Transcript Potassium Practice Suggestion

Ann Bingham
11/24
 Not
a policy
 A safety tip
 Intended to be a useful reference
 Collaborative effort by anesthesiology,
nephrology, vascular surgery
 First/second/third
degree heart block,
bradycardia, asystole
 Ventricular tachycardia, ventricular fibrillation
 Decreased myocardial contractility
 Extracardiac effects: muscle weakness
 Respiratory depression
 Dialysis
dependent pts or those presenting for
dialysis access placement should have K+
checked on the am of surgery
• Chemistry panel with AM labs
• VBG in preop drawn by anesth or RN and run by AT
• K+ verified to be acceptable before starting any
regional or general anesthesia (part of block pause)
• Check more frequently if a temporizing measure was
instituted
 Normal
 Max
 Max
plasma potassium level = 3.4-5.0 mmol/L
K+ 5.5 mmol/L when starting minor surgery.
K+ 5.0 mmol/L when starting major surgical
procedures with potential muscle breakdown,
hemolysis, or transfusion requirements.
 If
K>6.0 despite temporizing measures it is
recommended to not proceed to surgery
without dialysis
 No
difference in cutoff value was chosen for
acute vs. chronic hyperkalemia.
 While chronic hyperkalemia may be better
tolerated in chronic renal failure patients, the
degree to which the tolerance to hyperkalemia
increases is not known.
 Tight
coordination among anesthesia, surgery,
nephrology and dialysis services is required
• Ask operator for nephrology fellow on call
• Do not page “hemodialysis” pager 14464 (that pager
sits on the charge RN desk and may not be answered).
 Initiate
discussion with nephrology when
temporizing measures are instituted
 In
ESRD patients on dialysis with recently
thrombosed AVF a higher max K+ may need to be
tolerated for the patient to have a fistula revision to
then receive dialysis (i.e. this is potentially an
urgent case).
 It may be beneficial to avoid placement of
temporary dialysis access (i.e. the risk benefit
analysis may favor allowing a higher than usual K+
in order to avoid morbidity associated with
placement of temporary access).
 Requires a discussion with surgeon

Calcium chloride (1 gm) or calcium gluconate (3 gm)
• Onset of action within 5 minutes. Duration of effect 30-60 minutes.
• No effect on K+ but antagonizes effect of hyperkalemia on myocardium.

Insulin + Glucose. Commonly used dose is 10 units regular insulin with 25
gm D50 followed by D5 infusion. Consider insulin infusion.
• Onset of effect approx. 15 minutes. Duration approx 60 minutes.
• CBG should be checked frequently after administration of any insulin bolus or infusion.


Correction of any acidosis (sodium bicarbonate for patients with metabolic
acidosis, hyperventilation or at least avoidance of hypoventilation). The
utility of bicarbonate in patients who are not acidotic is questionable.
β2-Adrenergic Stimulation (eg. Albuterol). Note that the inhaled albuterol
dose for the management of hyperkalemia is significantly higher than that
used for the management of bronchospasm (nebulized: 10-20 mg vs 5 mg,
MDI: approx. 1200 mcg vs 100 mcg).
• Onset of effect within 10 minutes. Duration of effect up to 2 hours.
K+ should be rechecked frequently. When temporizing measures are discontinued expect a
rebound in plasma potassium level.







narrowing and peaking of T waves,
shortening of the QT interval,
widening of the QRS complex,
low P wave amplitude,
AV nodal block, and
ventricular tachycardia.
severe hyperkalemia: sine wave pattern of ventricular flutter occurs,
followed by asystole.

Disclaimer: ECG is insensitive and non-specific for severe
hyperkalemia, so absence of ECG signs cannot be taken as
reassurance that the patient will not experience a life threatening
arrhythmia. The clinical course is unpredictable and sudden death
can occur in the absence of sentinel ECG changes.
In patients with preexisting ECG abnormalities the presenting ECG
sign of hyperkalemia may be normalization of the ECG.

 Patients
with ECG signs of hyperkalemia are at
risk for life-threatening arrhythmias and should
not undergo surgery.
 Consider administering IV calcium.
 If a life threatening arrhythmia or conduction
disturbance develops, such as VT, VF, heart
block, prolonged PR interval or widened QRS
then IV calcium is immediately indicated.
Caution: Blood pressure should be monitored and additional measures may be
needed to avoid hypertension resulting from calcium chloride administration or
hypotension from calcium gluconate administration.
Remove K+ from the body if possible (Note:
furosemide will not be effective in anuric or very
oliguric patients).
 Kayexalate is not considered helpful in the
intraoperative period (oral or rectal).
 Succinylcholine is expected to increase the potassium
concentration by 0.5-1 mmol/L and should be avoided.
 Fasting patients with CKD suppress insulin and tend to
become hyperkalemic. Non-diabetic patients at risk for
hyperkalemia should receive glucose containing fluids
during their NPO time.
 Continuous cardiac monitoring is indicated

 Special
thanks to Robert Shangraw, Ryan
Anderson, Andy Neice, Jennifer Shatzer
 Nephrology (especially Richard Parker)
 Vascular Surgery
 6A nurses
 Anesthesia Techs
 Michele Noles & Quality Team
 Anesthesia leadership