High (sort of) potassium

I work ED. No it's not the norm where I work. Sometimes kayexalate will be given.

Usually it's the floor nurses that get worked up about labs that are little off. "Why didn't you correct that magnesium?" they say accusingly, when it's only slightly hypo. I'll just answer "would you care to speak with the ER Doc? " that shuts them up.

Lol @ "would you care to speak with ER Doc?" - I'm going to utilize this question - thank you!

Ok, so I'm not off-base in my assessment that these docs are getting really excited when there is no need...

In your ER experience, when do you start to get excited about K levels (asymptomatic), and in what instances are you pushing calcium gluc, insulin, dextrose & giving albuterol? (other than a code, or unstable situation?) If asymptomatic, just kaexylate, or facilitating dialyis asap for renal pts?

Thank you for your input!

57 minutes ago, tachyallday said:

Lol @ "would you care to speak with ER Doc?" - I'm going to utilize this question - thank you!

Ok, so I'm not off-base in my assessment that these docs are getting really excited when there is no need...

In your ER experience, when do you start to get excited about K levels (asymptomatic), and in what instances are you pushing calcium gluc, insulin, dextrose & giving albuterol? (other than a code, or unstable situation?) If asymptomatic, just kaexylate, or facilitating dialyis asap for renal pts?

Thank you for your input!

At about 6

Thank you!

41 minutes ago, tachyallday said:

Thank you!

I think with the dialysis patients they are less aggressive since they tolerate pretty high serum K+.

".Anyway, a nurse told me she saw someone arrest with a K of 5.5 - does that really happen, or was there possibly another cause for the code vs. a K of 5.5 that was not known, and perhaps a cause there would never be an answer for?"

On 4/29/2019 at 3:39 AM, tachyallday said:

New ED nurse here, but not a new nurse & just looking for some insight..I have extensive ICU experience, and I have seen high potassium many, many, many times, upwards of 6 without symptoms, even upwards of 7 without symptoms...I never recall anyone getting too terribly excited for a potassium level between 5 - 6. I don't actually recall remembering anyone symptomatic with a K between 5 & 6

Twice now I have had patients with heart rates in the 40s, one was sinus brady on a fit 60 year-old, one was junctional-ish looking on a not-fit 80 year-old.

Both were A & O, stable on RA, BP WNL, no S/s of decreased perfusion. One came in for back pain, the other with throat "tightness". Not overt cardiac symptoms, but definitely could be considered atypical if it were cardiac-related...

Both Ks were 5.5-5.7 (iStats & serum) - mild hyperkalemia

On both cases, the docs were really worked up and like, "we need to do Calcium gluc, insulin and dextrose NOW for the hyperkalemia + albuterol." I was thinking, "ok you're really excited, and I've only ever done this during codes, and never saw anyone get this excited, but ok sure why not let's do this."

I realize that people different thresholds for symptoms r/t potassium

Both times, gave all those meds, heart rate/rhythm didn't change, not one bit. K verified to be down to 5.1 for one patient, and below 5 for the other. All other labs normal, except for Cr of 1.7 on the 80 year old (there was that person's cause of high K).

Anyway, is this normal to do this protocol all the time? Is this just part of how you rule out causes of bradycardias? The fit 60 year old could have been living in the 40s & the 80 year old was on a beta-blocker...Anyway, a nurse told me she saw someone arrest with a K of 5.5 - does that really happen, or was there possibly another cause for the code vs. a K of 5.5 that was not known, and perhaps a cause there would never be an answer for?

Also can CKD patients tolerate higher potassium levels because they are chronically elevated?

Thank you!

A few thoughts-

"Anyway, a nurse told me she saw someone arrest with a K of 5.5 -"

Plenty of people have arrested with a K of 5.5. But there is a huuuuuuuuuge stretch between cause and correlation. It is always possible that the the problem contributing to the high K also contributed to the arrest, but I am not buying an arrest caused by K 5.5. Scales vary, but according to Merck, Hyperkalemia is a serum potassium concentration > 5.5 mEq/L .

"In your ER experience, when do you start to get excited about K levels (asymptomatic), and in what instances are you pushing calcium gluc, insulin, dextrose & giving albuterol?"

Ideally this is based on presentation. At least a few sources use 6.5 as an absolute indication and 5ish-6.5 with symptoms attributable to to the hyperkalemia as an indication. Asymptomatic bradycardia in a PT on beta blockers seems like a bit of a stretch.

Why not just ask the provider for the rationale? In my experience, most ER docs like nurses understanding the treatment plan. I think I would have questioned the logic- not as a challenge, but for education. Could be a really good reason. Could be an inexperienced doc following an algorithm uncritically.

"Also can CKD patients tolerate higher potassium levels because they are chronically elevated?"

Yes.

It has been noted that patients with CKD who develop chronic hyperkalemia can have serum potassium levels in excess of 6.0 mg/dl without apparent electrocardiographic or cardiovascular manifestations

The only question I would throw in there is "are there EKG changes" that maybe we are unaware of. As an ENP, Ive seen my fellow MDs see/think/treat something that would never cross my mind. ? No idea

On 4/29/2019 at 3:39 AM, tachyallday said:

New ED nurse here, but not a new nurse & just looking for some insight..I have extensive ICU experience, and I have seen high potassium many, many, many times, upwards of 6 without symptoms, even upwards of 7 without symptoms...I never recall anyone getting too terribly excited for a potassium level between 5 - 6. I don't actually recall remembering anyone symptomatic with a K between 5 & 6

Twice now I have had patients with heart rates in the 40s, one was sinus brady on a fit 60 year-old, one was junctional-ish looking on a not-fit 80 year-old.

Both were A & O, stable on RA, BP WNL, no S/s of decreased perfusion. One came in for back pain, the other with throat "tightness". Not overt cardiac symptoms, but definitely could be considered atypical if it were cardiac-related...

I know you have provided quite a bit of info, but there's probably more upon which the decisions were based. Simple overkill is certainly not unheard of. In the interest of patient safety, we must seek to understand in order to advocate properly. Plus, working that closely with physicians and other providers can benefit our own knowledge base. They don't like to be quizzed ignorantly and rudely, but I've never had someone refuse to entertain sensible questions especially when they know that I'm asking because I want to take good care of my patient.

It doesn't sound like either of these patients was shocky in any way, but the combo of blockers + bradycardia + AKI/RF + hyperk might have been concerning anyway. Maybe they were still thinking of BRASH or enough of its elements to cause concern.

Maybe there was more to the patients' histories.

Maybe they were concerned when they didn't need to be.

It's hard to say.

Ask questions! ?? ?

ER doc here.

It's not just the number. It's how fast that number increased, what their baseline is, the reason for the hyperK, how quickly it may return to normal while treating the cause, the meds they are on, the vital signs, renal function, other lab values like calcium and bicarb, the patient's clinical appearance and the EKG. All of that factors into my decision making when assessing and treating a patient with hyperkalemia.