Successful management of acute intraoperative hyperkalemia during huge liver cancer resection following neoadjuvant chemotherapy: a case report.

Background: Intraoperative hyperkalemia from necrotic tumor cells is a rare but serious complication of neoadjuvant chemotherapy (NAC) for liver tumors. Herein, we report a case of acute hyperkalemia that occurred intraoperatively during liver resection in a patient with tumor bleeding induced by preoperative chemotherapy. Case Description: The patient was a 68-year-old man, 170 cm in height and weighing 62 kg, with a history of hepatitis C. Contrast-enhanced computed tomography revealed a massive tumor measuring 16 cm in diameter in the right lobe of the liver. The patient received three courses of preoperative chemotherapy with atezolizumab and bevacizumab. Due to bleeding from the tumor, early surgical resection was scheduled. Preoperative laboratory evaluations showed normal renal function and potassium levels. During intraoperative manipulation, including ligation of feeding vessels and compression of the liver, arterial blood gas analysis showed a sudden rise in serum potassium from 5.0 to 6.3 mmol/L. Glucose-insulin (GI) therapy was administered, and the Pringle maneuver (PM) was avoided to limit further potassium release. By the end of the procedure, potassium level had decreased to 4.6 mmol/L. Conclusions: The potential for hyperkalemia due to potassium release from necrotic tumor cells should be considered in patients undergoing liver resection after NAC. Careful intraoperative monitoring, along with appropriate surgical and anesthetic strategies, is crucial to prevent fatal arrhythmias.