Great points brought up by everyone. This wasn't a particularly challenging from a pure anesthesia management standpoint, but it did involve a lot of moving parts and coordination between different services.
As I described earlier, patient came in to ER with K > 10 and was surprisingly awake and responsive. EkG was clearly sinusoidal pattern consistent with the severe hyperkalemia. All the hyperkalemic treatments were initiated (albuterol, insulin/glucose, bicarbonate, calcium, lasix, aggressive IV hydration) with the exception of kayexalte because absent NG tube and concern for aspiration. He was clearly going into acute renal failure, his Foley showed small amount of dark muddy colored urine. This did not appreciably increase even with attempt at forced diuresis. He was also given a dose of opioid (not sure why) and his gas showed PaCO2 of 60.
Given the above, my thoughts regarding management:
1. He should have been intubated as soon as possible, in the ER and hyperventilated to shift the potassium levels. I don't understand why he was given a medication that could worsen his hyperkalemia and acidemia and consider this a medical error. Mechanical ventilation would also improve thr ability to breathe away the extra co2 load from bicarbonate administration.
2. Should the fasciotomy be performed right away vs medically stabilize patient? This was a judgement call as there are risks and benefits to both. Medical stabilization would involve performing intermittent dialysis prior to the OR to drive down the potassium levels. This would reduce his immediate risk of fatal arrhythmia from hyperkalemia. However the 2 hours needed to perform this stabilization would potentially allow more muscle to become ischemic and die from compartment syndrome, potentially worsen the metabolic and hemodynamic effects once the fasciotomies were performed. Decision was made to do dialysis ASAP followed by OR.
3. Where should we do the fasciotomies? Case was booked for the OR. I pushed the surgeons why it couldn't be done at the bedside in ICU with anesthesia support. The last thing we would want is for the patient to code after the fasciotomies especially on the elevator ride back to the ICU. It would also allow the patient to remain on dialysis the whole time. My thoughts fell on deaf ears. Both ICU and surgical teams did not appear so concerned, and ultimately we did the case in the OR.
4. Additional supportive measures: discussed whether we needed cardiopulmonary bypass on standby in case of hyperkalemic arrest.
Hospital course -
Transferred from ER to ICU. Pads on, art line placed. Repeat EKG showed significant improvement from sinusoidal pattern to regular QRS with peaked T waves. Vascath placed and dialysis in ICU for 2 hours bringing down K to around 7. Continued aggressive measures. Intubated by us after I found out about the PaCO2 and that he wasn't yet on mechanical support, and hyperventilated him to Paco2 30. Went to OR and did the case. Placed a triple lumen central line for vasoactive drugs and ran levo and phenylephrine. Fasciotomies completed with pink and viable looking tissue (fortunately). Potassium and lactic acid remained elevated but controlled. Kept intubated to ICU, where he remained intubated and on CVVH for the next 7 days. 4 pressors, despite everything done above Bicarb went down to 5, cpk through the roof, shock liver, dic, arf from ATN. Never coded. Extubated day 9.
