Check K+ for Renal Failure patients?

[BLADEMDA]

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Alright boys and girls here is where I share some information that some of you will find heretical: When I have a stable renal failure patient for an AV Fistula I don't check a K+.
That's right, if the patient had dialysis the day before or the day of surgery I don't check the K+. I've been doing that for the past ten years and so far no issues whatsoever.

But, if the patient is farther out that 24-30 hours from his/her last dialysis I usually check a K+. This may be overkill but I feel better doing it. That said, I've seen K+ of 6.1 but still done the case. The chance of cancelling a case is small.

For example, if the patient is having Surgery Thursday afternoon and his last dialysis was Wednesday I don't bother with a new K+. But, if his dialysis was Tuesday and he is due for dialysis today (but not yet done) I usually check a K+. Again, these K+ can be high but I rarely cancel any of these cases.

 

[PMPMD]

Alright boys and girls here is where I share some information that some of you will find heretical: When I have a stable renal failure patient for an AV Fistula I don't check a K+.
That's right, if the patient had dialysis the day before or the day of surgery I don't check the K+. I've been doing that for the past ten years and so far no issues whatsoever.

But, if the patient is farther out that 24-30 hours from his/her last dialysis I usually check a K+. This may be overkill but I feel better doing it. That said, I've seen K+ of 6.1 but still done the case. The chance of cancelling a case is small.

For example, if the patient is having Surgery Thursday afternoon and his last dialysis was Wednesday I don't bother with a new K+. But, if his dialysis was Tuesday and he is due for dialysis today (but not yet done) I usually check a K+. Again, these K+ can be high but I rarely cancel any of these cases.

Where I trained we had a crusty anesthesia staff who did all the vascular cases and had the same philosophy. If the patient has not interrupted their normal HD schedule, he would not check a K.

 

[BLADEMDA]

Where I trained we had a crusty anesthesia staff who did all the vascular cases and had the same philosophy. If the patient has not interrupted their normal HD schedule, he would not check a K.

Glad to hear it. I'm just sharing what works in hundreds/thousands of cases over the past ten years.

 

[pie944]

But, if the patient is farther out that 24-30 hours from his/her last dialysis I usually check a K+.

Just a personal cutoff to check? How did you pick it?

 

[BLADEMDA]

Just a personal cutoff to check? How did you pick it?

I noticed way back that checking a K+ on these patients came back less than 5.5 (usually normal) if dialysis was within 30 hours of the blood draw. So, I started checking K+s only on patients who were farther out since their last dialysis. This is a good study for academia as checking a K+ doesn't need to delay a lot of these cases.

 

[PMPMD]

Most ESRD patients on HD are on a 3/week schedule: MWF or TTS. So, twice a week, they go 48 hours between dialyses and once a week, 72 hours. MWF patients don't typically go sine wave every Sunday afternoon.

It's also well documented that ESRD patients get tolerant to the effects of chronic hyperkalemia. So the downside of checking a K is discovering and quantifying a usual state of hyperkalemia that is technically abnormal but one that the patient walks around with constantly.

 

[BLADEMDA]

Most ESRD patients on HD are on a 3/week schedule: MWF or TTS. So, twice a week, they go 48 hours between dialyses and once a week, 72 hours. MWF patients don't typically go sine wave every Sunday afternoon.

It's also well documented that ESRD patients get tolerant to the effects of chronic hyperkalemia. So the downside of checking a K is discovering and quantifying a usual state of hyperkalemia that is technically abnormal but one that the patient walks around with constantly.

Agreed. But, once they are more than 36 hours out I get concerned that the high K+ of 6.1 may go to 6.8 once the anesthesia/drugs are given causing a resp. acidosis.

Perhaps, I'm still too conservative in checking a K+ but it's my arse on the line here.

 

[PMPMD]

Agreed. But, once they are more than 36 hours out I get concerned that the high K+ of 6.1 may go to 6.8 once the anesthesia/drugs are given causing a resp. acidosis.

Perhaps, I'm still too conservative in checking a K+ but it's my arse on the line here.

Yes this is a valid point - you want to leave a little wiggle room there.

 

[proman]

Can J Anaesth. 2003 Jun-Jul;50(6):553-7.
Absence of adverse outcomes in hyperkalemic patients undergoing vascular access surgery.
Olson RP, Schow AJ, McCann R, Lubarsky DA, Gan TJ.
Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA. [email protected]

PURPOSE:
The decision to cancel vascular access surgery because of hyperkalemia requires knowledge of the risks vs benefits. This study sought to identify and characterize cases where surgery had been performed in patients with uncorrected hyperkalemia.
METHODS:
One thousand four hundred and seventy-two consecutive cases of vascular access surgery at an academic medical centre between 1995 and 2000 by a single surgeon were analyzed retrospectively.
RESULTS:
Eight cases had clear documentation that the case proceeded with hyperkalemia. Anesthesia techniques were one general anesthetic, one regional block, five monitored anesthesia care (MAC), and one local infiltration only. Mean potassium was 6.9 mmol x L(-1) (range 6.1-8.0). In this series of selected asymptomatic hyperkalemic patients undergoing low risk surgery, no adverse results occurred.
CONCLUSION:

While this review of eight cases (only one receiving general anesthesia) cannot be used to prove the safety of proceeding to surgery with uncorrected hyperkalemia, it does suggest that asymptomatic hyperkalemia may not be an absolute contraindication to vascular access surgery.

 

[BLADEMDA]

They still checked the K. Do you? I rarely cancel these cases but 7.0 or greater would really need to be urgent.

 

[aneftp]

Blade. Totally understand your thoughts.

My old hospital has a department policy for all renal patients. We did more than 25-30 av grafts/fisulas/declots a day routinely. The surgeons are fast. This arised out of 3 patient deaths in a 90 day period way back in 1991 before my time. We all know renal patients are high risk. You do 1000 cases, chances are sometime will happen to them no matter what.

Standard renal labs day of surgery, unless documented dialysis within 24 hours.
It's a written policy. 6.0 was our limit

Does your department have a written policy?

 

[BLADEMDA]

Blade. Totally understand your thoughts.

My old hospital has a department policy for all renal patients. We did more than 25-30 av grafts/fisulas/declots a day routinely. The surgeons are fast. This arised out of 3 patient deaths in a 90 day period way back in 1991 before my time. We all know renal patients are high risk. You do 1000 cases, chances are sometime will happen to them no matter what.

Standard renal labs day of surgery, unless documented dialysis within 24 hours.
It's a written policy. 6.0 was our limit

Does your department have a written policy?

No. And we have had several deaths over the past ten years. High risk patients.

Your policy seems quite sound.

 

[proman]

They still checked the K. Do you? I rarely cancel these cases but 7.0 or greater would really need to be urgent.

If the most recent K documented isn't outrageous, and they've since had dialysis (as in the last 24 hours) then I wouldn't check another K. If the EKG in the OR looked suspicious then I'd check a K from the OR. Overall I don't get all that worked up about potassium levels.

The only case I've canceled this past year was for a somnolent patient with a TSH of 10.

 

[BLADEMDA]

If the most recent K documented isn't outrageous, and they've since had dialysis (as in the last 24 hours) then I wouldn't check another K. If the EKG in the OR looked suspicious then I'd check a K from the OR. Overall I don't get all that worked up about potassium levels.

The only case I've canceled this past year was for a somnolent patient with a TSH of 10.

Where do I begin to tell you the things I've seen? Sure, I don't get worked up about a K+ level either; that's why I don't bother to even check one if the patient had dialysis within the past 30 hours. But what about the K+ of 6.5 in a patient who was last dialyzed on Saturday and today is Tuesday Afternoon (no dialysis)? Why can't the patient get dialysis today and be re-scheduled for tonight or tomorrow? Or, do you not care about this elective case and the documented K+ of 6.5?

 

[olaf]

Don't normally check it. If its high then check an EKG. If EKG is ok then to the or. Haven't had to check an EKG in my 4 yrs since residency tho

 

[proman]

Where do I begin to tell you the things I've seen? Sure, I don't get worked up about a K+ level either; that's why I don't bother to even check one if the patient had dialysis within the past 30 hours. But what about the K+ of 6.5 in a patient who was last dialyzed on Saturday and today is Tuesday Afternoon (no dialysis)? Why can't the patient get dialysis today and be re-scheduled for tonight or tomorrow? Or, do you not care about this elective case and the documented K+ of 6.5?

Start telling!

I think if an abnormal value is documented we're committed to checking it. Last K 6.5 I would check a new one.

 

[BLADEMDA]

Start telling!

I think if an abnormal value is documented we're committed to checking it. Last K 6.5 I would check a new one.

Ok. Repeat K+ is 6.6. Now What?

 

[proman]

Ok. Repeat K+ is 6.6. Now What?

6.6 after dialysis isn't normal. Depends on the case, the less invasive the more likely I am to do it. If it's HD access then I'd do it regardless.

 

[Idiopathic]

Ok. Repeat K+ is 6.6. Now What?

you dont do an elective case with a K of 6.6. you will win no awards and someday will regret it.

what you are saying is not crazy, but if someone allegedly stable on dialysis is out there with K>6.0 then Im not putting them to sleep for elective surgery. i do not check the K of patients who are stable on dialysis (i.e. new fistulas, takedowns, hernia repair) assuming they have a normal level and are reliably maintained.

 

[OB1🤙]

http://www.anesthesiologynews.com/V...ology&d_id=1&i=March+2012&i_id=820&a_id=20334

 

[sevoflurane]

Yeah... you just have to use some discretion. If it's wednesday and their last dialysis was on monday and their last lab is 5.5K+.... I'm cancelling.

Dialysis patients = Type F- protoplasm. Typically with ischemic heart issues from long standing HTN/diastolic failure.

Had a cowboy surgeon revise a fistula under local not too long ago. K+ was 6.5.

Patient was a COPD'er, DM, obese, OSA, vasculopath... you dudes know the type.

Anywho, I get called because the patient is combative for the revision and the surgeon needs my help to control the situation.

They gave him a good dose of MORPHINE and versed. When I got there, he was combative because he was in the early stages of CO2 narcosis.

Now what does respiratory acidosis do to your potassium?

I was pissed. Drew off a K+ and it came back at 9.0+

Insulin/glucose, beta agonists, controlled ventilation.

He got an ear full that day. Hasn't happened since.

 

[cincincyreds]

The surgeon won't go to court with you. So if the K is not normal, I just don't do elective cases. The surgeon would have to actually write in the chart that the patient will die without the procedure.

Usually the just find someone else in my group to do the case then.

 

[sevoflurane]

Usually the just find someone else in my group to do the case then.

That is not acceptable. You need to stand together as a department... unless you are not a group and are individual practicioners.

 

[pgg]

Usually the just find someone else in my group to do the case then.

Unless someone else has specific skills or training (from long experience or fellowship) that makes them a better choice to do a case than me I would view that as a problem. Disagree and criticize me privately if you think I'm inappropriately canceling cases, but as much as possible there should be public support and solidarity within an anesthesia group.

I would need a really, really compelling reason to put up my hand and say I'll do a case that a colleague just delayed or cancelled. And I'd expect to get an earful from that colleague later.

 

[pgg]

That is not acceptable. You need to stand together as a department... unless you are not a group and are individual practicioners.

I think it's even more important if they're a bunch of individuals.

An individual who gets a reputation as "the guy who won't do tough cases" has a job security problem. If that individual's cases are getting done without him doing them, maybe the institution doesn't need that individual after all.


I'd be annoyed but I'd get over it if a colleague at the .mil job did a case I'd just cancelled. I'll just go goof off on SDN for an hour.

Where I'm an occasional hourly locums moonlighter though, I've got my reputation and next month's hours to think about, and it would not be OK for someone to undermine me in that way.

 

[sevoflurane]

If you are a solo practicioner 🙂barf🙂, you are in direct competition with other solo practicioners in the OR. I hate that system, cuz it encourages anesthesiologists to kiss surgeons arses.

 

[Arch Guillotti]

That is not acceptable. You need to stand together as a department... unless you are not a group and are individual practicioners.

From previous posts, his work environment is not ideal.

 

[cincincyreds]

From previous posts, his work environment is not ideal.

I just do what is right for the patient. Sure standards are nice, the just don't exist where I work. I don't even want to talk about other stuff that goes on cause it truly makes me sick to my stomach.

 

[BLADEMDA]

http://www.anesthesiologynews.com/V...ology&d_id=1&i=March+2012&i_id=820&a_id=20334

But the findings are not quite convincing enough for him to stop doing so in his patients.
“I’m a little concerned about using preliminary, retrospective data from one practice to advocate for a change in practice overall,” Dr. Cohen told Anesthesiology News. “Just because in those 13 patients with high potassium levels there were no adverse outcomes does not mean that with a larger group of patients, you wouldn’t see a difference.”

 

[BLADEMDA]

I'll be honest here: I've done a few AV fistula surgeries with a K+ of 6.0/6.1. But, 6.5+ or greater? Sorry. Unless the surgeon tells me it's an emergency I won't do the case.

I don't blame anyone for using 6.0 as a cut-off but I'm always being pushed to the FINAL line in the sand.

YEs, these patients can be the worst dog poop for protoplasm. We have had several die in the O.R. over the past ten years (since the time I started my policy of not checking the K+).

 

[cincincyreds]

I'll be honest here: I've done a few AV fistula surgeries with a K+ of 6.0/6.1. But, 6.5+ or greater? Sorry. Unless the surgeon tells me it's an emergency I won't do the case.

I don't blame anyone for using 6.0 as a cut-off but I'm always being pushed to the FINAL line in the sand.

YEs, these patients can be the worst dog poop for protoplasm. We have had several die in the O.R. over the past ten years (since the time I started my policy of not checking the K+).

You've probably been doing this longer than I have, but unless the value is in a normal range, I insist the patient get dialized before hand, even if is .1 above normal. The patient's families will have no problem submitting the lawsuit and there will be some piece of garbage person claiming to be an Anesthesiologist who hasn't practice in 20 years saying how bad of a clinician you are. In the past year, I've had to help out 2 attendings who played the line in the sand game with the potassium as the patients were arresting on the table.

 

[BLADEMDA]

You've probably been doing this longer than I have, but unless the value is in a normal range, I insist the patient get dialized before hand, even if is .1 above normal. The patient's families will have no problem submitting the lawsuit and there will be some piece of garbage person claiming to be an Anesthesiologist who hasn't practice in 20 years saying how bad of a clinician you are. In the past year, I've had to help out 2 attendings who played the line in the sand game with the potassium as the patients were arresting on the table.

That won't work in my practice. A 6.0 limit is one thing (reasonable) but normal K+ in Chronic Renal Failure? Come on.