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Dear Editor, Approximately 29% of patients with long-term chronic renal failure (CRF) undergo parathyroidectomy to control secondary hyperparathyroidism that occurs as a result of chronic parathyroid stimulation caused by failure of adequate Vitamin D synthesis. 1 Patients with renal failure have associated metabolic complications and electrolyte disturbance. 2 The senior authors (RJE, SR) in this study were involved with a 20year-old patient with renal failure undergoing total parathyroidectomy, who had a cardiac arrest intra-operatively. Despite aggressive resuscitation, the patient died. At the commencement of the resistant ventricular fibrillation arrest, the patient's serum potassium level had risen from 3.3 mm at induction to 7.8 mm over 1 h. After such a devastating complication, potassium levels were subsequently monitored in these patients during the operation. On reviewing the literature, there is no mention of this intraoperative complication during renal parathyroidectomy. Hyperkalemia is recognised as a complication within the first 24 h post-operatively after parathyroidectomy. 3 This study is a prospective analysis of intra-operative monitoring of potassium levels for patients with CRF undergoing parathyroidectomy under the care of the senior author (RJE). , all patients with CRF undergoing parathyroidectomy at Hull Royal Infirmary were included in the study. All the parathyroidectomies were performed by a single surgeon (RJE). Four-gland parathyroidectomy was planned and achieved in every patient. Typically, the patients had received multiple anaesthetics in the past. Anaesthesia for parathyroidectomy did not differ significantly from the previous anaesthetics. The drugs used at induction of anaesthesia were propofol, fentanyl, ondansteron and atracurium as laid down by a previously agreed anaesthetic protocol; maintenance with oxygen ⁄ nitrous oxide ⁄ sevoflurane mixture; morphine intra-operatively for further analgesia and reversal of neuromuscular blockade with glycopyrrolate ⁄ neostigmine at the end. If the pre-operative post-dialysis potassium levels were above 5.3 mm, the planned parathyroidectomy procedure was cancelled. As there was no mention in the literature of similar problems, after discussion with the nephrologists, it was decided that a rise of more than 0.5 mm of potassium levels from the post-induction level to intra-operative would be considered significant.Twenty-nine patients are included in the study (Table 1), and no patients were excluded. All the operations were performed on a morning operating list. All patients had a post-dialysis pre-operative potassium level check on the morning of the surgery, at least two potassium checks in theatre and one post-operative potassium level measurements (Fig. 1). The first potassium check was immediately after induction, and the second potassium level was checked after the second parathyroid gland had been removed (earlier if ECG changes became evident). Intra-operative potassium was measured using a venous sample in a blood-gas machine ...

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