Venting...

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Had a pt with HHS, sugar 1300, pH 7.2, K 6.5, Cr. 3, mild peaked t's on EKG. In addition to fluids, insulin gtt, I gave him some calcium gluconate as well. Otherwise stable gentleman.

Spoke with the IM admitting resident who wants me to give him...kayexalate?

1. It strikes me as odd, in a pt who is at risk for total body K depletion, that the medicine resident really wants to add kayexalate to the mix. Hydration and insulin alone should resolve the acidosis, re-distribute the K, increase the urine output without risking bottoming out the K.

2. It also strikes me as odd that every medicine resident I talk to about hyperkalemia do not immediately ask about the immediate lowering/redistribution agents and cardioprotecting agents....they ask about the kayexalate. I send you to this link for further review: http://www.asn-online.org/press/file...erns_study.pdf

I tried my best to convince him (tersely) that this was unwarranted, without much avail. He came by the ED and wrote for a dose of kayexalate on the pt's chart which just infuriated me more.

Am i crazy or what?

Are you a pre-med? This seems well outside the range of someone not even in med school.

I, for one, were I the consultant, would be puzzled and somewhat irate if some college student was calling.

Originally Posted by studyinghard

Had a pt with HHS, sugar 1300, pH 7.2, K 6.5, Cr. 3, mild peaked t's on EKG. In addition to fluids, insulin gtt, I gave him some calcium gluconate as well. Otherwise stable gentleman.

Spoke with the IM admitting resident who wants me to give him...kayexalate?

1. It strikes me as odd, in a pt who is at risk for total body K depletion, that the medicine resident really wants to add kayexalate to the mix. Hydration and insulin alone should resolve the acidosis, re-distribute the K, increase the urine output without risking bottoming out the K.

2. It also strikes me as odd that every medicine resident I talk to about hyperkalemia do not immediately ask about the immediate lowering/redistribution agents and cardioprotecting agents....they ask about the kayexalate. I send you to this link for further review: http://www.asn-online.org/press/file...erns_study.pdf

I tried my best to convince him (tersely) that this was unwarranted, without much avail. He came by the ED and wrote for a dose of kayexalate on the pt's chart which just infuriated me more.

Am i crazy or what?

Who cares... let them have their kayexelate...

You're admitting to their service and they get to deal with repleting the K the next day.

If it makes you feel better, you're right.

Take heart. There's little evidence that kayexalate does much to lower total body K anyway...

I agree with the OP - treat the DKA, hold the kayexalate, and watch the K fall.

Originally Posted by Apollyon

Are you a pre-med? This seems well outside the range of someone not even in med school.

I, for one, were I the consultant, would be puzzled and somewhat irate if some college student was calling.

His account was created in 2006...my bet is that puts him as a 1st/2nd/3rd year resident who never updated his profile.

Just tell them no. They can order that insanity when the patient gets to the floor.

.

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Originally Posted by Birdstrike

This always gave me a chuckle. Medicine LOVES kayexalate for some reason. Its almost like the lamer or slower working the drug, the more they like it. LOL. Why the hell are they always such a hurry to give the one drug for hyperkalmia that takes the longest to work, in the first place? I always thought this was funny.

It just the art of dealing with consultants. Sometimes they make requests that make you scratch your head. Some times it's because they haven't a clue about something. Sometimes it's because they know something you don't.

Maybe it's a CYA thing, shows that they noticed the hyperkalemia even though it won't actually do much.

Originally Posted by Birdstrike

This always gave me a chuckle. Medicine LOVES kayexalate for some reason. Its almost like the lamer or slower working the drug, the more they like it. LOL. Why the hell are they always such a hurry to give the one drug for hyperkalmia that takes the longest to work, in the first place? I always thought this was funny.

It just the art of dealing with consultants. Sometimes they make requests that make you scratch your head. Some times it's because they haven't a clue about something. Sometimes it's because they know something you don't.

Originally Posted by johnnydrama

Maybe it's a CYA thing, shows that they noticed the hyperkalemia even though it won't actually do much.

I think it stems from nursing. Nurses hate when there's a number out there that isn't being treated somehow ("My license! My license!"). If you're the IM resident and you don't give the Kayexelate for the "hyperkalemia" you guarantee yourself a dozen calls. In that case the Kayexelate is great because it doesn't work and it gives everyone something to do while the DKA treatment works.

Originally Posted by docB

I think it stems from nursing. Nurses hate when there's a number out there that isn't being treated somehow ("My license! My license!"). If you're the IM resident and you don't give the Kayexelate for the "hyperkalemia" you guarantee yourself a dozen calls. In that case the Kayexelate is great because it doesn't work and it gives everyone something to do while the DKA treatment works.

I don't know. My ER nurses despise kayexelate. Its the only drug that takes an hour before its given. The calcium, insulin, D50 and albuterol were given immediately (rightfully so), but then the patient got two doses of dilaudid and zofran and whatever that comes from the same pharmacy and then finally just before they go upstairs they got the kayexelate that was invariably ordered at the same time as the rest of the hyperkalemia cocktail.

Originally Posted by logos

I don't know. My ER nurses despise kayexelate. Its the only drug that takes an hour before its given. The calcium, insulin, D50 and albuterol were given immediately (rightfully so), but then the patient got two doses of dilaudid and zofran and whatever that comes from the same pharmacy and then finally just before they go upstairs they got the kayexelate that was invariably ordered at the same time as the rest of the hyperkalemia cocktail.

They give the Kayexalate just before the patient leaves the ED not because they hate the Kayexalate, but because they hate the floor nurses. Kayexalate causes horrible diarrhea, and noone wants to deal with that. Less crap in the ED = better!

Ideally, the patient should be drinking the Kayexalate in the elevator on the way upstairs... same thing with the lactulose you order on the hepatic encephalopathy patients you admit.

Scott Wiengart..

http://emcrit.org/misc/is-kayexalate-useless/

Originally Posted by EctopicFetus

Scott Wiengart..

http://emcrit.org/misc/is-kayexalate-useless/

Yeah. I know. But what the heck else are you supposed to do? Just give the "temporary shifting intracellular stuff" and then they code for whatever reason 3 hours late; its hard to defend.

Empirically, kayexelate seems to work. I often recheck K levels given our long ED stays (sometimes 24 hours + for ICU patients) and they do seem to go down with kayexelate.

Originally Posted by logos

Empirically, kayexelate seems to work. I often recheck K levels given our long ED stays (sometimes 24 hours + for ICU patients) and they do seem to go down with kayexelate.

If kayexalate is the only thing you're giving then I would argue you're committing malpractice.
If you think the change you see is only related to kayexalate and not the other treatments, I would argue you're being dense.

Originally Posted by Dr.McNinja

If kayexalate is the only thing you're giving then I would argue you're committing malpractice.
If you think the change you see is only related to kayexalate and not the other treatments, I would argue you're being dense.

this..

BTW not giving kayexalate.. not hard t defend.. if they are that sick.. it would be harder to defend why they arent getting dialyzed.

The fear of malpractice is real but in instances like this highly overblown.

Put this in your chart "I dont believe giving this drug is in the patient's best interest. I spoke with the admitting service and they ask that I give it. I explained that this may cause harm. I invited the admitting service to come to the ED and write orders for this medication if they feel it is so critical. The patient is stable and other more appropriate therapies have been instituted."

Pretty sure that would save your ass.

For a lawsuit you need causation and you need to deviate from the standard of care.

Me I give it if they want. I wont pick this as my battle...

I'd give them fluids as someone in HHS is dehydrated with often times a 6L deficit. HHS patients also tend to be whole body potassium deplete. Fluids by themselves will drop the K (dilution and shifts). If they don't have EKG changes, I'd recheck a potassium in one hour along with all your other labs. If they have EKG changes, give insulin, glucose, calcium chloride (if they truly have EKG changes), and albuterol. Consider lasix. If they don't improve, then you've got to consider dialysis.

If you look at the original studies regarding Kayexalate there would be very little chance it would get through the FDA now. The evidence for its efficacy is poor. Also I'd be very cautious to use kayexalate in any patient since it can cause bowel necrosis secondary to the SPS (although it's been reported primarily in postoperative, dialysis, and transplant patient it has been reported to happen in patients without those comorbidities).

Just to clarify I wasn't defending Kayexelate. I don't give it anymore but it is routinely ordered by my internists and nephrologists. I was suggesting a reason why it's use persists. The nursing push is hard to ignore.

For example, my nurses are of the belief that any patient with an SBP of <90 must be placed on pressors immediately. I frequently have happy, pink, LOLs in NAD making urine with Bps of 85/55 and the nurses are screaming for Leave-'em-dead ("My license!"). And I've already written extensively about how no nurse in my area code will discharge an asymptomatic hypertensive patient without the magic that is Clonidine.

I don't think kayexalate probably works, but if you take a step back you'll see that we don't have strong evidence that it doesn't. We just don't have good evidence that it does work, which puts it in the same category as 90% of therapies in medicine. And I don't really see good evidence out there that it's harmful either. When all this stuff came out a couple years ago I too got really passionate about not giving it, and I still don't order it unless someone suggests it, but frankly I don't think it really matters much. It's easy to get worked up about being an EBM contrarian but I think you can waste a lot of energy that way and it's better to keep some perspective.

And if I have an admitted patient, the admitting team can write for anything they want and I don't think it's my place to get offended. If it is something really inappropriate you can always try to convince them, but if no one seems to agree with you then you must occasionally ask why that is

.

While I'm not a huge proponent of kayexalate and I doubt it works, the one thing I do consider is that there is sorbitol mixed in with it. Sorbitol = diarrhea = possible potassium loss. So if someone asks for it, I don't put up a fuss. Unless the person has a reason that diarrhea is going to be a major issue like short gut syndrome or a colostomy, that is.

I agree with the perspective of "Meh, I'm not going to fight what's likely a non-effective but benign treatment", but if doing what the consultant asks for is likely to hurt the patient, I'll fight.

This case may fall into the latter category: Is this patient's renal failure chronic or acute? If acute, is it prerenal and thus likely to resolve with fluids? It's quite possible that this patient is total body hypokalemic, and once you have the glucose down and the patient's rehydrated the K is going to be 3.0 and you're going to be wishing the patient wasn't expelling potassium in their watery stool.

Originally Posted by docB

The nursing push is hard to ignore.

For example, my nurses are of the belief that any patient with an SBP of <90 must be placed on pressors immediately. I frequently have happy, pink, LOLs in NAD making urine with Bps of 85/55 and the nurses are screaming for Leave-'em-dead ("My license!"). And I've already written extensively about how no nurse in my area code will discharge an asymptomatic hypertensive patient without the magic that is Clonidine.

Oh God. We have a sepsis protocol in our hospital and they're really pushing it. We have a nurse manager who is doing a study on how many patients with BP's in the sepsis protocol range aren't being treated as septic patients. So I have a 79 year old man happily sitting up in bed waiting for someone to come back with his clothes so he can go home - discharged - eating french fries with a heart rate of 74 BPM, oxygen sat of 97%, normal white count and completely afebrile, but his BP is 85/55 and she's pushing me to manage him according to the sepsis protocol (I can't even remember what he came in with - probably random abdo pain). I suggested that since he was sitting up and eating with absolutely no other signs or symptoms of sepsis maybe this would be overkill, particularly since we are in the middle of yet another c.diff outbreak (wonder why ) and that maybe we could just suggest he cut back his Norvasc. I'm pretty sure I got reported for that. Oh well,
M
Argh!

Originally Posted by pinipig523

Who cares... let them have their kayexelate...

You're admitting to their service and they get to deal with repleting the K the next day.

Originally Posted by Birdstrike

This always gave me a chuckle. Medicine LOVES kayexalate for some reason. Its almost like the lamer or slower working the drug, the more they like it. LOL. Why the hell are they always such a hurry to give the one drug for hyperkalmia that takes the longest to work, in the first place? I always thought this was funny.

It just the art of dealing with consultants. Sometimes they make requests that make you scratch your head. Some times it's because they haven't a clue about something. Sometimes it's because they know something you don't.

Because the insulin, calcium gluconate, sodium bicarbonate, etc. will wear off in an hour, and the Kayexalate should start working by then.

It's like ED docs rushing to give furosemide IV without reducing preload with some nitroglycerin that will work much faster.

Originally Posted by Dr.McNinja

If kayexalate is the only thing you're giving then I would argue you're committing malpractice.
If you think the change you see is only related to kayexalate and not the other treatments, I would argue you're being dense.

Nah. There are pleanty of situations where just giving a little token kayexelate is good enough. We have a huge population of dialysis patients that just don't go to dialysis. They are well conditioned to tolerate hyperkalemia so if its mild and no ekg changes sometimes we will only use kayexelate.

Also you are aware that the rest of the cocktail is a shell game, you hide the K intracellularly for a bit because its quick but if you recheck the K in 6 hours it should have returned to where it was. When I add kayexelate it dosen't seem to do that. I know the evidence is poor but it makes me feel good to give the stuff, likely I'm following the textbook.

We have one patient that I know that is "allergic" to kayexelate. I order her a dose every time she comes in and then let her refuse it. She doesn't go to dialysis at all except by showing up to our and about a half dozen other ERs and getting admitted for hyperkalemia or fluid overload. I actually called her dialysis center once and they told me she hadn't been in for dialysis there in months.

.

Originally Posted by Birdstrike

The onset of action of kayexalate is "hours to days" orally.

http://www.drugs.com/mmx/kayexalate.html

You could redraw another potassium, send it to the lab, get the results and re-dose your insulin/D50, bicarbonate, calcium, and albuterol or even get dialysis going before your kayexalate gets working.

Still doesn't make sense to demand a drug be given in seconds to minutes if it won't start working for hours to days, but like everyone else said, "whatever".

It's not a battle worth fighting.

http://www.globalrph.com/toxicology.htm

This says 1-2 hours. You can either give it or keep redosing insulin or bicarbonate. Calcium is only a stabilizer and to my knowledge does nothing to actually lower potassium levels.

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Originally Posted by Birdstrike

I believe that's the enema, which works quicker than po kayexalate. Correct, calcium stabilizes only.

Yep, not every time you give Kayexalate do you have to give it PO.

Regardless, if the admitting doc requests something, I usually order it unless it's really unreasonable.

Medical residents/attendings are jackasses wearing lab coats. nothing more, dont even let me start on Surgery. and yes you are right ...