What do you do?

[Idiopathic]

90 y.o. female, relatively healthy, presents for total hip. Preop K+ is 2.0, on on lasix and K+. She is cancelled for optimization. PCP sees her, adjusts K+ supplement, gets a value of 4.6 and says "cleared for surgery". I see her, day of surgery (one month after initial presentation), check K+, its 2.7 with U waves on EKG. No symptoms. what do you do?

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[seinfeld]

seriously gonna replace a 90 year olds hip? ie this is not hip fx. She better have be currently walking miles a day.

Cancel again for the hypokalemia

 

[nap$ter]

seriously gonna replace a 90 year olds hip? ie this is not hip fx. She better have be currently walking miles a day.

Cancel again for the hypokalemia

ditto. she needs to be chronically in the normal range. send her back to the PCP and declare her "cleared for stable medical optimization".

 

[SexPanther]

ditto. she needs to be chronically in the normal range. send her back to the PCP and declare her "cleared for stable medical optimization".

And add a P.S. Suck it.

 

[CrazyJake]

Cancel till pt's K is stable. suggest she find a PCP familar with normal therapeutic ranges and electrolyte managment.

CJ

 

[BF2BC EMT]

And add a P.S. Suck it.

hahah

 

[KungPOWChicken]

I would not cancel this case as the patient is likely chronically hypokalemic and she has likely compensated from a metabolic standpoint. Ideally I would like to see her potassium above three so I would give some IV potassium and recheck. If she was trending in the right direction I would proceed with a spinal anesthetic assuming she has preserved left ventricular function and no other contraindication. I'm unaware of any patient arresting from chronic hypokalemia and she already survived a potassium of 2.

 

[Sergio99]

I would not cancel this case as the patient is likely chronically hypokalemic and she has likely compensated from a metabolic standpoint. Ideally I would like to see her potassium above three so I would give some IV potassium and recheck. If she was trending in the right direction I would proceed with a spinal anesthetic assuming she has preserved left ventricular function and no other contraindication. I'm unaware of any patient arresting from chronic hypokalemia and she already survived a potassium of 2.

You are very brave and adventurous. I would want her in better shape, with a stable potassium in the normal range. This is completely elective, not a hip fracture, like Seinfeld pointed out.

 

[SexPanther]

You are very brave and adventurous. I would want her in better shape, with a stable potassium in the normal range. This is completely elective, not a hip fracture, like Seinfeld pointed out.

Moreover, she has evidence of cardiac manifestations of the hypokalemia with the U waves on EKG.

 

[KungPOWChicken]

Oh my gosh she has a U wave lets shock her!!!!! Actually "U" waves can often be seen on normal ekg's and are meaningless as far as I'm concerned. Chances are in this particular lady she's had "U" waves on all her ekg's and unless I see a significant change I honestly don't care about it.

 

[Gas you down]

After the first time, I would have suggested that she be admitted the night before. Fix the K, and do the surg the next morning.
And even if I only saw her that morning, I would give her iv K and do surg later that day.

 

[nap$ter]

Oh my gosh she has a U wave lets shock her!!!!! Actually "U" waves can often be seen on normal ekg's and are meaningless as far as I'm concerned. Chances are in this particular lady she's had "U" waves on all her ekg's and unless I see a significant change I honestly don't care about it.

"chances are" is not a defensible position. in a 90 yo for an elective case you need to be as certain as possible, and you should at least mention checking her historical potassiums and ekg's. I give you the benefit of the doubt and assume that's what you meant, but board examiner's will not.

so you would delay her case the 1-2hrs (optimistically) to replete and recheck her K (and EKG)(gonna be fun to coordinate that one)? The better choice here is clearly to send her back to the PCP, cowboy.

there was another doc fond of repleting K+ in 90yo's... ahh, Kevorkian.

 

[fakin' the funk]

Oh my gosh she has a U wave lets shock her!!!!! Actually "U" waves can often be seen on normal ekg's and are meaningless as far as I'm concerned. Chances are in this particular lady she's had "U" waves on all her ekg's and unless I see a significant change I honestly don't care about it.

You don't care about a clear electrophysiologic abnormality in a person with a clear etiology for it, and which is treatable, and the clinical context is non-urgent?

 

[pgg]

Oh my gosh she has a U wave lets shock her!!!!! Actually "U" waves can often be seen on normal ekg's and are meaningless as far as I'm concerned. Chances are in this particular lady she's had "U" waves on all her ekg's and unless I see a significant change I honestly don't care about it.

I tried to talk myself into posting that I would do this case, but I couldn't do it.

A couple times in the last year, I've caught myself doing borderline cases that I probably should've canceled, and social reasons factored into those decisions more than they should have. No one likes to send a patient home, especially old people or patients who might have a limited window of postop family help (vacation time to help grandma out is hard to reschedule).

But I wouldn't do this one. There's just no up side. It's like fudging our society's NPO guidelines. If you do an elective case 5 hours after the patient chows a bagel, probably nothing bad will happen, but if something does go wrong - even if it's not your fault - you will be absolutely alone in the world. Same with this case.

 

[KungPOWChicken]

There's absolutely nothing wrong with canceling a case if you're uncomfortable with proceeding, but doing it here is not evidence based by any means. you're just picking a number and going with it. No study has shown that a K of 2.7 has lead to increased mortality or poor outcome that I'm aware of and we'll probably never know anyways because the mortality rate and adverse event rates are so low in general. I've had patients with intra-op potassiums around that level on numerous occasions and I've never seen a hint of a irregularity related too this. What do I do. I simply try to correct it slowly and follow up on it. You're more likely to run into problems correcting too rapidly anyways. Again, this is a chronic problem, just like a potassium of 5.8 or 5.9 in a dialysis patient. If I canceled a vascular surgeon's case for that he would probably start laughing and I would look like a fool.
From Miller “As a rule, all patients undergoing elective surgery should have normal serum potassium levels. However, we do not recommend delaying surgery if the serum potassium level is above 2.8 mEq/L or below 5.9 mEq/L, if the cause of the potassium imbalance is known, and if the patient is in otherwise optimal condition.”

 

[Mman]

If I canceled a vascular surgeon's case for that he would probably start laughing and I would look like a fool.
From Miller “As a rule, all patients undergoing elective surgery should have normal serum potassium levels. However, we do not recommend delaying surgery if the serum potassium level is above 2.8 mEq/L or below 5.9 mEq/L, if the cause of the potassium imbalance is known, and if the patient is in otherwise optimal condition.”

None of my partners do our vascular cases with a K of 5.8 or 5.9. Some of the older guys get picky above 5.1, but most will go to about 5.5. Getting close to 6? Sorry, a HD patient isn't in "otherwise optimal condition". They likely are in need of some dialysis before coming to the OR.

 

[KungPOWChicken]

I wouldn't. Any AV fistula patient I would simply do a peripheral nerve block and proceed. Better yet. Just have the surgeon infiltrate some local. I would not be too concerned about it.

 

[KungPOWChicken]

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]

Abstract
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

 

[pgg]

you're just picking a number and going with it.

Yes.

From Miller “As a rule, all patients undergoing elective surgery should have normal serum potassium levels. However, we do not recommend delaying surgery if the serum potassium level is above 2.8 mEq/L or below 5.9 mEq/L, if the cause of the potassium imbalance is known, and if the patient is in otherwise optimal condition.”

And your Miller reference picked a number and went with it, too.


Look, I don't think anybody here really thinks something awful is likely to happen if you take this 2.7 elective hip arthroplasty to the OR, U waves or no U waves, given the fact that she has recently lived at 2.0 ...

It's just a matter of risk management. Beyond not inconveniencing the patient and surgeon, what's the up side to straying outside the envelope? What's the down side to getting her K issues fixed (which she needs anyway) before replacing her hip?

 

[KungPOWChicken]

my reasoning is that she's already been canceled once, now we're canceling her case a second time. She's not getting any younger. Her K is actually improved significantly from last time and I'm sure it will improve more this time when I give her some IV potassium and go ahead with the case. A K around 2.7 has never been demonstrated to cause adverse outcome and I'm sure we've all seen these levels intraoperatively on occasion. She'll be happy, I'll be happy, the surgeon will be happy and the hospital won't loose out on a case that could have been placed there.

 

[Bertelman]

Where's urge when you need him...

pent-sux-tube.

That'll fix her K+

 

[cchoukal]

so you would delay her case the 1-2hrs (optimistically) to replete and recheck her K (and EKG)(gonna be fun to coordinate that one)? The better choice here is clearly to send her back to the PCP, cowboy.

40 mEq of K takes 4 hours to run in IV (unless you have a central line), and, often, the patients complain about burning even at that slow rate.

And I would not advise making clinical decisions about high risk patients based on lack of relatively rare adverse events in a sample of 8 patients.

 

[nap$ter]

my reasoning is that she's already been canceled once, now we're canceling her case a second time. She's not getting any younger. Her K is actually improved significantly from last time and I'm sure it will improve more this time when I give her some IV potassium and go ahead with the case. A K around 2.7 has never been demonstrated to cause adverse outcome and I'm sure we've all seen these levels intraoperatively on occasion. She'll be happy, I'll be happy, the surgeon will be happy and the hospital won't loose out on a case that could have been placed there.

Perioperative atrial arrhythmias in noncardiothoracic patients: a review of risk factors and treatment strategies in the veteran population.
Burris JM, Subramanian A, Sansgiry S, Palacio CH, Bakaeen FG, Awad SS.
Am J Surg. 2010 Nov;200(5):601-5.

There are numerous studies demonstrating increased morbidity and mortality from perioperative hypokalemia. The risk increases with the distance from the normal values and the acuity of the derangement.

This woman may be symptomatic - you aren't sure whether her U-waves are pathological or physiological, because you have not compared with previous ekg's. if the U's are new, or if the amplitude is increased, they may be pathological and predictive of bad sh** to come. and she's ninety, and this is elective.

the number of times her case has been previously cancelled is irrelevant - she needs to be in tip-top shape for surgery, and she is not.

you contradict yourself. if the potassium is ok at 2.7, why would you correct it? you should think about why your plan is not the norm on this forum...

 

[KungPOWChicken]

I would hang 20 meq of kcl and let it drip in through a mini drip slowly. If she received the full bag I would recheck her K just see how she trended. This can easily be done with a automated machine in less than 5 minutes. Either way I wouldn't delay the case. I would just treat it like I normally do. If her K went above 3 I would be fine with that if she stayed below 3 I would give her another 20meq. They can continue to correct it throughout her stay

 

[pgg]

I would hang 20 meq of kcl and let it drip in through a mini drip slowly.

Her total body K deficit is in the 100s as K is mostly intracellular. You can't fix her hypokalemia the day of surgery. If you're OK with 2.7 you're OK with it. Microdripping in 20 mEq doesn't seem especially useful to me ... nor do I see much utility in rechecking her level after 20 mEq.

I guess what I'm saying is that if you care enough about her low K to want to start replacing it intraop, maybe you shouldn't be doing the case electively in the first place.


PS Although I'm sort of arguing with you, I'm glad you posted. Seeing where others draw their lines is one of the best things about the forum.

 

[KungPOWChicken]

So why bother giving iv insulin/glucose, bicarb, all that bull**** to treat hyperkalemia when it doesn't really matter because all K in your body is intracellular??? Potassium doesn't equilibrate (go intracellular instantaneously) that quickly when infused, and it's the potential difference that really matters in terms of heart function, hence the bodies ability to adjust to a chronic hypokalemia vs acute, just as chronic hyponatremia. Honestly, I really don't care about treating her hypokalemia that much aka not a big concern, and I'm mainly doing it for ****s and giggles aka documenting that I treated it.

 

[buckeye12]

So why bother giving iv insulin/glucose, bicarb, all that bull**** to treat hyperkalemia when it doesn't really matter because all K in your body is intracellular??? Potassium doesn't equilibrate (go intracellular instantaneously) that quickly when infused, and it's the potential difference that really matters in terms of heart function, hence the bodies ability to adjust to a chronic hypokalemia vs acute, just as chronic hyponatremia. Honestly, I really don't care about treating her hypokalemia that much aka not a big concern, and I'm mainly doing it for ****s and giggles aka documenting that I treated it.

You didn't treat anything.

Giving her K means one of two things: 1) you think her K was too low or 2) you are giving her sh** she doesn't need.

If the division chief asked you why you gave her K, what would you say? Would you say you gave it to her for "****s and giggles" or would you say you thought her K was too low?

 

[KungPOWChicken]

lets get this straight once and for all. I don't care about correcting her potassium intraoperatively. Would it be nice if it were higher. Yes. Would I like to see a potassium above 3. Yes. But its not going to change my anesthetic plan or my decision to do the case or not. My decision was made when I recognized that she has been chronically hypokalemic and stable and her K is much improved from last time. I'm treating her potassium now as part of her hospital stay as she will be admitted post-op obviously and her K can continue to be supplemented in a slow gradual manner as it should be. Kinda like treating someone's pre-op blood glucose of 300. Again my goal is not achieve a normal K level but to gradually correct it during her stay as should be done. It will not affect my anesthetic outcome what so ever. period.

 

[buckeye12]

lets get this straight once and for all. I don't care about correcting her potassium intraoperatively. Would it be nice if it were higher. Yes. Would I like to see a potassium above 3. Yes. But its not going to change my anesthetic plan or my decision to do the case or not. My decision was made when I recognized that she has been chronically hypokalemic and stable and her K is much improved from last time. I'm treating her potassium now as part of her hospital stay as she will be admitted post-op obviously and her K can continue to be supplemented in a slow gradual manner as it should be. Kinda like treating someone's pre-op blood glucose of 300. Again my goal is not achieve a normal K level but to gradually correct it during her stay as should be done. It will not affect my anesthetic outcome what so ever. period.

That doesn't clarify anything.

- You don't care about her intraoperative K level.
- You'd like to see a higher K level, but her hypokalemia won't affect anything you do.
- You think her K is stable, which you then use as a rationale for giving her K.


She had a K of 2.0, probably saw her PCP one week later, adjusted K up, saw PCP another week later with a K of 4.6 on new dose... and presents two weeks after that with a K of 2.7. That's not stable. They already canceled a surgery for low K, and now a month later you want to proceed with surgery despite an uncorrected K that's actually trending DOWN from the last check...

Also, since when are U waves on an ECG without comparison considered stable?

 

[KungPOWChicken]

let me make an analogy since you don't understand me then I'll stop posting on this topic because its been burnt to the ground. A patient who is diabetic comes in with lets say a glucose of 300. Assuming no other issues do I cancel the case. No. Does that glucose change my anesthetic plan. No. Would I like a glucose of under 200 yes. Would 120 be great. Yes. Do I treat the glucose of 300 yes. Do I give a shiit. No. Hopefully that helps

 

[pgg]

Settle down, we're all pals here.

I wouldn't reflexively cancel a case for a glucose of 300.

A 90 year old with hypokalemia, which has gone from 2.0 to 4.6 to 2.7, with EKG changes, yeah I'd cancel that.

 

[nap$ter]

I would hang 20 meq of kcl and let it drip in through a mini drip slowly. If she received the full bag I would recheck her K just see how she trended. This can easily be done with a automated machine in less than 5 minutes. Either way I wouldn't delay the case. I would just treat it like I normally do. If her K went above 3 I would be fine with that if she stayed below 3 I would give her another 20meq. They can continue to correct it throughout her stay

ok. say you put in your spinal, surgeon as you say is happy to get under way, lil' blood loss, you replace with LR or whatever, she goes into aflutter rate of 140, BP 70, she passes out. you've rechecked her K+ and it's still 2.7 despite your mini-drip with 20 of K.

just because she's walked around at home with a K of 2 doesn't mean she's gonna tolerate a spinal and the fluid shifts of hip surgery with hypokalemia that is still unstable, and the chronicity of which is questionable.

i am also glad you posted but honestly i am surprised at your cavalier attitude and apparent lack of willingness to read about and understand something as basic as hypokalemia.

 

[gaspasser2004]

I'm a little late to the discussion...

This is an elective case in a patient who has, in my opinion, a dangerously low potassium level. The number itself (2.7) and the presence of EKG abnormalities (U waves) are huge red flags.

Here are three different approaches to this case:

Academic Practice
Cancel the case. Tell the surgeon to take the patient back to her PCP and make sure the PCP does the job right the next time.

Private Practice - cowboy approach
Do the case as is. Make sure you have a defibrillator and several good lawyers available should the case go awry.

Private Practice - passive/aggressive but rational approach
"Dr. Bonecutter, thank you very much for again blessing me and my partners with such a lucrative medicare hip on a sick patient. We would absolutely love to do this case, but we can't quite do it at this moment. You see, her potassium is very low and she has abnormalities on her EKG. I realize you sent her to the PCP, but those treat em' and street em' guys never really fixed the problem. I'll tell you what I'm going to do. Ms. 90 y/o hip is going to be admitted to the hospital and I'm going to have one of my crack hospitalists tune her up. In the mean time, we're going to send for your next patient and get he/she in the room ASAP. At the end of the day, if Ms. 90 y/o has a potassium above 3.0 and the U waves have improved/resolved, we'll do the case (unlikely). If not, we'll do it first thing in the morning (more likely)."

 

[IN2B8R]

I'm a little late to the discussion...

This is an elective case in a patient who has, in my opinion, a dangerously low potassium level. The number itself (2.7) and the presence of EKG abnormalities (U waves) are huge red flags.

Here are three different approaches to this case:

Academic Practice
Cancel the case. Tell the surgeon to take the patient back to her PCP and make sure the PCP does the job right the next time.

Private Practice - cowboy approach
Do the case as is. Make sure you have a defibrillator and several good lawyers available should the case go awry.

Private Practice - passive/aggressive but rational approach
"Dr. Bonecutter, thank you very much for again blessing me and my partners with such a lucrative medicare hip on a sick patient. We would absolutely love to do this case, but we can't quite do it at this moment. You see, her potassium is very low and she has abnormalities on her EKG. I realize you sent her to the PCP, but those treat em' and street em' guys never really fixed the problem. I'll tell you what I'm going to do. Ms. 90 y/o hip is going to be admitted to the hospital and I'm going to have one of my crack hospitalists tune her up. In the mean time, we're going to send for your next patient and get he/she in the room ASAP. At the end of the day, if Ms. 90 y/o has a potassium above 3.0 and the U waves have improved/resolved, we'll do the case (unlikely). If not, we'll do it first thing in the morning (more likely)."

Agree wholeheartedly with your response. Even a level-headed orthopod would totally agree with this management. There is zero benefit (beyond a measly medicare fee) and greater risk for doing such a case without optimal medical management.

 

[seinfeld]

KungpowChicken stop looking at the nice Maple tree in front of you and start looking at the giant forest.

What do you personally gain from doing an elective hip on a 90 year old with a sever electrolyte abnormality?

I am a cowboy at times but not even a cowboy goes to a gun fight with a knife.

 

[Frank Rizzo]

Private Practice - passive/aggressive but rational approach
"Dr. Bonecutter, thank you very much for again blessing me and my partners with such a lucrative medicare hip on a sick patient. We would absolutely love to do this case, but we can't quite do it at this moment. You see, her potassium is very low and she has abnormalities on her EKG. I realize you sent her to the PCP, but those treat em' and street em' guys never really fixed the problem. I'll tell you what I'm going to do. Ms. 90 y/o hip is going to be admitted to the hospital and I'm going to have one of my crack hospitalists tune her up. In the mean time, we're going to send for your next patient and get he/she in the room ASAP. At the end of the day, if Ms. 90 y/o has a potassium above 3.0 and the U waves have improved/resolved, we'll do the case (unlikely). If not, we'll do it first thing in the morning (more likely)."

Well said. Sums up, almost step by step, a case I didn't do this week for very similar reasons.

 

[dhb]

I understand KungPow's stance: chronic condition very unlikely to affect outcome.
And i understand others pov: benefit not worth taking the risk.

So my question is if this is a benefit vs risk scenario at what price would the "obstructionists" be doing the case 200-500-1000$?

I agree that admitting the patient and tuning the K is a good political move.

 

[Frank Rizzo]

I understand KungPow's stance: chronic condition very unlikely to affect outcome.
And i understand others pov: benefit not worth taking the risk.

So my question is if this is a benefit vs risk scenario at what price would the "obstructionists" be doing the case 200-500-1000$?

I agree that admitting the patient and tuning the K is a good political move.

Really? you're selling your soul... the case i cancelled this week was a R TKR in his 50's who had insurance.

 

[pgg]

So my question is if this is a benefit vs risk scenario at what price would the "obstructionists" be doing the case 200-500-1000$?

Well, strictly speaking, the dilemma isn't our benefit vs patient risk, but rather patient benefit vs patient risk.


Of course, it's all a thought experiment for me. I get paid the same for the uninsured unemployed illegal immigrant as I do for the private insurance patient.

If you put me on the spot, I think the price of that piece of my soul starts in "briefcase full of Krugerrands" territory.


gaspasser2004 articulated the best answer.

 

[CCMDoc]

Anybody checked Mg level? Chronic diuretics and hypokalemia while on supplements, suspicious.

 

[Idiopathic]

awesome discussion guys

 

[pgg]

awesome discussion guys

So what'd you do?

 

[proman]

I would hang 20 meq of kcl and let it drip in through a mini drip slowly.

This, by the way, is a profoundly bad idea.

 

[Idiopathic]

So what'd you do?

case was cancelled after diplomatic discussion with surgeon regarding how i was willing to do the case but we should both be on board in case there were complications, etc. i did not like the precipitous drop and the EKG sealed it. ultimately it may have been easier for me being in academics, but i think its the right move.

 

[jennyboo]

Without the U-waves:
A-line
large bore IV, x2 preferably
IV K repletion & recheck K intraop
neuraxial vs general anesthesia (depends on patient & surgeon)
blood products as needed
PACU post-op

With the U-waves: the above, plus discuss with surgeon to determine whether maybe we should do her at the end of the day or tomorrow after K repletion & rechecking K/EKG. It's academics, speed is not of the essence. I would not send the patient home, she will just come back hypokalemic!

After hospital discharge, this patient will become hypokalemic at rehab and will continue to be hypokalemic at home. You are only fixing a number for a few days to buff the chart.

 

[Bertelman]

Without the U-waves:
A-line
large bore IV, x2 preferably
IV K repletion & recheck K intraop
neuraxial vs general anesthesia (depends on patient & surgeon)
blood products as needed
PACU post-op

With the U-waves: the above, plus discuss with surgeon to determine whether maybe we should do her at the end of the day or tomorrow after K repletion & rechecking K/EKG. It's academics, speed is not of the essence. I would not send the patient home, she will just come back hypokalemic!

After hospital discharge, this patient will become hypokalemic at rehab and will continue to be hypokalemic at home. You are only fixing a number for a few days to buff the chart.

You drop an A-line and 2x large bore, with blood products available for every 90 y/o hip?

 

[jennyboo]

You drop an A-line and 2x large bore, with blood products available for every 90 y/o hip?

Depends on the surgeon and the patient. Not every patient needs an a-line. I would definitely crossmatch a couple of units since oftentimes these patients will bleed further postop requiring transfusion in the next 24 hours, so the blood will likely be administered by the surgeon if not by me. Not every surgeon needs blood in the room, while some need blood in the room all the time regardless of patient profile.

Since I would expect to be checking K and possibly Hb in this case, it would be within reasonable practice to do an a-line for blood draws as well as for close hemodynamic monitoring.

 

[PL32]

That doesn't clarify anything.

- You don't care about her intraoperative K level.
- You'd like to see a higher K level, but her hypokalemia won't affect anything you do.
- You think her K is stable, which you then use as a rationale for giving her K.


She had a K of 2.0, probably saw her PCP one week later, adjusted K up, saw PCP another week later with a K of 4.6 on new dose... and presents two weeks after that with a K of 2.7. That's not stable. They already canceled a surgery for low K, and now a month later you want to proceed with surgery despite an uncorrected K that's actually trending DOWN from the last check...

Also, since when are U waves on an ECG without comparison considered stable?

buckeye, in all fairness he did clarify himself. you still disagree? fine. obviously most do. i would not autoproceed either. so chances are an "expert witness" may due him in, if he went to court over this, as we all seem to disagree in practice. however, he has explained his rationale well, and i respect his informed decision. theres no concensus asa stand here...its up to a reasonable practitioner to decide what to do.

 

[Bertelman]

Depends on the surgeon and the patient. Not every patient needs an a-line. I would definitely crossmatch a couple of units since oftentimes these patients will bleed further postop requiring transfusion in the next 24 hours, so the blood will likely be administered by the surgeon if not by me. Not every surgeon needs blood in the room, while some need blood in the room all the time regardless of patient profile.

Since I would expect to be checking K and possibly Hb in this case, it would be within reasonable practice to do an a-line for blood draws as well as for close hemodynamic monitoring.

That sounds downright scary.

 

[jennyboo]

That sounds downright scary.

It is. Those patients are not offered a neuraxial anesthetic.