Torsades de pointes (TP),Case report A four-yr-old 18 kg caucasian boy was scheduled for orthotopic liver and small bowel transplantation because of cirrhosis secondary to short bowel syndrome. No symptoms of central nervous system dysfunction were observed. Preoperative laboratory values included a serum potassium of 3.9 mFxl-L -l (3.5-4.7 normal) and magnesium of 2.3 rag. dl -I (1.7-3.0 normal). There was no history of arrhythmia or prolonged QT interval, or family history of sudden death. A corrected QT interval (QTc) of 370 msec was measured preoperatively ( Figure A). After uneventful induction and maintenance of anaesthesia with isoflurane and muscle relaxation with pancuronium, the native fiver was excised and the donor liver placed. During the anhepatic phase, the urine output was noted to be minimal, so furosemide, 15 mg/v, was given. During donor graR placement, the aorta was crossclamped above the renal arteries for a total of 40 rain. Following unclamping, anuria was noted. Furosemide, 180 nag,/v in divided doses was given over three hours with no effect. At that point, the Foley catheter was found to be occluded. Upon recatheterization, 2.7 1 urine were measured over the ensuing 21A hr. Over the same time, serum potassium concentration decreased from 3.9 to 2.9 mEq. L -~, while serum magnesium concentration remained unchanged at 2.3 nag. dl -~. Serum ionized calcium concentrations during this time were 1.17 to 1.18 retool. L -~ (1.18 to 1.30, normal), and arterial blood pH CAN J ANAESTH 1995 / 42:12 / pp 1137-9

1. Cardiopulmonary bypass is associated with an increase in nitric oxide concentrations, and plasma levels of tumour necrosis factor and interleukin-1. Aprotinin, a serine protease inhibitor, commonly used during cardiopulmonary bypass to reduce blood loss, has been demonstrated to exhibit significant anti-inflammatory effects during and after cardiopulmonary bypass. 2. Airway nitric oxide was measured during cardiopulmonary bypass in 10 controls (Group 1), 10 subjects receiving half-dose aprotinin (Group 2) and 10 patients receiving full-dose aprotinin (Group 3). In vitro, a murine bronchial epithelial cell line (LA-4) was cultured with cytomix (a combination of tumour necrosis factor, interleukin-1, and (gamma-interferon) with and without aprotinin in increasing concentrations. Nitrite concentrations, the stable and measureable end-product of nitric oxide oxidative metabolism, were measured in the culture supernatant by chemiluminescence. 3. Airway nitric oxide concentrations were increased after 50 min cardiopulmonary bypass compared with that measured at 5 min in controls (53 +/- 5 versus 29 +/- 3 ppb, P < 0.05) but not in the aprotinin-treated groups (25 +/- 4 versus 14 +/- 5, Group 2; 21 +/- 6 versus 15 +/- 3 ppb, Group 3). 4. In a dose-dependent manner, nitrite levels (means +/- S.E.M.) were significantly reduced by aprotinin at 500 and 1000 units/ml when compared with cells cultured in the presence of cytomix alone (P < 0.05). 5. These data demonstrate that aprotinin, in a dose-responsive manner, reduces nitric oxide production in vivo and reduces cytokine-induced nitrite production by murine bronchial epithelial cells in vitro. Since increased airway nitric oxide is found in inflammatory lung diseases, like asthma, and anti-inflammatory therapy reduces the concentration of airway nitric oxide, these data support the concept that aprotinin is anti-inflammatory during cardiopulmonary bypass.

A successful liver transplant program needs cooperation and communication from the surgical, blood banking, pathology, primary care, and anesthesia services. Rapid availability of laboratory data, efficient blood banking services, ability to infuse blood products rapidly, coagulation management capability, and plentiful manpower are essential.

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