Case 5

[sozme]

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Case #5 (attribution to follow)
Link to case 4

48 year old renal transplant recipient with a history of COPD, T2DM, hyperlipidemia admitted to the VA directly from the outpatient resident clinic with a K+ of 8.5 mEq/L. Patient was complaining of nausea, poor oral intake, and mild diarrhea at the time of presentation. Medications: cyclosporine, KCl, lisinopril, sprironolactone. He is adherent to a low Na+ diet.

Exam revealed some mild volume depletion. First K+ showed K+ 9.1 mEq/L, HCO3- 20, Cr 2.5. EKG initially read as normal but when you look at it, there is actually a 3rd-degree AV block. He admitted directly to the ICU at the VA, where you are the intern in house with no one else on site. What do you do.
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CONCLUSION

 

[WheezyBaby]

I'm assuming the rest of the BMP we already have is unremarkable and he doesn't have concurrent hypoNa? Baseline Cr? Recency of transplant? Regardless, this crap is above my pay grade, but if I'm stuck by myself and doomed anyway, hook up to tele, get pads in the room in case he needs TCP, 1L IVF + Lasix, calcium gluconate, continuous albuterol, dextrose and insulin, cyclosporine level, renal US with doppler. If he's diuresing well, up the fluids. If he doesn't pee, stop the fluids, call renal and get a vascath. Repeat the 12 lead and BMP mg p

 

[BigRedBeta]

@sozme are you posting the "answers" to these cases somewhere?

 

[cbrons]

@sozme are you posting the "answers" to these cases somewhere?

He posts summaries at the end but im not sure there is one single correct answer.

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[cbrons]

Case #5 (attribution to follow)
Link to case 4

48 year old renal transplant recipient with a history of COPD, T2DM, hyperlipidemia admitted to the VA directly from the outpatient resident clinic with a K+ of 8.5 mEq/L. Patient was complaining of nausea, poor oral intake, and mild diarrhea at the time of presentation. Medications: cyclosporine, KCl, lisinopril, sprironolactone. He is adherent to a low Na+ diet.

Exam revealed some mild volume depletion. First K+ showed K+ 9.1 mEq/L, HCO3- 20, Cr 2.5. EKG initially read as normal but when you look at it, there is actually a 3rd-degree AV block. He admitted directly to the ICU at the VA, where you are the intern in house with no one else on site. What do you do.

KAYEXALATE STAT

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[FindMeOnTheLinks]

KAYEXALATE STAT

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lolololololol


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[Crayola227]

Case #5 (attribution to follow)
Link to case 4

K+ of 8.5 mEq/L.
Medications: KCl, sprironolactone

I make this point not as immediate management, but when you do med rec be sure to hold these home meds, or look like the biggest tool ever.

EDITED: for clarity and a typo

 

[The Knife & Gun Club]

In my very limited knowledge when you have someone with a renal transplant you always get the cyclosporine/tacrolumis level ASAP and compare creatinine with baseline too. 2.5 is not great but could be within normal range I think...it doesn't scream "rejection" (too bad since that's probably the only thing I know how to manage)


Where I used to work whenever someone was admitted for anything they'd take some blood and urine for cultures and check to see if there were detectable viral loads of BK or CMV.

Usually they'd start some preventative antibiotics too, although this appears to be mostly a heart and electrolyte issue.

As for the more "fix the immediate problem" type stuff that's beyond my level.

 

[TooMuchResearch]

Shift. Calcium. Talk to nephrology. Yes to tele monitor and pads. Difficult to get good capture with transcutaneous pacing in hyper K, but with an appropriate shift and some calcium, this shouldn't be a problem.

Oh, and try and figure out underlying cause.

 

[group_theory]

No immediate management, but when you do med rec be sure to hold these home meds, or look like the biggest tool ever.

(my reaction as an ICU attending if this is your response to the above scenario)


If you are the only intern on site in this scenario, I hope your answer is to immediately contact your senior resident and attending. There are some things that your seniors/attending should be notified, and this is one of them.

 

[Crayola227]

(my reaction as an ICU attending if this is your response to the above scenario)


If you are the only intern on site in this scenario, I hope your answer is to immediately contact your senior resident and attending. There are some things that your seniors/attending should be notified, and this is one of them.

that was missing a T and meant to be "not," as in, I'm not meaning to imply that holding the patient's KCl & spironolactone is the emergent priority in managing this patient's hyperkalemia, and that I'm not meaning to say that's all that should be done here, but pointing out likely contributors to this current problem. And to think about that sort of thing in med rec (i.e. what home meds are going to be of benefit/harm to patient for current admit).

 

[sozme]

I'm assuming the rest of the BMP we already have is unremarkable and he doesn't have concurrent hypoNa? Baseline Cr? Recency of transplant? Regardless, this crap is above my pay grade, but if I'm stuck by myself and doomed anyway, hook up to tele, get pads in the room in case he needs TCP, 1L IVF + Lasix, calcium gluconate, continuous albuterol, dextrose and insulin, cyclosporine level, renal US with doppler. If he's diuresing well, up the fluids. If he doesn't pee, stop the fluids, call renal and get a vascath. Repeat the 12 lead and BMP mg p

He is basically at his baseline. Rest of BMP is unremarkable.

 

[cbrons]

In all seriousness though, are there actual nephrologists who use that toxic Kayexalate garbage anymore?

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[TooMuchResearch]

In all seriousness though, are there actual nephrologists who use that toxic Kayexalate garbage anymore?

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Yes. But I don't start it for them.

 

[sozme]

 

[sozme]

CONCLUSION

@sozme are you posting the "answers" to these cases somewhere?

Ok so this one didn't catch on too well. Here is the "official" "answer".

Scenario derived from real-life case presented by Dr. Lederer from U of Louisville: - (38 minutes in)

This was her response to an extremely similar case:
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"Grabbed nurse, bag of saline, 100 mg Lasix, an amp of bicarb, an amp of D50, 10 U regular insulin, and 2 amps Ca gluconate, and 30g Kayexalate enema. Plugged 2 IVs into him and gave everything at once, then hung D5W with 3 amps bicarb, 1 amp D50, 10 U regular insulin to match urine output. Poor guy peed and pooped all night."

"What did I not do?
- Call for a Shiley and page the dialysis nurse
- Wait for ICU transfer
- Ask for another stat K+
- Wait for urine lytes to come back
- Give calcium, bicarb, and glucose, and check K+ in the morning"

"Result:
- K+ 4.9 next morning
- EKG normal
- Cr down to 1.8
- No dialysis required
- Medication adjustments made at discharge"
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Here is some bonus material on Kayexalate in the treatment of Hyperkalemia:
Is Kayexalate Useless? from EMCrit (see bottom of page for 16 minute podcast and paper reference)

 

[neusu]

He admitted directly to the ICU at the VA

Go back to bed in the call room and tell the team in the morning.