Another case

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milrisome

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I hope no one's getting tired of cases. This one happened to me just this last weekend.

55 yo guy with the basics, DM, HTN, CAD, history of CHF, obesity to the tune of 300 lbs. But he's also got renal insufficiency with a creatinine of 1.6. He's from out of town and staying at his sister-in-law's house, when he gets up early in the morning (before eating) and falls down the stairs. Now he has an open periprosthetic fracture (he has a total knee) of the femur. Oh, and one last thing: his potassium is 7.0! :eek: (yes, I re-checked it)

Any bright ideas?

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I hope no one's getting tired of cases. This one happened to me just this last weekend.

55 yo guy with the basics, DM, HTN, CAD, history of CHF, obesity to the tune of 300 lbs. But he's also got renal insufficiency with a creatinine of 1.6. He's from out of town and staying at his sister-in-law's house, when he gets up early in the morning (before eating) and falls down the stairs. Now he has an open periprosthetic fracture (he has a total knee) of the femur. Oh, and one last thing: his potassium is 7.0! :eek: (yes, I re-checked it)

Any bright ideas?

Geez...dontcha just love some of the s h it you're faced with in this biz?

Must be on a potassium sparing diuretic or an ACE, or his glucose is 600 and he's in DKA, or rhabdo...I dont recall ever seeing a K that high being attributable to frank-renal failure with a Creatinine of 1.6.

Gotta let the fleas work their magic for a few hours would be my guess...but if youre pressed, IVF, Ca, Insulin, Bicarb, albuterol nebs..if its DKA, hydrate like hell (yes, even with a history of CHF), insulin 10 units then ten units an hour, and anticipate HYPOkalemia eventually so watch the K and eventually add K-gluconate to IVF.....dont know about kayexalate since pooping around an open fx aint good.....then use the force and a Tuohy/27" spinal needle for CSE.

I'd rather wait though butcha cant wait too long since its an open fx.
 
I hope no one's getting tired of cases. This one happened to me just this last weekend.

55 yo guy with the basics, DM, HTN, CAD, history of CHF, obesity to the tune of 300 lbs. But he's also got renal insufficiency with a creatinine of 1.6. He's from out of town and staying at his sister-in-law's house, when he gets up early in the morning (before eating) and falls down the stairs. Now he has an open periprosthetic fracture (he has a total knee) of the femur. Oh, and one last thing: his potassium is 7.0! :eek: (yes, I re-checked it)

Any bright ideas?


Ugh, I had pretty much the same patient. A little thinner, but not much. I delayed it a little to get some fluids, bicarb, and insulin in, but like it was said, it was an open fracture so around the fifth hour I just went ahead with a spinal. No sedation. Calcium, bicarb, insulin ready to roll and hoped he didn't die.
 
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I've seen a K that high in the same kind of pt - ACE inhibitors, maxzide, Actos & metformin.....was he at the sister-in-law's for a party - wedding, graduation, anniversary celebration? Those drugs, combined with a bit of liquor & some dehydration makes the K pop. I'm curious - what was the INR?

I agree, I don't like the idea of Kayexalate since you're going to have to take him anyway & he'll still poop kayexalate in the OR.

I can't give you any input on what you did anesthesia wise since thats not my thing. I hope you stopped the metformin!

I'm looking forward though to seeing what you all would have done & what you actually did.
 
I think Jet covered it all.
It's an open fracture so we can't wait too long.
If the EKG does not show signs of severe hyperkalemia, I would do the insulin + Glucose, 1 or 2 amps of Bicarb, give a gram of Calcium Chloride, go to the OR and do a spinal.
If there are EKG changes I would be more aggressive with my treatment and insist on waiting until the EKG normalizes and potassium is less than 6.
 
Yep, he was on enalapril. Not on metformin or actos, just glipizide. He was on HCTZ but apparently it didn't help. Funny thing was, when he got to the ED, they sedated the snot out of him with about 15 each of valium and morphine. He was practically comatose. So I got the history from his wife (not much help) and called the home hospital and cardiologist for records. Of course, the ED had also done the whole insulin/glucose/calcium thing. I called the Bean flea to ask his thoughts and he said that with a creatinine of 1.6 he ought to be able to get rid of the K himself. The orthopod was in a case for a couple hours, so I gave 40 of Lasix and made sure the guy started fillin' the foley. I also gave Kayexelate rectally as the fracture was distal femur. EKG was fine.

Did a spinal with 22g, bupi 15mg, no PFMS as the guy was already snowed. Told the CRNA no more sedation. By the time we got the art line in his K was 6.2:cool:
 
Yep, he was on enalapril. Not on metformin or actos, just glipizide. He was on HCTZ but apparently it didn't help. Funny thing was, when he got to the ED, they sedated the snot out of him with about 15 each of valium and morphine. He was practically comatose. So I got the history from his wife (not much help) and called the home hospital and cardiologist for records. Of course, the ED had also done the whole insulin/glucose/calcium thing. I called the Bean flea to ask his thoughts and he said that with a creatinine of 1.6 he ought to be able to get rid of the K himself. The orthopod was in a case for a couple hours, so I gave 40 of Lasix and made sure the guy started fillin' the foley. I also gave Kayexelate rectally as the fracture was distal femur. EKG was fine.

Did a spinal with 22g, bupi 15mg, no PFMS as the guy was already snowed. Told the CRNA no more sedation. By the time we got the art line in his K was 6.2:cool:
 
Yep, he was on enalapril. Not on metformin or actos, just glipizide. He was on HCTZ but apparently it didn't help. Funny thing was, when he got to the ED, they sedated the snot out of him with about 15 each of valium and morphine. He was practically comatose. So I got the history from his wife (not much help) and called the home hospital and cardiologist for records. Of course, the ED had also done the whole insulin/glucose/calcium thing. I called the Bean flea to ask his thoughts and he said that with a creatinine of 1.6 he ought to be able to get rid of the K himself. The orthopod was in a case for a couple hours, so I gave 40 of Lasix and made sure the guy started fillin' the foley. I also gave Kayexelate rectally as the fracture was distal femur. EKG was fine.

Did a spinal with 22g, bupi 15mg, no PFMS as the guy was already snowed. Told the CRNA no more sedation. By the time we got the art line in his K was 6.2:cool:

Nice case.

Bean flea?........................HAHAHAHAHAHAHAHAHAHA once again I'm dying laughing in front of a computer screen.....man I'm easily amused.....
 
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