mmHg, his SpO2 was 100%, and ECG showed atrial fibrillation with a HR of 80 beats/min. The patient's pupil reflex returned to a normal response. Electrolytes and cardiac enzymes were evaluated. Neither hypokalemia nor hypocalcemia was detected, and all electrolyte values were within normal levels. The patient's CK was 106 IU/L, CK-MB was 2.6 ng/ml, and Troponin I was slightly elevated to 0.10 ng/ml. Bedside echocardiography revealed no regional wall motion abnormality or evidence of myocardial ischemia.\nOn the second day of ICU admission, pulse-less large QRS tachycardia appeared twice. Both events were terminated after applying defibrillation using 150 J and cardiac compression for 2 minutes. Metabolic acidosis, intravascular volume loss, and pulmonary edema were aggravated and the patient's BP and SpO2 continued to decrease. On the fourth day in the ICU, the patient expired. ECG showed a marked prolonged QTc interval (). Nevertheless, cardiac echocardiography performed on the day of the patient's expiry showed normal findings. No regional wall motion abnormality was observed, and the left ventricular wall thickness was normal with a calculated ejection fraction of 56%. The patient's systolic pulmonary arterial pressure was 33 mmHg.