Hyperkalemia, Compartment Syndrome

[coffeebythelake]

Middle aged guy without any known medical history who passed out after taking bunch of drugs woke up later that day unable to move his leg and an arm. Brought to ER by ambulance. Found to have critically high potassium levels with sinusoidal ekg (tall peaked T-waves and widened QRS). In the ER received aggressive IV hydration, calcium gluconate, insulin/glucose, lasix, mannitol, albuterol, bicarbonate, was also briefly on pressors for hypotension. 1 hour later repeat K was 8. Ortho wants to do fasciotomies ASAP for compartment syndrome. You speak to the patient who is awake and a little groggy.

Go.

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[patriot6]

Obligatory prop, roc, tube.

 

[abolt18]

Obligatory prop, roc, tube.

I agree. This is "life or limb". You go easy on the prop. Heavy on the roc. And then keep going with the aggressive potassium correction. Strongly consider putting pads on and loading with additional Calcium prior to induction.

 

[Arch Guillotti]

CRRT. Otherwise proceed and hope for the best.

 

[gaspasser127]

Get the patient quickly to the OR. Don’t waste time with pre op nurse check in.

pads on

prop, roc, tube

Hyperventilating him will Correct your K+

Continue with other corrective therapies as were previously being done.

arterial line to check K and lactate on serial gasses

keep a keen eye on UOP. High likelihood he will need to be dialyzed ASAP.

 

[Arch Guillotti]

Get the patient quickly to the OR. Don’t waste time with pre op nurse check in.

pads on

prop, roc, tube

Hyperventilating him will Correct your K+

Continue with other corrective therapies as were previously being done.

arterial line to check K and lactate on serial gasses

keep a keen eye on UOP. High likelihood he will need to be dialyzed ASAP.

That’s fine and dandy until he arrests after the fasciotomies are completed.

 

[abolt18]

CRRT. Otherwise proceed and hope for the best.

Very reasonable, but will they initiate it in the OR for you? That would be the most ideal circumstance I think. If other measures fail, you call renal and place a dialysis line and try to get them to send an ICU nurse to the OR to start the RRT.

 

[CodeBlu]

Clearly he can tolerate the K of 8... Kidneys shot probably. Need to know what the UOP is... Pushing more lasix.... not gonna work. Give volume. Lots of it.
Hyperventilate.
More calcium. CaCl2 to chase your roc and propofol. Keep that pressure up.
Shifting him repeatedly isn't gonna work after 2 or 3 shifts. Insulin shifts potassium into cells by stimulating the activity of Na+-H+ antiporter on cell membrane, promoting the entry of sodium into cells, which leads to activation of the Na+-K+ ATPase, causing an electrogenic influx of potassium. So, your pH is gonna be up from hyperventilating.

Dialysis. He needs dialysis. Badly. a 0 K bath for 2 hours should be good.

 

[Arch Guillotti]

Dialysis. He needs dialysis. Badly.

Yes although who in the hell does this before an emergent OR case. You do, unless you want to risk doing chest compressions. At least bring it up as an option to the surgeon/ER guy/hospitalist or whatever. Because if the guy codes, you will wish you had.

 

[vector2]

What's his admission Cr, CPK, and current UOP?

Had a case like this a couple months ago but the K wasn't quite as bad as yours. Shifted in ED. I stated bicarb drip in the OR. CaCl2 for induction. More CaCl2, bicarb and vaso for the fasciotomies. Had resident place trialysis and made sure the nurse had CRRT ready to go when he hit the ICU.

 

[chocomorsel]

CRRT. Otherwise proceed and hope for the best.

FYI: You do not fix life threatening potassium with CRRT. Doesn’t work fast enough. You need IHD and pressors after fluid loading.

 

[chocomorsel]

Yes although who in the hell does this before an emergent OR case. You do, unless you want to risk doing chest compressions. At least bring it up as an option to the surgeon/ER guy/hospitalist or whatever. Because if the guy codes, you will wish you had.

Yup. Call renal on the way to the OR and ask them to come set up. They can do that in an OR w access to water.

 

[CodeBlu]

Yes although who in the hell does this before an emergent OR case. You do, unless you want to risk doing chest compressions. At least bring it up as an option to the surgeon/ER guy/hospitalist or whatever. Because if the guy codes, you will wish you had.

100% have inserted a dialysis line and dialyzed in the OR during the case. Hemodynamic rollercoaster. But... he didn't die.

 

[Ronin786]

ED should have got him dialyzed from the minute they saw that K of 10. Also why do they need to go to the OR to do fasciotomies? Send to the ICU, get HD going while he gets tubed and do bedside fasciotomies. One stop shop.

 

[chocomorsel]

ED should have got him dialyzed from the minute they saw that K of 10. Also why do they need to go to the OR to do fasciotomies? Send to the ICU, get HD going while he gets tubed and do bedside fasciotomies. One stop shop.

Very good points. Who medically treats a K of 10. And why hasn’t he coded yet though? Is this a a real story?

 

[coffeebythelake]

Very good points. Who medically treats a K of 10. And why hasn’t he coded yet though? Is this a a real story?

Yes this is real. I will DM you. Highest nonhemolyzed potassium I've ever seen in an awake, non coding patient. Will provide additional details about this case, management, outcome later tonight when I get off work.

 

[Beeftenderloin]

If your worried about instability of HD just have surgery come place a perc PD cath in the OR and start dialyzing that way. Don’t need nearly as much equipment. Won’t be as efficient as HD, but will start getting rid of K immediately and might be easier to coordinate.

 

[jwk]

ED should have got him dialyzed from the minute they saw that K of 10. Also why do they need to go to the OR to do fasciotomies? Send to the ICU, get HD going while he gets tubed and do bedside fasciotomies. One stop shop.

C'mon man - they do fasciotomies in the field on Rescue 911.

 

[chocomorsel]

C'mon man - they do fasciotomies in the field on Rescue 911.

And it’s the paramedics that do it! Lol

 

[Mehd School]

100% have inserted a dialysis line and dialyzed in the OR during the case. Hemodynamic rollercoaster. But... he didn't die.

Yep. I've done probably 4 liver transplants where dialysis is initiated in the OR. It takes a challenging case and makes it a stupid one (but still fun).

 

[GassYous]

Yep. I've done probably 4 liver transplants where dialysis is initiated in the OR. It takes a challenging case and makes it a stupid one (but still fun).

I'm not sure I would call a liver transplant fun. Now a nice abdominal case with an a line, epidural and a stable patient, that is fun.

 

[Arch Guillotti]

FYI: You do not fix life threatening potassium with CRRT. Doesn’t work fast enough. You need IHD and pressors after fluid loading.

That is not my forte, more of a critical care issue. The only reason I mentioned it instead of regular dialysis is that CRRT is reported to be better in hemodynamically unstable patients which I am not sure applies to this pt. as presented. My point is that all this crap that has been done for hyperkalemia hasn't helped all that much. Doing it all again may help some more but it isn't guaranteed. At some point you need something definitive to clear it.

My concern is that reperfusion can cause hyperkalemia. Prop, roc, tube may be fine to get him to sleep but what happens when the compartments are released? At least with major vascular reperfusion scenarios incredibly bad things can happen. Sure he had a K+ of 10 and is still alive but at some point if the potassium gets too critical lethal rhythm disturbances can occur. At this point you will wish dialysis was available.

Of course I could be going down the wrong rabbit hole here, will be interested when the OP gives an update.

 

[chocomorsel]

That is not my forte, more of a critical care issue. The only reason I mentioned it instead of regular dialysis is that CRRT is reported to be better in hemodynamically unstable patients which I am not sure applies to this pt. as presented. My point is that all this crap that has been done for hyperkalemia hasn't helped all that much. Doing it all again may help some more but it isn't guaranteed. At some point you need something definitive to clear it.

My concern is that reperfusion can cause hyperkalemia. Prop, roc, tube may be fine to get him to sleep but what happens when the compartments are released? At least with major vascular reperfusion scenarios incredibly bad things can happen. Sure he had a K+ of 10 and is still alive but at some point if the potassium gets too critical lethal rhythm disturbances can occur. At this point you will wish dialysis was available.

Of course I could be going down the wrong rabbit hole here, will be interested when the OP gives an update.

True dat. You call nephrology and put the line in. They make decision on IHD/CRRT.
And yeah, best to be ready with a dialysis line for the upcoming worsening acidosis/hyperkalemia/hypotension that follows for sure. And use it in the meantime to pump more fluid in the dude.
I wonder if this was an itty bitty hospital with hospitals and FM people running the ED. I don't think a true ED doc would sit around throwing meds at a K of 10. Just doesn't smell right.

 

[chocomorsel]

Yes this is real. I will DM you. Highest nonhemolyzed potassium I've ever seen in an awake, non coding patient. Will provide additional details about this case, management, outcome later tonight when I get off work.

Was he making any urine? I presume not or if so, very little?

 

[deleted875186]

Good responses above.

Put in dialysis line and start traditional HD unless you think you really can’t support the volume shifts, sounds like he got a bunch or fluid already so probably will tolerate with some vasopressors. CVVH in the ICU after.

I also get weary of inducing and intubationing these people because their respiratory drive is high, hate to have apnea make acidosis or hyperkalekia worse. I also worry about reperfusion, with a K still above 6, would not want the leg reperfused.

Have ED put in dialysis line and start, when K hits 6 I would do the case. Or I would do it if CVVH was started and could be continued in the OR.

 

[coffeebythelake]

Was he making any urine? I presume not or if so, very little?

minimal urine output, going into ATN

 

[Arch Guillotti]

Have ED put in dialysis line

Big variable there if they don't normally put them in. I don't put them in normally for that matter. Very tough call to make if surgeon is chomping at the bit like they normally do.

 

[Arch Guillotti]

Hyperventilating him will Correct your K+

Not sure how much this would help in the grand scheme of things.

 

[gaspasser127]

Not sure how much this would help in the grand scheme of things.

it’s just one additional thing you can check off on your check list of things you can say you’ve done. It will help a good amount if they have a significant respiratory acidosis to begin with. I thought the OP had mentioned patient had a markedly elevated paco2 but i guess I was thinking about another case.

 

[chocomorsel]

Big variable there if they don't normally put them in. I don't put them in normally for that matter. Very tough call to make if surgeon is chomping at the bit like they normally do.

How can you be an ED doc and not know how to put in an dialysis line. I will give us in the OR a break on that, but what does an ER doc do when someone is in severe need of dialysis?
Try to get IR to place them? Call surgeons or anesthesiologists? Delay care in the process?
Seems, not right.

 

[coffeebythelake]

it’s just one additional thing you can check off on your check list of things you can say you’ve done. It will help a good amount if they have a significant respiratory acidosis to begin with. I thought the OP had mentioned patient had a markedly elevated paco2 but i guess I was thinking about another case.

sorry it is true, PaCO2 was elevated. patient was hypoventilating which obviously worsens his acid base status and hyperkalemia.
i deleted that part in my original post when i edited it.

was going to post an update about management yesterday evening but zonked out after i got home.
promise i will do so today

 

[coffeebythelake]

How can you be an ED doc and not know how to put in an dialysis line. I will give us in the OR a break on that, but what does an ER doc do when someone is in severe need of dialysis?
Try to get IR to place them? Call surgeons or anesthesiologists? Delay care in the process?
Seems, not right.

If u know how to put in a regular central line u should know how to put in a dialysis catheter

 

[chocomorsel]

If u know how to put in a regular central line u should know how to put in a dialysis catheter

True. But if you’ve never done it like me till fellowship, and if you work in a small shop, will cut you a break.
It’s like putting in a Big Mac but it had been ages since I had done that either.

 

[2Fast2Des]

If u know how to put in a regular central line u should know how to put in a dialysis catheter

Lol exactly, bigger dilator, big catheter, NBD. Just confirm not in carotid!

 

[bigdan]

Agree with going to OR while temporizing, and I'd place the HD line pre-op (if time) or in OR while surgeons are operating. Would start RRT intraop if able. I think all the relevant medical therapies were mentioned, but getting the blood sugar way up and then using high dose insulin, continuous albuterol, HCO3-, and loop diuretic are all within our wheelhouse in the OR. I don't see a compelling reason not to try an enteral binding resin, given the K level. Calcium serially (or as a continuous infusion) would of course be obligatory.

The compartment syndrome is the cause for the rhabdo and therefore for the K+ elevation, so not treating that/delaying treatment will not help in any way. The mechanics of getting iHD or CRRT actually started (i.e.: machine in room, up and running) is probably the rate limiting step in our hospitals - the fastest I've seen it up and running is about 40 minutes (from my call to nephrologist to blood running through the tubing), and that was with a dialysis RN in-house, a free machine, and everyone willing to get things done. 90-120 minutes is more often the case for emergent RRT, and 3+hours is routine if you're not humping someone's leg to get it done "STAT".

 

[nimbus]

If CPB is available, fem-fem CPB may be a good temporizing measure until K+ is corrected.

 

[coffeebythelake]

If CPB is available, fem-fem CPB may be a good temporizing measure until K+ is corrected.

Glad u mentioned this point

 

[Arch Guillotti]

it’s just one additional thing you can check off on your check list of things you can say you’ve done. It will help a good amount if they have a significant respiratory acidosis to begin with. I thought the OP had mentioned patient had a markedly elevated paco2 but i guess I was thinking about another case.

I agree but just hyperventilating this guy isn’t going to be what keeps him alive.

 

[secretasianman]

FYI: You do not fix life threatening potassium with CRRT. Doesn’t work fast enough. You need IHD and pressors after fluid loading.

Impressive.

My first thoughts on this case would be:
FML
This guy is already hypotensive, groggy, probably already very acidotic. Can we do this under block, spinal, or even field block by surgeon? He’s already sedated or partly dead so how much anesthesia would he need? How long does it take to get lines, get dialysis? I don’t count on that to happen that quickly so I would opt to take care of the surgical cause first. Maybe put pads, Aline, in case he codes mid case... it may be exciting when the pressure is released..

Maybe I’m missing something.

 

[Arch Guillotti]

The case needs to be done sooner rather than later. The debate over management of hyperkalemia is interesting though. I doubt most places could get dialysis going in a timely manner before a case like this so your hand is forced unfortunately.

 

[Ronin786]

If CPB is available, fem-fem CPB may be a good temporizing measure until K+ is corrected.

I understand the thought behind this, but it seems like it would make a lot more sense to expend the time and resources into putting this guy on the extra-corporeal machine that will actually save his life rather than just give us time for nephrology to get everything in place.

Kind of sad/ironic/puzzling that it's faster to put someone on bypass than to dialyze them...

 

[2Fast2Des]

The case needs to be done sooner rather than later. The debate over management of hyperkalemia is interesting though. I doubt most places could get dialysis going in a timely manner before a case like this so your hand is forced unfortunately.

So if dialysis isn't timely available and you've done the medical stuff you can max out on, just take to the OR with the K and pray? Having lines for bypass is a good idea as well

 

[Arch Guillotti]

So if dialysis isn't timely available and you've done the medical stuff you can max out on, just take to the OR with the K and pray? Having lines for bypass is a good idea as well

What else is there to do besides kayexalate? The case is an emergency although I am sure some podunk hospitals would ship it out I doubt that would fly most places.

 

[WheezyBaby]

Yes this is real. I will DM you. Highest nonhemolyzed potassium I've ever seen in an awake, non coding patient. Will provide additional details about this case, management, outcome later tonight when I get off work.

K over 10 without arresting is impressive. Someone with chronic exposure to elevated K presumably?

As far as hyperK management, I'd make sure he got an appropriate dose of diuretic, my assumption would be he did not. Give a little extra fluid along with 200 of Lasix. Maybe it'll help, maybe not, but try to temporize. Redose your calcium. Not being an anesthesiologist, out of my scope here, but if the patient is lucid or has a proxy decision maker to have a risk / benefits / alternatives discussion to OR now VS delay, great, have that discussion, but if I'm the one making the call the risk of K efflux after fasciotomy would have me leaning in the direction of risk the limbs and get HD going before bedside fasciotomy in ICU. He's already gotten temporizing measures, I think the prognosis of resuscitating a hyperK arrest when you have no real means to drive down the K any further is pretty abysmal

 

[turkeyjerky]

How can you be an ED doc and not know how to put in an dialysis line. I will give us in the OR a break on that, but what does an ER doc do when someone is in severe need of dialysis?
Try to get IR to place them? Call surgeons or anesthesiologists? Delay care in the process?
Seems, not right.

You'd be surprised.... (I'm EM and do them, but I've met many colleagues who refuse to)

Seems to me that this patient needs dialysis b4 he gets a fasciotomy. The K is just gonna skyrocket once the compartments are released. A well organized system should be able to accomplish this w/in a 2-3 hour timeframe, right?

 

[deleted875186]

K over 10 without arresting is impressive. Someone with chronic exposure to elevated K presumably?

As far as hyperK management, I'd make sure he got an appropriate dose of diuretic, my assumption would be he did not. Give a little extra fluid along with 200 of Lasix. Maybe it'll help, maybe not, but try to temporize. Redose your calcium. Not being an anesthesiologist, out of my scope here, but if the patient is lucid or has a proxy decision maker to have a risk / benefits / alternatives discussion to OR now VS delay, great, have that discussion, but if I'm the one making the call the risk of K efflux after fasciotomy would have me leaning in the direction of risk the limbs and get HD going before bedside fasciotomy in ICU. He's already gotten temporizing measures, I think the prognosis of resuscitating a hyperK arrest when you have no real means to drive down the K any further is pretty abysmal

If you think the patient is going to die from hyperkalemia, then I would not give them the offer of doing surgery now, I’m not required to anesthetize someone with medical treatment if I think it will result in their death.

as said before, fasciotomy can also be done at bedside with me.

 

[WheezyBaby]

If you think the patient is going to die from hyperkalemia, then I would not give them the offer of doing surgery now, I’m not required to anesthetize someone with medical treatment if I think it will result in their death.

as said before, fasciotomy can also be done at bedside with me.

There's a risk of arrest. I don't know what an expected rise would be postfasciotomy in this case. If the expected rise is anticipated to be minimal, I could see theoretically see offering emergency surgery and ongoing temporizing measures if the benefit of potential limb salvage was worth the risk of arrest to the patient. But as I said, my inclination would be risk the limbs and defer surgery. I'd expect the risk of a substantial K spike in essentially a found down intoxicated patient with multiple compromised compartments is.... Not modest

 

[coffeebythelake]

QUESTION; would you use NS or LR or another fluid for this patient? Why

 

[WheezyBaby]

QUESTION; would you use NS or LR or another fluid for this patient? Why

Isotonic bicarb. Patients respiratory status is more or less intact and can blow off the co2, the acidemia is likely primarily nongap related to the renal insufficiency, and you may get some shift benefit for the K. Def ringers over NS though

 

[nimbus]

Myth-busting: Lactated Ringers is safe in hyperkalemia, and is superior to NS.

Introduction 0 Several months ago I gave a grand rounds on pH-guided resuscitation which was summarized in this post. This included a discussion that

emcrit.org