Hyperlactemia associated with secondary hepatocellular carcinoma resection in relation to circulation stability and quality of recovery: A case report

Table 1 Results of blood gas analysis in a patient with metastatic liver cancer who underwent resection of multiple metastatic tumors in the right lobe of the liver

Measure	Pre-anesthesia	Intraoperative 1	Intraoperative 2	Intraoperative 3	Recovery room 1	Recovery room 2	Recovery room 3
pH	7.4199	7.2946	7.2964	7.4551	7.3541	7.2965	7.3666
Potassium (mmol/L)	3.6836	3.8524	3.9770	3.5277	3.3718	3.6577	3.0349
Glucose (mmol/L)	6.2544	10.6121	15.5280	14.4482	11.2476	10.3345	10.1226
Lactic acid (mmol/L)	3.1100	2.3355	4.7321	6.3023	8.1477	9.3126	9.8924
Base surplus (mmol/L)	-1.53	-3.53	-6.24	-0.56	-5.10	-7.82	-4.87
Hct	33.382	31.879	29.717	24.776	27.867	25.012	22.024
PaO2 (mmHg)	72.2	207.4	253.8	185.9	226.9	86.0	101.5
FiO2	0.21	0.60	0.60	0.60	0.60	0.21	0.21

FiO₂: Fraction of inspired oxygen; Hct: Hematocrit; PaO₂: Partial pressure of oxygen.

Table 2 Pre-operative and post-operative liver function in a patient with metastatic liver cancer who underwent resection of multiple metastatic tumors in the right lobe of the liver

Measure	Preoperative	Postoperative day 1	Postoperative day 2	Postoperative day 5	Postoperative day 6
ALT (U/L)	11.2	405.4	383.3	151.1	109.9
AST (U/L)	27.9	745.8	531.3	54.2	35.1
TP (g/L)	56.2	48.1	41.6	49.1	48.8
ALB (g/L)	34.7	30.4	27.4	35.8	36.4
A:G	1.61	1.72	1.93	2.69	2.94
TBIL (μmol/L)	6.3	6.7	12.3	11.9	15.4

A:G: Albumin:globulin ratio; ALB: Albumin; ALT: Alanine transaminase; AST: Aspartate aminotransferase; TBIL: Total bilirubin; TP: Total protein.

Table 3 Etiology, treatment, and prognosis of hyperlactatemia associated with resection of secondary hepatic metastatic carcinoma

Causes of disease		Treatment	Prognosis
Excessive lactic acid production	Insufficient volume leading to inadequate tissue perfusion	Aggressive fluid replacement to improve tissue perfusion	Severe hyperlactatemia is associated with failure of all vital organs and is difficult to reverse with a poor prognosis
	Longer hepatic portal block, traumatic injury leading to ischemic reperfusion injury	Rehydration, potassium replacement, correction of acidosis
	Hypothermia	Insulation therapy
Decreased lactate clearance	Blockage of blood flow to the liver leading to a decrease in the liver's ability to remove lactic acid	Minimize hepatic portal block time, temperature protection	Severe hyperlactatemia is associated with cardiac surgery, epilepsy and other conditions where the primary condition can be reversed, and has a mild impact on patients with a good prognosis
	Impaired liver function associated with surgical resection	Hepatoprotective therapy
	Impaired kidney function	Maintain circulatory stability and rehydration

Table 4 Case report timeline

Item		Timeline
Preoperative	1	Ten months after diagnosis of sigmoid colon cancer, 4 months after postoperative chemotherapy for liver metastasis
	2	History of “cerebral infarction” for more than six months without special treatment
	3	Abdominal CT scan suggestive of liver metastasis
	4	The operation was performed under general anesthesia
Perioperative	5	Invasive blood pressure was monitored and arterial blood gas analysis was conducted
	6	BIS was monitored
	7	Induction of conventional anesthesia with tracheal intubation
	8	CVC after general anesthesia. Ultrasound-guided transversus abdominis block was performed
	9	Maintenance of anesthesia was performed using static inhalation compound general anesthesia
	10	The operation was performed using Pringle's method to block the hepatic metastases, and arterial blood gases were monitored dynamically intraoperatively. Hyperlactatemia was detected and treated aggressively with fluid replacement and other treatments. However, the patient's vital signs were stable
	11	The surgery was successfully completed
Postoperative	12	After the operation, the patient was transferred to the PACU. There was still hyperlactatemia detected. However, the patient's vital signs were stable
	13	Treatments such as temperature protection as well as arterial blood gas testing were implemented, and although hyperlactatemia was present, vital signs were stable and awakening was satisfactory. The patient returned to the ward after surgery
	14	The patient was discharged six days after surgery
	15	The patient was followed up two months after the operation

BIS: Bispectral index; CT: Computed tomography; CVC: Central venous catheter; PACU: Post-anesthesia care unit.