case_images: PMC8062170_01
case_images: 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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case_images: PMC8062170_01_CRIA2021-6635696.001.jpg
case_images: fig1
case_images: Preoperative computed tomography revealed remarkable abdominal distension caused by an enlarged polycystic liver (Figure 1).
case_images: 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.
case_images: CRIA2021-6635696.002.jpg
case_images: PMC8062170_01_CRIA2021-6635696.002.jpg
case_images: fig2
case_images: 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).
case_images: 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.
case_images: CRIA2021-6635696.003.jpg
case_images: PMC8062170_01_CRIA2021-6635696.003.jpg
case_images: fig3
case_images: 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).
case_images: Correlation between Ca2+ and QTc interval. R2 indicates coefficient of determination.
case_images: CRIA2021-6635696.004.jpg
case_images: PMC8062170_01_CRIA2021-6635696.004.jpg
case_images: fig4
case_images: Postoperative analysis of the relationship between QTc interval and Ca2+ during surgery showed a strong negative correlation (Figure 4).