Would you postpone this case?

[militarymd]

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Tough....I like it when you antagonize me....it's half the reason I come here!!...we're colleagues....I just don't like it when you antagonize the nurses.

and the answer to your question:

Because of NS's low pH, it will result in a higher serum K level than giving LR (with negligent amount of K) with it's higher pH.

K restricted diets very rare....even in dialysis patients.

When I did my nephro rotation at the VA the nephrologist I worked with had some dialysis patients on a potassium restricted diet. Granted this situation is different.


Let me rephrase the question.. how would you explain it in court if you had to?

 

[militarymd]

My practice philosophy is to approach things from a DIFFERENT angle.

Manage risk from a different perspective.

I feel that the risk of SUX and LR are overstated in basic anesthesia training...which I learned not to be true in my CCM training and experience..so I see no problems with using it.

But I feel that the K is kind of high and should be managed in a way that brings it lower...hence my other therapeutic measures (dilution, diuresis, acid/base shift)

The guys airway was marginal....but it is the typical marginal airway that I see 10 times a day....so I would choose to approach it like I approach it the other 9 times during the day....use a short acting muscle relaxant to intubate.

I completely agree with your nationally recognized mentors...I was partners with one who trained there and wrote a chapter in one of their books...it's about risk management.

I post this only because that I know that my approach is different ,but I don't feel that I push the "envelope"......I simply "fold" the envelope in a different way....write the address in a different way...and put the stamp on the lower left hand corner rather than the upper right hand corner.

First post here so not meant to offend.

Militarymd, I'm trying to figure out what your practice philosophy is. It seems to me that you are pushing the envelope in terms of anesthetics.

Pt. with a K of 6 and asymptomatic. I'd say most anesthesiologists would be concerned about raising the K any higher. So I'm going to give succ, I'm gowing to give LR? Why?

(We all know that succ elevates K by only 0.5 meq and K in LR is negligibe. But why even go there, when you can give a non depolarizer and NS)

Why not do everything that you can to keep the K low? Why not use a non depolarizer? You stated that the airway was marginal? If it was marginal, why induce? Why not go fiber?

If it was the "marginal" but not scareway...then why not prove mask ventilation, then give a non depolarizer? Or go with an intubating LMA?

In addition, if you were not concerned about the K? Why would give bicarb, give lasix? It seems like you say one thing but also hedge. BTW why wouldn't you give calcium since it is probably the most important thing to give to stabilize the cardiac membrane ?

I'm confused about your practice philosophy. Is it to push the limits of a "safe" anesthetic so that you can prove that you can live on the razor's edge? Is it not your patient's health that you are gambling with not your own?

I've had the honor of training with some of the greats of anesthesia. Eger, Gregory, Rosen. And the one thing that I've learned from all of them is that anesthesiology is about managing risk. Do everything to reduce risk cuz you can't eliminate it.

 

[militarymd]

Pretty scary case, when you think about it. 90% of M+M conferences start with "Just a Saturday morning cysto" or "Simple lum/lam"

Definitely agree with you that its okay to do the case, but wouldnt use sux, if only because of how stupid it would look when the guy arrested.

You are right there...and yet they still happen...with the traditional approaches.

 

[pd4emergence]

I disagree......and what kind of "magic" do REAL doctors have that anesthesiologists don't have?????

We're not talking about a AAA here....we're talking about a lum /lam....a no blood loss...20 minute procedure ...with no deliberate or otherwise hypotension .

Sure I could get the K down but that still doesn't answer why it is up in the first place. What happens if he is truly in renal failure, you put him to sleep and then he blames you and the surgery for having to go on dialysis. Those real doctors you mentioned have the benefit of time. I just don't have time during the day to deal with getting this guys K down. Sure I can give him the Kaexolate wait for him to crap, recheck it, then wait for him to be NPO again but I just don't have time during a busy OR day. Also, I think trying to get the K+ down acutely so that the patient can have an elective surgery that day is on the margin of safety in a patient that has no previously diagnosed renal problems. But, I do give props to your spine guy, I usually see at least 100-150 cc blood loss and it usually takes 45 min to do even a single level.

 

[ucsfgaspain]

Militarymd,

I enjoy your "thinking outside of the box" postulations.

So if I understand you correctly, you would argue that the NS given it's strong ion effect and resultant slight acidosis produces more hyperkalemia than 0.5 meq from giving succinycholine?

I honestly don't know the answer to this one. although my suspicion is- that at least with one liter of NS the resultant drop in your pH would produce less than 0.5 meq rise in K.

BTW do you have any quick rule of thumb how much K rises per 0.10 drop in pH?

Actually, after rereading your post, I don't believe that this is your postulation. (you were just comparing LR to NS?) Interesting thought and I am unsure as to whether the pH change would offset the miniscule amount of K in LR- that is if we compare giving the patient only one liter.

 

[militarymd]

someone else posted the link to an article comparing the 2 (ns vs lr) in a previous thread.

\

Militarymd,

I enjoy your "thinking outside of the box" postulations.

So if I understand you correctly, you would argue that the NS given it's strong ion effect and resultant slight acidosis produces more hyperkalemia than 0.5 meq from giving succinycholine?

I honestly don't know the answer to this one. although my suspicion is- that at least with one liter of NS the resultant drop in your pH would produce less than 0.5 meq rise in K.

BTW do you have any quick rule of thumb how much K rises per 0.10 drop in pH?

Actually, after rereading your post, I don't believe that this is your postulation. (you were just comparing LR to NS?) Interesting thought and I am unsure as to whether the pH change would offset the miniscule amount of K in LR- that is if we compare giving the patient only one liter.

 

[militarymd]

I didn't change his total body K much....beyond having him pee a little more......

My medical assessment, something that only Physicians can do versus what a CRNA can do:

for him is that he has chronic renal insufficiency like the thousand of other htn/dm patients we put to sleep.

Sure I could get the K down but that still doesn't answer why it is up in the first place. What happens if he is truly in renal failure, you put him to sleep and then he blames you and the surgery for having to go on dialysis. Those real doctors you mentioned have the benefit of time. I just don't have time during the day to deal with getting this guys K down. Sure I can give him the Kaexolate wait for him to crap, recheck it, then wait for him to be NPO again but I just don't have time during a busy OR day. Also, I think trying to get the K+ down acutely so that the patient can have an elective surgery that day is on the margin of safety in a patient that has no previously diagnosed renal problems. But, I do give props to your spine guy, I usually see at least 100-150 cc blood loss and it usually takes 45 min to do even a single level.

 

[SexPanther]

Militarymd,


BTW do you have any quick rule of thumb how much K rises per 0.10 drop in pH?

QUOTE]

The rule of thumb I was taught and use is for every pH decrease of 0.1, the K will increase by 0.6.

 

[jetproppilot]

I don't see how this is being a troll? How are the questions I asked offensive? UCSF gas pain is where I trained for both residency and fellowship. Interesting that you would ban me for asking, I think very pertinent questions.

Looks like I misjudged you.

Your post I misjudged was (I think) your first or second post ever and appeared misrepresentative.

We've had issues in the past with s%it-stirrers opening up another name from the same IP address.

I see you've started another informative, clinical thread.

I was wrong, and I apologize.

 

[militarymd]

So I just wanted to give the follow up to this case because it generated the most controversy, and also to show the residents and those who aren't indoctrinated to see how things work in PP.

So, I did the case just like I do all the other cases. It goes just like I expected it to go...the things that got done differently than normal:

I asked the surgeon to admit the guy..he says "no sweat".
I asked a hospitalist buddy to see the guy...he says "thanks for the business"
I tell the patient he's going to stay in the hospital a couple of days instead of going home....he says "ok"
So the hospitalists does a few things....makes his bucks...stop the lisinopril, everything good in a couple of days, and the dude goes home on a better medical regimen than what he came in on.

So the surgeon is VERY happy that his surgical schedule doesn't get screwed up....my stock just went up in his eyes....so when I want to do something that he doesn't like, I have political capital to burn with NO QUESTIONS asked.

So the hospitalist buddy gets a easy consult DURING THE DAY, so that when I have some crap for him at night, he'll remember the GOOD cases I got for him.

The patient is REALLY happy, he got his back fixed, AND he got a good doctor to address his medical issues without having to wait for an appointment for days/weeks with his primary care doc.

The only institution screwed....the hospital....instead of a lucrative outpatient case....I, orthopod, hospitalist just burned up their per diem reimbursement for a outpatinet case...and turned it into a lower paying inpatient case...I'm OK with that


Or we could do it the other way (for lack of a better term - the academic way)

- Cancel case
- let the guy go home
- let him wait for days/weeks to get in to see his doc
- his doc sucks ...otherwise he wouldn't have come to surgery with his labs out of wack
- let his doc spend days/weeks to dic k around with his meds to fix labs...
- have the surgeon think that I'm a puss
- don't get a case for my hospitalist buddy
- don't get to screw the hospital.
- don't get paid for doing a case

 

[dhb]

I asked the surgeon to admit the guy..he says "no sweat".
I asked a hospitalist buddy to see the guy...he says "thanks for the business"
I tell the patient he's going to stay in the hospital a couple of days instead of going home....he says "ok"
So the hospitalists does a few things....makes his bucks...stop the lisinopril, everything good in a couple of days, and the dude goes home on a better medical regimen than what he came in on.

Very true, most residents don't get this kind of perspective. I moonlight in an ED which has a private surgery clinic merged with it and when you call the orthopod for someone with a fracture the guy's there within 10min and almost wheels the patient to the OR no diking around...

 

[pd4emergence]

So I just wanted to give the follow up to this case because it generated the most controversy, and also to show the residents and those who aren't indoctrinated to see how things work in PP.

So, I did the case just like I do all the other cases. It goes just like I expected it to go...the things that got done differently than normal:

I asked the surgeon to admit the guy..he says "no sweat".
I asked a hospitalist buddy to see the guy...he says "thanks for the business"
I tell the patient he's going to stay in the hospital a couple of days instead of going home....he says "ok"
So the hospitalists does a few things....makes his bucks...stop the lisinopril, everything good in a couple of days, and the dude goes home on a better medical regimen than what he came in on.

So the surgeon is VERY happy that his surgical schedule doesn't get screwed up....my stock just went up in his eyes....so when I want to do something that he doesn't like, I have political capital to burn with NO QUESTIONS asked.

So the hospitalist buddy gets a easy consult DURING THE DAY, so that when I have some crap for him at night, he'll remember the GOOD cases I got for him.

The patient is REALLY happy, he got his back fixed, AND he got a good doctor to address his medical issues without having to wait for an appointment for days/weeks with his primary care doc.

The only institution screwed....the hospital....instead of a lucrative outpatient case....I, orthopod, hospitalist just burned up their per diem reimbursement for a outpatinet case...and turned it into a lower paying inpatient case...I'm OK with that


Or we could do it the other way (for lack of a better term - the academic way)

- Cancel case
- let the guy go home
- let him wait for days/weeks to get in to see his doc
- his doc sucks ...otherwise he wouldn't have come to surgery with his labs out of wack
- let his doc spend days/weeks to dic k around with his meds to fix labs...
- have the surgeon think that I'm a puss
- don't get a case for my hospitalist buddy
- don't get to screw the hospital.
- don't get paid for doing a case

Mil,
I work in private practice. There isn't one of my partners that would have done that case. I would say most of the attendings on this board would not have done that case. It's not a academic/private practice mentality thing. I don't want residents on this board to read this and think that doing an elective case in a patient with a potassium of 6 is a good idea. Sure everybody's happy 'cause everything turned out ok. But at the first sign of trouble the othropod would be pointing his finger at you. The hospitalist would have said "I don't know why I did not get consulted sooner". The primary care physician would have denied any knowledge of anything wrong with the patient and your lawyer would have a hard time finding somebody to say that they would have done the case. It may have been your medical opinion that the guy was good to go but no matter what you say most doctors would not have done that case. To be honest with you, when I see cases like that getting done, I see surgeons calling the shots and the anesthesiologists in that situation just being yes men. I'm glad everything went ok and everybody's happy. Maybe next time when you have a patient with a K of 6.5 you can do the same thing because that is what your surgeons are going to expect.

 

[Pooh & Annie]

YOU'RE A TROLL, OBVIOUSLY.

Save your "no meaning to offend" crap, think up another catchy screenname, and go troll somewhere else.

Your IP address is on the watch screen as of now.

Why not do a single shot epidural?

 

[militarymd]

Mil,
I work in private practice. There isn't one of my partners that would have done that case. I would say most of the attendings on this board would not have done that case. It's not a academic/private practice mentality thing. I don't want residents on this board to read this and think that doing an elective case in a patient with a potassium of 6 is a good idea. Sure everybody's happy 'cause everything turned out ok. But at the first sign of trouble the othropod would be pointing his finger at you. The hospitalist would have said "I don't know why I did not get consulted sooner". The primary care physician would have denied any knowledge of anything wrong with the patient and your lawyer would have a hard time finding somebody to say that they would have done the case. It may have been your medical opinion that the guy was good to go but no matter what you say most doctors would not have done that case. To be honest with you, when I see cases like that getting done, I see surgeons calling the shots and the anesthesiologists in that situation just being yes men. I'm glad everything went ok and everybody's happy. Maybe next time when you have a patient with a K of 6.5 you can do the same thing because that is what your surgeons are going to expect.

That's my point...When I say "no" for ANY REASON.......there's not one single PEEP from ANYONE in the hospital from the most bossy surgeon to the money grubbing administration.

what you describe is YOUR lay of the land...how your medical community works.

I'm telling you MY land of the land, and how my medical community works...

As cop said...it's about "relationships"....I've built them with my medical colleagues

Nothing would have gone wrong with the case....It is SAFER for a guy with a high K to be in the hospital under my care and in my hospitalist's friends care than for him to go home and do it the other way.

I know TONS of attendings who would do this case....it's a no brainer....I'm very surprised that there are experienced folks out there who won't do this case.

 

[militarymd]

Why not do a single shot epidural?

sure but why?

 

[toughlife]

ok, so the issue here is the sux-induced hyperkalemia in a pt with a K= 6 and a difficult airway.

Well, why not just avoid sux and do a an inhalational induction with sevo and tube the guy? Or you could have induced with propofol/alfentanyl (1-2mg/kg + 50mcg/kg) and tube the guy without paralytics. I would have had a glidescope on standby just in case. Once airway secure, you could have used any non-dep blocker.

I've tubed patients using the second method in which avoidance of paralytics was desired. It works well.

 

[militarymd]

Sux-induced hyperkalemia.....Everyone is talking about the this entity....which exists...and which KILLs people...but when you look in pubmed...and restrict the search to case reports....you find cases where the hyperkalemic responses is EXAGGERATED because of RISK FACTORS....and the patients arrest REGARDLESS of what their INITIAL K is.

I've seen this more than once....and each time, the anesthesiologist just says "The K was 3.5 when I took this patient to the OR".....

I think it is kind of funny when the gas guys used to come to the ICU to intubate (while I'm rounding with my residents), and the first thing out of their mouths was "what's the last potassium level?"....and NOT what risk factors exist for an exaggerated hyperkalemic response.

Anyways, hypoventilation from an inhalational induction would probably rasie the serum K more than the 0.5 meq/l that 1mg/kg of sux would....

Like I said, when it comes to monkey skills....I like to keep it the same each time.....I approach marginal airways with Propofol/sux....and see if the tube will go it.

There's a ton of nifty little toys out there, but I don't use them.

BTW, in my department, the CRNAs (and the MD's who have poor a/w skills) are the ones trying to buy the Glidescope...the MD's in my group (all experienced) said it is not needed, and bought another bronchoscope.

HOw do you like that Tough? You advocating a CRNA tool.

ok, so the issue here is the sux-induced hyperkalemia in a pt with a K= 6 and a difficult airway.

Well, why not just avoid sux and do a an inhalational induction with sevo and tube the guy? Or you could have induced with propofol/alfentanyl (1-2mg/kg + 50mcg/kg) and tube the guy without paralytics. I would have had a glidescope on standby just in case. Once airway secure, you could have used any non-dep blocker.

I've tubed patients using the second method in which avoidance of paralytics was desired. It works well.

 

[toughlife]

Sux-induced hyperkalemia.....Everyone is talking about the this entity....which exists...and which KILLs people...but when you look in pubmed...and restrict the search to case reports....you find cases where the hyperkalemic responses is EXAGGERATED because of RISK FACTORS....and the patients arrest REGARDLESS of what their INITIAL K is.

I've seen this more than once....and each time, the anesthesiologist just says "The K was 3.5 when I took this patient to the OR".....

I think it is kind of funny when the gas guys used to come to the ICU to intubate (while I'm rounding with my residents), and the first thing out of their mouths was "what's the last potassium level?"....and NOT what risk factors exist for an exaggerated hyperkalemic response.

Anyways, hypoventilation from an inhalational induction would probably rasie the serum K more than the 0.5 meq/l that 1mg/kg of sux would....

Like I said, when it comes to monkey skills....I like to keep it the same each time.....I approach marginal airways with Propofol/sux....and see if the tube will go it.

There's a ton of nifty little toys out there, but I don't use them.

BTW, in my department, the CRNAs (and the MD's who have poor a/w skills) are the ones trying to buy the Glidescope...the MD's in my group (all experienced) said it is not needed, and bought another bronchoscope.

HOw do you like that Tough? You advocating a CRNA tool.

It is readily available at my institution so that is what I know. It is obviously easy to use and many attendings love it. I always ask to do DL first. However, some attendings refuse.

Yes, I know. It is a sign of weakness. The fiberoptic bronchoscope is definitely the masta's tool and believe me I would love to use it all the time but I get told "No, let's use the glidescope". When I have had med students in the room, the glidescope is useful to show them the anatomy for learning purposes.

I hear you loud and clear on the poor airway skills comment.

 

[toughlife]

duplicate

 

[militarymd]

It is readily available at my institution so that is what I know. It is obviously easy to use and many attendings love it. I always ask to do DL first. However, some attendings refuse.

Yes, I know. It is a sign of weakness. The fiberoptic bronchoscope is definitely the masta's tool and believe me I would love to use it all the time but I get told "No, let's use the glidescope". When I have had med students in the room, the glidescope is useful to show them the anatomy for learning purposes.

I hear you loud and clear on the poor airway skills comment.

just needling ya🙂

 

[Planktonmd]

In general when people give Sux to patients with hyperkalemia and an adverse event results or the patient dies, they tend not to publish their mishap because of obvious implications.
This is why you would find a few case reports about people who were initially hyperkalemic, received Sux, and nothing happened, but I highly doubt that you will find case reports about hyperkalemic patients who received Sux and died.
This same simple logic applies to many things that are considered not to be safe by the majority of practitioners, if any one attempts a different approach and a bad outcome results they won't publish it (unless they are crazy).

 

[epidural man]

Had this posed to me as part of a mock oral recently.

Craniotomy for tumor resection. Patient basically healthy, takes HCTZ for hypertension. Preop K is 2.9. No evidence of elevated ICP. Not an emergent or urgent case.

My answer was that I wouldn't delay the case for the K of 2.9, provided it had not changed recently, while recognizing that I would have to be more cautious about hyperventilating the patient given the risk of dropping her K further via a respiratory alkalosis.

since it started out as hypokalemia......

I think the issue of K below 3.0 was much more of an issue when digoxin was used a lot more and hypokalemia with digoxin use was of much greater concern. I think in this case, I would proceed as many above have also said they would also. I doubt a chronic 2.9 K level is going to give much arrythmias.

My practice philosophy is to approach things from a DIFFERENT angle.

Manage risk from a different perspective.

I feel that the risk of SUX and LR are overstated in basic anesthesia training...which I learned not to be true in my CCM training and experience..so I see no problems with using it.

I have to agree with MMD. Since this guy walked in, this K of 6 is probably a long standing K and I don't think his risk is as great as a normal person suddenly developing a K of 6.

Another subtle point is MMD is critical care trained. I think that people with specialty trained areas get more leeway because of their training. I had an ENT surgeon tell me that he gives epi with lido in all those areas (nose tip, ears, etc) that all the textbooks say in large red letters not to. He said he wouldn't recommend that regular practitioners do the same. My point is, that as you become specialty trained, your understanding of certain points make your defensibility better. If an FP gave 30mg adenosine for SVT, he may get into problems on the stand, but cardiologists do it all the time and can defend their position easily...why? Because they are cardiologists - not because they understand physiology better than the FP. I think it may be a minor point. All of MMD's explainations to this point have sounded pretty good. I agree that most anesthesiologists wouldn't proceed because they have read in a book that they shouldn't, not because of experience.....that certainly would be the case for me. I've never had a hyperkalemic arrest yet (but then again, I haven't had a ton of things yet....)

I didn't change his total body K much....beyond having him pee a little more......

My medical assessment, something that only Physicians can do versus what a CRNA can do:

for him is that he has chronic renal insufficiency like the thousand of other htn/dm patients we put to sleep.

Again, excellent point.

There's a ton of nifty little toys out there, but I don't use them.

BTW, in my department, the CRNAs (and the MD's who have poor a/w skills) are the ones trying to buy the Glidescope...the MD's in my group (all experienced) said it is not needed, and bought another bronchoscope.

I however disagree with you here. Nifty little toys are not only fun to play with (you should try them, they are fun to use), but I think they are the future as fiberoptics and cameras improve, I would guess that DL as we know it will someday be a thing of the past. It is true that as technology improves, certain skills become less important. Look at the cardiac exam, which used to be so damn complicated with all the manuevers to bring out the S2 or murmur, now if you hear a murmur, you get an echo. If you have radicular symptoms, you get an MRI, if you have crackles, you get a chest xray. I doubt they even teach the ottowa ankle rules to rule out ankle fracture based on physical exam in the ER anymore. Ankle pain = xray. It's just the way things move. I'm not saying it is right, I'm just saying that it is the way medicine works.

As technology improves, the attitude changes toward those that don't embrace it. Who still does a cut down for central line placement? If you did, saying you don't need the silly seldinger technique, people would look at you strange and consider you dangerous. I know in the pain realm, those who do epidural steroids without fluoroscopy are considered hacks. Ultrasound for central lines is SLOWLY becoming that way.

 

[epidural man]

Militarymd,

So if I understand you correctly, you would argue that the NS given it's strong ion effect and resultant slight acidosis produces more hyperkalemia than 0.5 meq from giving succinycholine?

Critical Care guys are always talking about the "strong ion effect." The new edition of Miller talks about it. It never made much sense to me. Why can't the fact that NS dilutes bicarb be explanation enough to why NS gives an acidosis?

someone else posted the link to an article comparing the 2 (ns vs lr) in a previous thread.

\

This idea of NS raising K more than LR is perplexing. Does anyone know of the link MMD refers to? I can't find it. VenTY?

 

[Planktonmd]

since it started out as hypokalemia......




I have to agree with MMD. Since this guy walked in, this K of 6 is probably a long standing K and I don't think his risk is as great as a normal person suddenly developing a K of 6.

So if a patient can walk then potassium levels should be ignored?
What is exactly the connection between the ability to walk and the seriousness of hyperkalemia?
If we agree that a potassium of 6 is ok (as long as it is chronic), then how about 7, 8 or 9...?
What is the magic number?
And since a potassium level is not important as long the patient can walk, can we give Sux regardless of potassium level?
How do we know if hyperkalemia is chronic if we don't have any previous labs? and how long exactly is chronic?
If we are not concerned about hyperkalemia to the point of giving an agent that is known to increase potassium, does it make any sense to later take measures to lower the potassium empirically?

 

[epidural man]

So if a patient can walk then potassium levels should be ignored?
What is exactly the connection between the ability to walk and the seriousness of hyperkalemia?
If we agree that a potassium of 6 is ok (as long as it is chronic), then how about 7, 8 or 9...?
What is the magic number?
And since a potassium level is not important as long the patient can walk, can we give Sux regardless of potassium level?
How do we know if hyperkalemia is chronic if we don't have any previous labs? and how long exactly is chronic?
If we are not concerned about hyperkalemia to the point of giving an agent that is known to increase potassium, does it make any sense to later take measures to lower the potassium empirically?

Like I implied, I wouldn't do the case. My point was that I think Mil's choice and defense of his choice is acceptable.

 

[militarymd]

In general when people give Sux to patients with hyperkalemia and an adverse event results or the patient dies, they tend not to publish their mishap because of obvious implications.
This is why you would find a few case reports about people who were initially hyperkalemic, received Sux, and nothing happened, but I highly doubt that you will find case reports about hyperkalemic patients who received Sux and died.
This same simple logic applies to many things that are considered not to be safe by the majority of practitioners, if any one attempts a different approach and a bad outcome results they won't publish it (unless they are crazy).

If it's not reported, then how do you know that it happens?????

 

[militarymd]

So if a patient can walk then potassium levels should be ignored?
What is exactly the connection between the ability to walk and the seriousness of hyperkalemia?
If we agree that a potassium of 6 is ok (as long as it is chronic), then how about 7, 8 or 9...?
What is the magic number?
And since a potassium level is not important as long the patient can walk, can we give Sux regardless of potassium level?
How do we know if hyperkalemia is chronic if we don't have any previous labs? and how long exactly is chronic?
If we are not concerned about hyperkalemia to the point of giving an agent that is known to increase potassium, does it make any sense to later take measures to lower the potassium empirically?

to learn about hyperkalemia:

get Harrisons...look under signs and symptoms of HYPERKALEMIA....it'll tell you.

 

[Planktonmd]

to learn about hyperkalemia:

get Harrisons...look under signs and symptoms of HYPERKALEMIA....it'll tell you.

😀
You forgot to remind us that you did a FULL YEAR fellowship in intensive care about 10 years ago and that makes you an expert.
Don't worry, I'll make sure no one forgets.

 

[Planktonmd]

If it's not reported, then how do you know that it happens?????

I know it happens because I have seen people like you do it and I saw the results.
People like you who will not report an adverse event even if it hit them in the eye.

 

[militarymd]

since it started out as hypokalemia......

I think the issue of K below 3.0 was much more of an issue when digoxin was used a lot more and hypokalemia with digoxin use was of much greater concern. I think in this case, I would proceed as many above have also said they would also. I doubt a chronic 2.9 K level is going to give much arrythmias.



I have to agree with MMD. Since this guy walked in, this K of 6 is probably a long standing K and I don't think his risk is as great as a normal person suddenly developing a K of 6.

Another subtle point is MMD is critical care trained. I think that people with specialty trained areas get more leeway because of their training. I had an ENT surgeon tell me that he gives epi with lido in all those areas (nose tip, ears, etc) that all the textbooks say in large red letters not to. He said he wouldn't recommend that regular practitioners do the same. My point is, that as you become specialty trained, your understanding of certain points make your defensibility better. If an FP gave 30mg adenosine for SVT, he may get into problems on the stand, but cardiologists do it all the time and can defend their position easily...why? Because they are cardiologists - not because they understand physiology better than the FP. I think it may be a minor point. All of MMD's explainations to this point have sounded pretty good. I agree that most anesthesiologists wouldn't proceed because they have read in a book that they shouldn't, not because of experience.....that certainly would be the case for me. I've never had a hyperkalemic arrest yet (but then again, I haven't had a ton of things yet....)



Again, excellent point.



I however disagree with you here. Nifty little toys are not only fun to play with (you should try them, they are fun to use), but I think they are the future as fiberoptics and cameras improve, I would guess that DL as we know it will someday be a thing of the past. It is true that as technology improves, certain skills become less important. Look at the cardiac exam, which used to be so damn complicated with all the manuevers to bring out the S2 or murmur, now if you hear a murmur, you get an echo. If you have radicular symptoms, you get an MRI, if you have crackles, you get a chest xray. I doubt they even teach the ottowa ankle rules to rule out ankle fracture based on physical exam in the ER anymore. Ankle pain = xray. It's just the way things move. I'm not saying it is right, I'm just saying that it is the way medicine works.

As technology improves, the attitude changes toward those that don't embrace it. Who still does a cut down for central line placement? If you did, saying you don't need the silly seldinger technique, people would look at you strange and consider you dangerous. I know in the pain realm, those who do epidural steroids without fluoroscopy are considered hacks. Ultrasound for central lines is SLOWLY becoming that way.

good points, but god dam n it.....I hate those sales reps.