Hyperkalemia a ticking time bomb?

Specialties CCU

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I have been a critical care nurse for less than a year, so I am looking for advice from nurses who have more experience with this situation.

I admitted a patient with a potassium of 6.4, BP 200/100, EKG with peaked T waves and occasional PVCs, and c/o weakness. Despite spending over 5 hours in ER, the only treatment she had received was an amp of D50 and 10 units of insulin. It was a Sunday afternoon and I work in a small hospital. Our pharmacy had left for the day, which meant the house supervisor was responsible for any medication problems. I had both calcium gluconate and sodium bicarb ordered, but due to issues with our pyxis and hospital policies, I was unable to give either without help from the supervisor. I repeatedly asked the supervisor for help, but he was so overwhelmed with various emergencies that I didn't receive either medication by the end of my shift. By the time the night supervisor came on and addressed the medications, 2 1/2 hours had elapsed since the patient was admitted to the floor.

My question is - during this time of waiting I was VERY upset. In my experience, patients with a critical high potassium and EKG changes should be treated as a ticking time bomb. At the end of my shift I ended up calling my director. Was I overreacting? Is the risk of sudden cardiac arrest or wide complex tachycardia not as high as I imagine?

Any opinions or advice would be appreciated :)

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Specializes in Cardiovascular ICU.

I would most certainly have been alarmed in that situation. 2 1/2 hours?! I get that the house sup probably had a multitude of things going on, but yikes! Hospitals have got to quit sending pharmacists home at certain hours. I've heard of this, but it still blows my mind. I think of how much I rely on mine on nights, and I can't fathom being without them. Being that that patient had a K that high and a blood pressure that high for that matter, that sounds like a train about to de-rail.

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Specializes in Dialysis.

Dialysis patient? They can tolerate higher potassiums and be pretty asymptomatic. Does your crash cart have the calcium gluconate or bicarb because that's where I would look if needed. Break into the crash cart a few times for meds and maybe your institution will rethink its policies.

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Specializes in MSN, FNP-BC.

My question to you, since you stated that you have less than a year, is how aggressive were you in obtaining these meds?

It's times like these (especially when your patient is obviously symptomatic and not being treated adequately), that you need to bite like a pitbull and not let go until you get what you need.

If you don't get a response at the immediate level, I would not have hesitated to immediately call the next person up until I got what my patient needed. I've been known to go to any attending I can get my hands on (that is on service in our unit) to get done what needs to get done.

Where was your charge nurse during this? They are another good person to have on your side to help you advocate.

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Acute renal failure, not a dialysis patient. I asked my director if I was permitted to crack the crash cart in this situation, and she said "It's probably best that you didn't." They figured out the sodium bicarb and why I couldn't pull it out of the pyxis (it was programmed incorrectly), so that one is fixed. And I got the okay to mix the calcium gluconate myself using a vial adapter, so next time I know what to do. The problem was that our policy was unclear. I was under the impression I was in no way to mix the medication myself.

I guess I'm just wondering if hyperkalemia is as emergent as I'm thinking.. or if it really wasn't a big deal that the patient waited so long for treatment.

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Specializes in SICU.

It's hard to say if it is a big deal or not. I think you had the correct amount of concern. The problem is, lets say 49/50 patients don't have anything happen to them on a night like this, and the 50th one goes into VT. It becomes a game of risk tolerance. Not sure why the ED didn't do more in this case. The one thing that would comfort me is that the patient was tolerating a K of 6.4 before receiving d50/insulin, so you at least know their potassium is lower than that now.

Small hospitals aren't really the place to go for emergent conditions anyways lol. That's the price of living rural.

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Did they not receive a calcium/sodium resin (e.g. Kayexalate) to excrete the excess K? If it was given in the ED it could have been nearly done in 2 1/2 hours. The insulin only hides the potassium, it doesn't get rid of it.

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This shift we happened to not have a charge nurse scheduled. We're a small hospital in a rural part of the state, so that happens occasionally. My only supervisor on premise was the house supervisor. I asked him face-to-face probably a half dozen times. I debated calling my director, but it was a Sunday evening. I ended up calling her at the end of my shift and I wrote up a variance. The only thing I could have done was call my director sooner. But she made me feel that I may have overreacted, hence the post here :/

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The doc on call that night ended up ordering Kayexalate. It had not been ordered prior.

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Specializes in Critical Care.

Many references list the "panic value" of hyperkalemia as being >7. It's certainly not unheard of for dialysis patients to get above 6 as that they get farther out from there last treatment.

While hyperkalemia needs to be dealt with I would give the BP issue basically equal importance.

I'm certainly not encouraging you to anything unsafe or against policy, but personally I'm of the belief that it's not only within the nurses abilities, but it's our responsibility to move any barriers that exist between my patient and what they need to be safe, if that means busting open a crash cart then I'm more than willing to do so (although I'm not sure I would have done that for a K+ of 6.4 prior to insulin/glucose).

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Specializes in Critical Care.
The doc on call that night ended up ordering Kayexalate. It had not been ordered prior.

I wouldn't be too concerned that they didn't kayexalate initially, it's been removed at least as a first line treatment for hyperkalemia in many treatment algorithms. There's little to any evidence it causes significant potassium excretion, and it's possible that statistically you're more likely to cause colon necrosis than you are to excrete additional potassium.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Acute renal failure, not a dialysis patient. I asked my director if I was permitted to crack the crash cart in this situation, and she said "It's probably best that you didn't." They figured out the sodium bicarb and why I couldn't pull it out of the pyxis (it was programmed incorrectly), so that one is fixed. And I got the okay to mix the calcium gluconate myself using a vial adapter, so next time I know what to do. The problem was that our policy was unclear. I was under the impression I was in no way to mix the medication myself.

I guess I'm just wondering if hyperkalemia is as emergent as I'm thinking.. or if it really wasn't a big deal that the patient waited so long for treatment.

Yes it's emergent and the patient was already showing EKG changes. The ED should have been more aggressive.

IN the future your supervisor is too busy (frankly, as a supervisor, I would have treated that as an emergency, unless the building was on fire, and told you to open the crash cart, go to ICU, or call in pharmacy) In the future....I would seek the advice of the ICU. They have access to and can mix a multitude of drugs.

Was this patient on telemetry?

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