A case

[dchristismi]

72 yo WM presenting by EMS c/o "not feeling right." Doesn't look terribly bad from the doorway, no distress. Three beats of what looks like VT on the monitor draw you into the room.

PMH most significant for ESRD on HD, and was feeling too bad to go to dialysis yesterday. Wife at bedside reports that this is the first time in 3 years he has missed it. Pt c/o pain in his right hand but "I just can't describe it - I feel bad." Recently hospitalized at another facility where he had a reportedly stable, clean-ish cath. All his healthcare is at this other place, and you have no records. Thankfully, wife is a great historian.

Exam notable for LUE fistula with thrill, pt awake and alert and answering questions appropriately.
Afebrile. BP 110/80, Pulse depends on when you look at the monitor, ranging from 40s-170s. R hand somewhat swollen and tender, but there are more pressing things to manage.

You immediately suspect you-know-what. You immediately launch into treatment of said catastrophe.

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[dchristismi]

You do not have labs back, nor will anything be back (other than a WBC of 21) for 45 minutes, despite multiple calls to the lab. And no, you don't have any helpful little things like an iStat. Well, you have an accucheck of 290.

You proceed with calcium, bicarb, insulin, magnesium, amiodarone, more bicarb, more calcium, fluids, more bicarb, more amio, more bicarb...

Your friendly nephrologist tells you that there are patients on every dialysis machine in the hospital and it will be at least 90 minutes until dialysis is an option.


EKG is as follows. This is one of approximately 25 EKGs over the next 2 hours, as the patient changes rhythms approximately every 30 seconds. Sometimes it looks like a LBBB. Sometimes it's slow AF. Sometimes it's VT. There are runs of what appears to be torsades.

Your patient is still conscious, but sleepy. Arouses to voice and still answering appropriately, but intermittently more confused. Still maintaining BP of 100s systolic.

What's your next move?

 

[RustedFox]

You're doing it right.

Arterial blood gas to look for pH status; though its going to be terribly difficult to interpret secondary to ESRD/HD status, and complicated by the fact that he (A) retains no bicarb from his beans, and (B: if you are where I think you are) this guy has concomitant COPD and other comorbidities making your job difficult.

Homeboy needs HD; badly. Period.

 

[RustedFox]

Also: The IM mouth-breather will tell you that you're "forgetting" to give him kayexelate.

 

[future_dr_house]

Continuous albuterol in addition to above treatments and a threatening call to renal informing them of your impending sine wave and need to stop HD in order to give to someone emergently rather than some elective HD case.


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[Petypet]

http://www.ncbi.nlm.nih.gov/pubmed/19789539

"Licorice: a sweet alternative to prevent hyperkalemia in dialysis patients?"

 

[RustedFox]

http://www.ncbi.nlm.nih.gov/pubmed/19789539

"Licorice: a sweet alternative to prevent hyperkalemia in dialysis patients?"

I love stuff like this.

Once upon a time, in the days of yore; diabetes was treated with french lilac tea. 800-some-odd years later, we isolated the anhydrous salt of the fench lilac and we called it Metformin.

Artemesin? ... Wormwood
Taxol-based chemotherapy? ... Pacific yew tree.
Digoxin? - Come on, man. Too easy.

 

[filhodeinferno]

I love stuff like this.

Once upon a time, in the days of yore; diabetes was treated with french lilac tea. 800-some-odd years later, we isolated the anhydrous salt of the fench lilac and we called it Metformin.

Artemesin? ... Wormwood
Taxol-based chemotherapy? ... Pacific yew tree.
Digoxin? - Come on, man. Too easy.

Hey save all your naturopath voodoo for the essential oils thread!

 

[RustedFox]

Hey save all your naturopath voodoo for the essential oils thread!

Yeah, for real. I knew that I'd draw some comments for posting that.

- but for real. Penicillin.... is mold. Its easy to make fun of the granola-munchers for their witchcraft; but we smear nitropaste on anterior chest walls and use lidoderm/duragesic patches to treat painful complaints. Its not hard to see *why* it is that they think that there could be something to what they do. - The only *something* that they're missing is a randomized, double-blinded, placebo-controlled study.

 

[gutonc]

The only *something* that they're missing is a randomized, double-blinded, placebo-controlled study.

And the isolation of the active ingredient.

But your point is a good one.

 

[WilcoWorld]

Yeah, for real. I knew that I'd draw some comments for posting that.

- but for real. Penicillin.... is mold. Its easy to make fun of the granola-munchers for their witchcraft; but we smear nitropaste on anterior chest walls and use lidoderm/duragesic patches to treat painful complaints. Its not hard to see *why* it is that they think that there could be something to what they do. - The only *something* that they're missing is a randomized, double-blinded, placebo-controlled study.

And dosage and purity standards regulated by the FDA...

 

[dchristismi]

Love the licorice idea, because if I'd known it, I'd have added it. I thought of the albuterol later, but didn't think to add it then.

pH came back at a surprising 7.32. Probably because he'd had 6 amps of bicarb by then and a bicarb drip running...

The nephrologist walked into the ED, saw the above EKG and exclaimed several 4 letter words, and I think pushed the damn dialysis machine to the ED herself. It still took waaaay longer than I wanted it to. Bottom line is that you apparently just keep pouring everything in as best you can. Critical care showed up and at that moment, patient's mental status tanked. Tubed, lined, dialysed...


...and quite alive this morning, following commands when sedation weaned, and K back down to 4.
Hot damn.
(And yes Fox, where you think.)

 

[dchristismi]

When the lab finally called, K was 7.8. An hour later, it was 7.9... and boy was I glad when that dialysis nurse showed up...

 

[Greenbbs]

The only times I've had an EKG like that is when the k>9. Must've been a brittle dialysis patient!!!

 

[shoal]

never missed dialysis. so makes sense physio. nice case, great story telling. id be tempted to shock that rhythm... and you sure as hell would hear me use some choice words...

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[Hair Police]

You're doing it right.

Arterial blood gas to look for pH status; though its going to be terribly difficult to interpret secondary to ESRD/HD status, and complicated by the fact that he (A) retains no bicarb from his beans, and (B: if you are where I think you are) this guy has concomitant COPD and other comorbidities making your job difficult.

Homeboy needs HD; badly. Period.

I love that trick too - I recently admitted a patient to the ICU for presumed DKA when all I had was an Accucheck reading "high" and a VBG (run by the RT) which showed a pH=6.8 because our lab decided to take a holiday.

Also, you can try lactulose instead of kayexalate

 

[deleted109597]

Also, you can try lactulose instead of kayexalate

I don't need them to poop though. And it's the SPS/sorbitol mix that causes the problem to begin with. Mixing it with lactulose doesn't make any theoretical sense, and certainly isn't something I would do.

 

[WilcoWorld]

So was the swollen, painful right hand anything significant, or just a red herring?

 

[RustedFox]

And the isolation of the active ingredient.

But your point is a good one.

Yeah, yeah. That, too... - and the purity standards listed in the separate post above.

There's a lot of good studies about curcumin (turmeric) used as an anti-inflammatory for ulcerative colitis/Crohn's disease.

I have UC.

I have said this once or twice on here before, and it bears repeating; I have noted a clear and measurable improvement in symptoms after taking 4-6 grams curcumin/day. Clear.

I did not write this; but I will reproduce it here:

A Brief History of Medicine:

2000 BC: "Here, eat this root. You'll feel better."
1200 AD: "That root is heathen; say this prayer. You'll feel better."
1820 AD: "That prayer is superstition. Drink this tonic. You'll feel better."
1920 AD: "That tonic is fraud. Take this pill. You'll feel better."
1940 AD: "That pill is placebo. Take this antibiotic. You'll feel better."
2000 AD: "That antibiotic is artificial. Here, eat this root. You'll feel better."

 

[link2swim06]

Calcium
Bicarb
Continous neb
Insulin and Glucose
Lasix (if he still makes urine)

Pray.

 

[dchristismi]

Still waiting to hear about the hand. It was surprisingly painful... to the point that once, I instinctively (accidentally) grabbed his hand once and he jerked so violently, I thought he had an AICD that fired. He didn't. It did change the rhythm briefly, ironically.

Critical care and ortho are evaluating the hand. I don't know where it fits in the whole scheme of things - might be a red herring, but might not. His lactate was elevated so I went with antibiotics presuming cellulitis, but could it have been something else contributing to the persistently elevated K? Maybe.

 

[gro2001]

One other option that may be on the table if HD really would take 90 minutes to arrange despite the best efforts of the nephrologist is to place a vast cath and ask the ICU to send down one of the nurses who can do CVVH. Works slower at getting rid of the K than HD, but works faster than no HD for over an hour.

I had a situation in the OR one of my off service rotations in residency with refractory hyperkalemia despite tons of calcium/insulin/dextrose/bicarb and a similar peri-arrest tracing. Placed a vasc cath, called the ICU attending, explained the situation, and within like 15 minutes there were a couple of ICU nurses placing the patient on CVVH right in the OR. Worked like a charm.

 

[fahimaz7]

I had a dka adult patient do this to me last month. He got 12 amps of bicarbonate and 4 of calcium citrate before he started to act better. Ph was 6.89 and k only 6.5. Keg looked like above 5 mins after one with mildly peaked t waves.

 

[Raryn]

Also: The IM mouth-breather will tell you that you're "forgetting" to give him kayexelate.

Even the most ardent advocate of that standard of care doesn't think it will work in the acute management of unstable hyperK. At best, it works in 4 hours. At worst, the sorbitol will make the patient poop sooner rather than later, but that number is still measured in hours.

Giving one dose in this specific case wouldn't make any difference and I probably wouldn't bother. It also likely won't harm the patient, given that the major downside (gut necrosis) is with (repeated) dosing in the setting of pre-existing ileus (almost always postoperatively), something most of us "mouth-breather"s are aware of and know to watch for.

 

[RustedFox]

Even the most ardent advocate of that standard of care doesn't think it will work in the acute management of unstable hyperK. At best, it works in 4 hours. At worst, the sorbitol will make the patient poop sooner rather than later, but that number is still measured in hours.

Giving one dose in this specific case wouldn't make any difference and I probably wouldn't bother. It also likely won't harm the patient, given that the major downside (gut necrosis) is with (repeated) dosing in the setting of pre-existing ileus (almost always postoperatively), something most of us "mouth-breather"s are aware of and know to watch for.

Then why do so many of you mouth breathers come down and scoff that we haven't ordered a dose of kayexelate in a guy who may not live to see his next BM?

 

[Raryn]

Then why do so many of you mouth breathers come down and scoff that we haven't ordered a dose of kayexelate in a guy who may not live to see his next BM?

Presumably the reasoning is, when you're throwing everything including the kitchen sink at a case, you should include the kitchen sink.

*shrug*. If the patient was admitted to me in the condition described by the OP (and I've had my fair share of borderline-stable patients where the ED initiated treatment and then called ICU to take over care, generally appropriately), I'd continue calcium, albuterol, insulin+dextrose, judicious fluids (depending on what he can tolerate given his ESRD), furosemide if he still made urine, bicarb if he had acidosis, and yes, I might give him the kayexalate. As I said above, it almost certainly wouldn't hurt. But nothing except dialysis is going to make anything more than a temporary difference in this guy, and I'd be surprised if there were many internists that would quibble with that statement.

 

[RustedFox]

Presumably the reasoning is, when you're throwing everything including the kitchen sink at a case, you should include the kitchen sink.

*shrug*. If the patient was admitted to me in the condition described by the OP (and I've had my fair share of borderline-stable patients where the ED initiated treatment and then called ICU to take over care, generally appropriately), I'd continue calcium, albuterol, insulin+dextrose, judicious fluids (depending on what he can tolerate given his ESRD), furosemide if he still made urine, bicarb if he had acidosis, and yes, I might give him the kayexalate. As I said above, it almost certainly wouldn't hurt. But nothing except dialysis is going to make anything more than a temporary difference in this guy, and I'd be surprised if there were many internists that would quibble with that statement.

In a patient who is in THAT kind of extremis, I agree. Few would quibble. However, they oh-so-frequently (as evidenced by the number of posters who "liked" my comment because they recognize the situation and behavior) Huff and Puff over the "dumb" ER doc who didn't give the k-squirts to the guy with the potassium of 6.4 who is doing just fine on insulin/glucose without the diarrhea.

 

[deleted547339]

Presumably the reasoning is, when you're throwing everything including the kitchen sink at a case, you should include the kitchen sink.

*shrug*. If the patient was admitted to me in the condition described by the OP (and I've had my fair share of borderline-stable patients where the ED initiated treatment and then called ICU to take over care, generally appropriately), I'd continue calcium, albuterol, insulin+dextrose, judicious fluids (depending on what he can tolerate given his ESRD), furosemide if he still made urine, bicarb if he had acidosis, and yes, I might give him the kayexalate. As I said above, it almost certainly wouldn't hurt. But nothing except dialysis is going to make anything more than a temporary difference in this guy, and I'd be surprised if there were many internists that would quibble with that statement.

It's always a little surpised that anyone uses kayexelate.

 

[dchristismi]

Update:

Pt out of the ICU, looking great, and I went by to check on him today. He didn't remember all of it, but most of it, and is now on the brink of discharge. The hand was just cellulitis in the end, and is healing up nicely. Whew!

 

[Arcan57]

Good job!