By the fifth postoperative day, she was noted to have a temperature of 38.5°C with an elevated white blood cell count of 14.4 xl09/L. A persistent sinus tachycardia (150/min) was present with a summation gallop and apical pansystolic murmur on auscultation. The ECG demonstrated significant changes from previous tracings, with deeply inverted T waves in leads I, aVL and V, to V6. Hemodynamic parameters had deteriorated with an increased pulmonary capillary wedge pressure and decreased Cl (Table 1). Echocardiogram performed that day demonstrated marked left ventricular (LV) dysfunction of a global nature, with only the basal inferoposterior wall moving adequately. The fractional shortening was 10 percent and there was an increased E point to septal separation of 2 cm (normal < 1.0 cm), in keeping with the low cardiac output state secondary to LV dysfunction. No valvular lesions were noted. At this time, serum electrolytes were normal, with a total serum calcium level of 2.43 mmol/L and inorganic phosphate level elevated at 3.16 mmol/L. Serum creatinine concentration was 763 |imol/L. Cardiac enzymes were not elevated (CK, 168 U/L; CK-MB, 5 U/L) with the total CK having fallen since surgery. Serum lipas e level was minimally elevated at 741 U/L. Medication at this time was morphine and diazepam for sedation, pancuronium, ceftazidime, and subcutaneous heparin. buy birth control
Treatment was started with intravenous nitroprusside up to a dose of 3^lg/kg/min, and hemodynamic state improved with Cl increasing to 3.4 L/min/m2. As the possibility existed that the myocardial depression was due in some way to a necrotic remaining right kidney, a remnant nephrectomy was performed on the sixth postoperative day. Histologic study of this specimen revealed a large area of acute necrosis with no evidence of residual tumor. The patient’s condition improved dramatically following this surgery, with a decrease in her heart rate and disappearance of the gallop rhythm. She was weaned off the nitroprusside infusion within 8 h of surgery and hemodynamic parameters normalized. Repeated echocardiogram 18 h after surgery showed significant improvement in LV function with only mild septal hypokinesis (Table 1). The fractional shortening was 21 percent and the E point to septal separation was 1.1 cm. The chest radiograph began clearing and she was extubated the following day with no further cardiac problems.