Metabolic Acidosis...

Editorial Team / Admin · Sep 16, 2015

Not familiar with the treatment of hyperkalemia in the ER, but if the patient is unconscious, how will you administer Kayexalate? That may influence another intervention that is needed...

Also agree with other posters that the K+ may not be the primary issue here. Always treat the cause, not just the symptoms.

KatieMI, BSN, MSN, RN · Sep 16, 2015

You are treating a number of 5.2, not a patient.

Think WHY this guy has high potassium and what underlying process causes it, and it will all become clear.

WCSU1987 · Sep 16, 2015

Would it be renal, lactic, or diabetic because the ketones and glucose are throwing me off. Wouldn't use sodium bicarbonate.

KatieMI, BSN, MSN, RN · Sep 16, 2015

WCSU, please let the OP solve the problem....I am really sick and tired of getting that sort of reports from nurses who, apparently, started under Florence Nightingale herself!

OP, I'll give you a clue: you are not treating hyperkaliemia here! It is something else, very simple and very common:yes:

mrsboots87 · Sep 17, 2015

Blood glucose of 420. My first thought is not to give the patient a med that is essentially a laxative that binds to potassium. A 5.2 is considered WNL in many facilities and even if not, it is not extremely elevated and not the priority here. I am truly not trying to be snarky. But think about this. What is this patient experiencing? How does that affect their potassium? When you intervene and fix this issue, will their potassium be resolved? Knowing those answers should point you in the direction of what the actual priority is and how it would be treated.

ArlyleRN · Sep 17, 2015

I need a little help on a question...
The patient is a 13 year old who presented to the ER unconscious with rapid breathing. His potassium is 5.2,glucose 420and is positive for ketones. He is in metabolic acidosis.
I'm thinking I would give him Kayexalate to decrease the potassium. ?
Start a second line for fluid resuscitation. I am slightly sure those are actions I would take..
But would I Initiate IV of NS 500 ml with Regular insulin 60 units at 50 mL/hr, give 2 L O2, and start a foley as well?

I need to know more. But Kayexalate enema.....definitely not. How did you arrive at the diagnosis of Metabolic acidosis? What are the ABGs? What are the OTHER lab values? V/S? What do the pupils look like? I would ask the doc for an order to give a little bit of SubQ insulin, start some fluids and try to get the kid into the ICU ASAP.

With the rapid breathing, the patient is in the early stages of Metabolic Acidosis. If you said Kussmaul's respirations, then that would be an Oh **** moment where we stick in an ETT and throw the kid on a vent right then and there.

Everyone is so quick to want to start a theoretical Insulin drip on a patient with a glucose above 250, but it may not be called for. In fact, you can make the K+ levels plummet and then you got some real problems. If you apply strict textbook solutions to everyday problems, then people will die.

How about some history? Eating disorder, non-compliant diabetic, or vulnerable population? Alcohol intoxication, suspected antifreeze ingestion, or starvation?

To emphasize- I ABSOLUTELY MUST KNOW THE ABGs. Specifically pH and BiCarb

Mavrick, BSN, RN · Sep 17, 2015

With the rapid breathing, the patient is in the early stages of Metabolic Acidosis. If you said Kussmaul's respirations, then that would be an Oh **** moment where we stick in an ETT and throw the kid on a vent right then and there.

Granted, the OP said rapid breathing so, you're jumping to Kussmaul but even then Kussmaul breathing is a respiratory attempt to compensate for a metabolic problem. Solve the problem. Keep in mind this is a school problem, not real life.

Aretaeus · Sep 17, 2015

- yes on insulin drip but keep things simple do 50 units in 500cc NS (why 60?), plus needs a lower insulin rate than posted lower rate, about 7 units/hour on avg weight for 13 year old, depending on his weight (around 0.1 unit/kg/hour),

- yes push fluids, at least 20ml*kg NS,

- yes on foley

- yes on second line

- the potassium will drop with the insulin drip, you will NOT need a potassium binder AT ALL, it might actually hurt! in all likelihood it will drop (as insulin goes into cells potassium will too and drop the intravascular k) and in all likelyhood they might have end up adding potassium iv with the fluids later

- the renal function will alter how you proceed after..

- btw what worries me more is that fact that the child is unconscious at that glycemia, that is is very very worrisome and should be investigated further, neuro eval, without more data (he/she will need cbc, abg, ct scan brain, ua, mag, phos, LFTs, ammonia, what meds he is on, known history of diabetes? and sadly these days you will need also a UDS, aspirin level, etoh level, tylenol level if there are no reliable parents to give you more data)

- i can't advice more but I can tell you something else is going on, remember also dka often has infection as underlying cause, if suspected you will need Blood Cultures and maybe and LP

- i am just noob so, please take everything i said with a grain of salt, i like ArlyleRN comments with one exception, patient should stay in ER and not be moved to ICU until he/she is stabilized, the team has more data and he/she has a working diagnosis, for all you know you if infection is a possibility, he/she will need LP, blood cultures and the right empirical antibiotics coverage hanging, now, not later..

loving2024, BSN, RN · Sep 18, 2015

I need a little help on a question...
The patient is a 13 year old who presented to the ER unconscious with rapid breathing. His potassium is 5.2,glucose 420and is positive for ketones. He is in metabolic acidosis.
I'm thinking I would give him Kayexalate to decrease the potassium. ?
Start a second line for fluid resuscitation. I am slightly sure those are actions I would take..
But would I Initiate IV of NS 500 ml with Regular insulin 60 units at 50 mL/hr, give 2 L O2, and start a foley as well?

Dont forget the heart though, you need to protect it.

ArlyleRN · Sep 18, 2015

I need a little help on a question...
The patient is a 13 year old who presented to the ER unconscious with rapid breathing. His potassium is 5.2,glucose 420and is positive for ketones. He is in metabolic acidosis.
I'm thinking I would give him Kayexalate to decrease the potassium. ?
Start a second line for fluid resuscitation. I am slightly sure those are actions I would take..
But would I Initiate IV of NS 500 ml with Regular insulin 60 units at 50 mL/hr, give 2 L O2, and start a foley as well?

Just when I thought I was out of this thread.....

Whoever gave you this scenario should be slapped with a full colostomy bag. Questions like these leave out so many confounding variables that it just irritates the living :spit: out of me. Humor me for a moment:

1. Blood Sugar of 420 and the kid won't get up? Did anyone even try? The pH has to be 7.0 or less.

2. Potassium of 5.2? Good, we have some wiggle room in case some idiot screws him up with an insulin drip (SubQ is just as good).

3. Seriously, metabolic acidosis and you don't even get to know the entire ABGs? Did anyone ever tell you that pediatric DKA is classified according to pH level and bicarbonate level?

4. Rapid breathing is a VERY early sign. I still can't believe the kid is unconscious.

5. What is the level of ketones: 80?

6. If this is DKA, then the kid is lucky. Usually DKA presents with Blood glucose of a lot more than 420 mg/dl.

Maybe the kid is high. I mean with the blood sugar of 420

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LoveER01 · Sep 24, 2015

I just realized I have a bunch of responses. This question is crap