By Ewa Lechowicz-Glogowska, Agata Rojek, Wieslawa DuszynskaFirst Online:
09 October 2019
A 63-year-old woman was qualified for an urgent, large supratentorial metastatic tumor of breast cancer resection. The patient’s initial Glasgow Coma Scale (GCS) was 14 points. Other comorbidities were as follows: ca mammae, hypertension and hypothyreosis. Diabetes and acute coronary syndrome (ACS) have never been diagnosed. According to the patient’s history, she did not suffer from pain in thorax and she was able to climb to the second floor without fatigue. Preoperative electrocardiographic (EKG) test was within a normal range, and due to the lack of any cardiac risk factors, echocardiography and stress test were not done preoperatively as a part of the routine testing. The patient received steroids preoperatively, as well as one dose at the time of surgery. Induction of anesthesia was started after the implementation of monitoring the heart rate (HR)-EKG (5 leads), invasive blood pressure measurement, saturation of the blood (SaO2)-pulsoxymetry, CO2 in the expiratory air (ETCO2),—capnography, bispectral index (BIS), train of four-myorelaxation monitoring, central body temperature. A central line catheter was inserted into the right jugular vein after patient’s intubation. The patient’s initial blood gases showed no abnormalities (SaO2-99%). After the intravenous (IV) induction of anesthesia (propofol, fentanyl and rocuronium), sevoflurane (minimal alveolar concentration 0.7–0.9), and an adjuvant dose of ketamine given by an IV infusion (0.2–0.3 mg/kg body weight/hour) was started.
BIS was maintained at a level of 40–50%. Normal body temperature, blood gases and electrolytes (Na, K, Mg) were maintained. Due to a slight drop in blood pressure, following induction of anesthesia, small doses of norepinephrine (NE) were infused (0.02–0.03 mcg/kg/min) to keep proper mean arterial pressure and intracranial perfusion pressure. No severe intra-operative bleeding was observed. Euvolemia was maintained. Normal heart function and HR of 70–80/min and systolic blood pressure (SBP) around 100 mmHg were noted till the 4th hour of the surgery.
A sudden and significant HR increase up to 130/min, followed by a SBP drop to 80 mm Hg, appeared during the final surgery stage resection of the deepest tumor mass. Hyperglycemia (480 mg%) with severe metabolic acidosis (pH 7.19, lactate 4.9 mmol/L), oliguria and electrolyte abnormalities developed within minutes. Table 1 presents the patient’s biochemical parameters before, during and 24–48 h after the surgical procedure. NE (0.05–0.9 mcg/kg/min) with amiodarone was administered in a continuous IV infusion, followed by additional epinephrine (ADR) (0.18–1 mcg/kg/min), bicarbonates, insulin and electrolytes that were given in increasing doses. No stabilization was achieved in 2 h until the discontinuation of the tumor resection. Figure 1 shows the magnetic resonance imaging (MRI) scans of the brain and solid tumor using a contrast. This surgical procedure was carried out with neuro-navigation.Read full article