The patient’s baseline lab and paraclinic data prior to anesthesia are shown in table 1. Table 1: Baseline laboratory and paraclinical data of a 49-year-old man, who presented severe hyperkalemia during liver transplantation Anaesthesia was induced using thiopental, morphine, fentanyl and midazolam.

Pancuroium was used for neuromuscular blockade. Ventilation was maintained with a mixture of air-oxygen plus isoflurane 1%. Normal saline and albumen 25% were administrated to maintain a central venous pressure of about 10 cm H2O. Calcium gluconate and sodium MLN2238 in vivo bicarbonate were used to correct Inhibitors,research,lifescience,medical low Ca2+ levels and metabolic acidosis (base excess ≤-4), respectively. We monitored cardiovascular functions using electrocardiogram, arterial pressure via a radial artery catheter, and central venous pressure via a catheter inserted into the right internal jugular vein.

The transplantation of the graft was performed using the piggy-back technique. Baseline potassium was 4 mmol/L. Urine output was Inhibitors,research,lifescience,medical more than 500 ml during 3 hours of hepatectomy, and surgical bleeding was less than 400 ml; therefore, no blood transfusion Inhibitors,research,lifescience,medical was performed. Metabolic parameters including serum potassium was checked by serial measurements of arterial blood gases (ABG) as needed (table 2). The first serum potassium was 4 mmol/L, and after 40 minutes of anesthesia and surgery it was in normal range. One hour after the start of surgery, hepatic artery was ligated. Thirty minutes after the ligation a tall T wave and bradycardia

were noted on EKG monitoring. Therefore, serum Inhibitors,research,lifescience,medical potassium was checked by measuring ABG. The serum potassium was 6.5 mmol/L. Hyperkalemia was managed by 10 ml calcium gluconate 10%, 50 ml dextrose 50%, and 25 U regular insulin. Near the end of hepatectomy phase, K increased to 7.8 mmol/L; therefore, the operation was stopped, and patient received 20 ml calcium gluconate 10%, Inhibitors,research,lifescience,medical 1150 ml NaHCO3, and 20 U to 210 U regular insulin. This led to a decrease of serum potassium from to 4.09 mmol/L without episode of hypoglycemia. The hepatectomy was then done, and the second phase of the operation was followed. Table 2: Metabolic parameters during anesthesia of a 49-year-old male, who presented severe hyperkalemia during liver transplantation Discussion Severe hyperkalemia frequently occurs immediately after revascularization during orthotropic liver transplantation.5,6 There is, however, only one report on severe pre-anhepatic hyperkalemia in living-related liver transplantation.7 The changes in metabolic and hemodynamic parameters in different phases of the liver transplantations surgery vary significantly. One of such parameters is serum potassium that may increase dramatically during any phase of the operation.