[Emergent operation for a patient of duodenal bleeding accompanied with fulminant myocarditis]

A 53-year-old woman developed general fatigue following an upper airway infection, which abruptly progressed to cardiogenic shock showing systolic blood pressure of 60 mmHg. An echocardiography revealed an ejection fraction of 0.11, diffuse severe hypokinesis and left ventricular thrombosis. Fulminant myocarditis was suspected, and intensive care including mechanical ventilation, intraaortic balloon pumping (IABP), catecholamine support and anticoagulation therapy was initiated immediately. Although the cardiac function gradually recovered, she developed a duodenal bleeding on the third therapeutic day. Factors such as low output syndrome, heparinization, steroid pulse therapy and platelet dysfunction due to IABP can enhance the hemorrhagic tendency. Since it was difficult to control bleeding by the endoscopy, blood transfusion was performed, and the operation was planned on the 13rd day when the cardiac function seemed to have recovered enough. The patient was anesthetized with ketamine, propofol and fentanyl. To maintain stable circulation, circulatory parameters such as blood pressure, central venous pressure, and cardiac output were monitored. After a preoperative consultation with the surgeon, the surgical technique had been preoperatively decided to reduce the surgical stress, and then partial duodenosectomy and gastro-jejunum anastomosis was performed. She was discharged on the 38th post operative day without complications. In cases of hemorrhagic disease accompanied by an acute phase of fulminant myocarditis, consultation among surgeons, cardiologists and anesthegiologists should be mandatory to determine the timing of the operation and to decide the degree of surgical invasion.