[Perioperative bleeding tendency in a hemodialysis patient during gastrectomy under total intravenous anesthesia...

A 64-year-old female receiving hemodialysis (HD) underwent subtotal gastrectomy for gastric cancer under total intravenous anesthesia. Anesthesia was performed using continuous infusion of propofol (5-8 mg.kg-1.h-1), buprenorphine i.v. (2.5 micrograms.kg-1), 2% mepivacaine epidural infusion (7 ml.h-1) and appropriate doses of vecuronium. The blood pressure and heart rate were stable within 120% of the preoperative level. However, 3 and half hours after propofol anesthesia, increased bleeding from the surgical field was observed. The activated clotting time (ACT) was 144 seconds. Furthermore, at the end of the operation (5 hours after propofol anesthesia), the ACT (219 sec), PT (14.8 sec), PT-INR (1.94) and APTT (102.5 sec) were significantly prolonged. The platelet count was unchanged. The intraoperative total bleeding was 844 g. The total propofol infusion time and dose were 310 minutes and 1,580 mg, respectively. Immediate recovery with spontaneous ventilation was observed. Postoperative bleeding from the wound continued. Finally, 7 hours after the surgery, the bleeding ceased and the ACT (125 sec), PT (12.4 sec), PT-INR (1.34) and APTT (22.5 sec) were normalized. The total postoperative bleeding was 404 g. Despite the advantage of short-acting anesthetic agent, we suspect that propofol induced the bleeding tendency via platelet inhibition. This platelet inhibition may gradually increase with time and the dose of propofol. We should utilize propofol cautiously for patients receiving HD or with bleeding tendency.