Question about my patient

[rn undisclosed name]

I had a pt who came in with a nonfunctioning av graft. He developed an infection around the site and it was draining. It was negative for a bruit/thrill. On admission his K was 6.0 but he was given kaexylate in the ER. The next am his K was 5.8. His DBP was a little high at 102. SBP was in the 140s so not too bad. Gave him his am meds expecting it would come down. His next BP was 150s/low 100s. Paged his doc. Never received return call but he was there within 30 minutes of paging him. Told him about his K and BP and he said he just needs HD which is what I was thinking. In the meantime he had also been scheduled for a revision of his graft with possible PC placement if needed. Surgery called to say they were ready for him. Told them his BP was a little off and they told me to just put a note on the front of the chart about his BP and I did. The surgeon was also aware of his labs.

My pt went down and I heard a code called in sx. Then I heard them paging his consults and his attending and knew this was my pt. He was completely fine when he went down with the exception of his BP and K level. My director was down there. They emptied a crash cart on him and transferred him to ICU. After my shift I went to the ICU to see how he was doing and was speaking to his nurse and I had to finish some charting in the chart. I thought for sure I was going to get this pt back after sx. In looking through the chart I saw his K shot up to 7.7. I'm not sure if that was from all the epi he received. BTW, they hadn't even started his sx when this pt coded.

I'm just curious - is it possible that your K can shoot up like that in a matter of hours. Also, how high does your K have to be to make you code. This is the highest K level I have seen. He only missed his dialysis from the previous day. I've had other pts miss more than 1 dialysis and not had any problems like this. I'm just wondering if maybe I missed something. I feel just awful. He didn't make it and died 5 minutes after I punched out. 10 minutes after I saw him in the ICU.

[Tweety, BSN, RN]

I think you did everything you could for this patient. There was no way to predict such an outcome. Interesting that the primary said he needed dialysis yet he went to surgery first. He didnt' sound medically clear.

I have had a patient's go from 6.0 to 8.0 rather quickly, so it is possible. This patient died as well.

[Blee O'Myacin, BSN, RN]

Tweety said:

I think you did everything you could for this patient. There was no way to predict such an outcome. Interesting that the primary said he needed dialysis yet he went to surgery first. He didn't' sound medically clear.

I have had a patient's go from 6.0 to 8.0 rather quickly, so it is possible. This patient died as well.

I guess since he needed a permacath or the av graft replaced, they opted to take him to surgery. (That's just my speculation here).

For all we know this patient's K could have lived in the high 5's which is why his doc opted to get the cath or graft and then have the HD. Personally, I'd have been more comfortable with a few more K-exalate enemas - as unpleasant as they are all around.

I agree with Tweety - I don't think you missed anything, and did all that you could do.

Blee

[CVICURN2003]

Had they already started to sedated him? Succs can increase your K level.

[traumaRUs, MSN, APRN]

An ESRD on HD can certainly fluctuate his K+ - 6.0 isn't too bad. Sounds like he should have had a femoral line placed for HD, then place the PC later. Howeve, hindsight is always 20/20!

The reason some patients do okay (not well mind you), but okay without HD for a couple of days, even a week is because they have some residual renal function. After you have been on HD for awhile (and the while varies with each pt), your urine production decreases and then will find yourself with symptoms of uremia: SOB, edema, n/v rather quickly.

Sounds like you handled things fine. BTW - my HD patients have been known to run consistently high K+ - one guy even survived a 9!

[skipaway]

CVICURN2003 said:

Had they already started to sedated him? Succs can increase your K level.

Yes it can, but I hope they wouldn't use Succynicholine on an end-stage renal failure patient. Both those procedures the OP mentioned, in our institution, are done with local and sedation, not as a general anesthetic.

[rn undisclosed name]

CVICURN2003 said:

Had they already started to sedated him? Succs can increase your K level.

I'm not sure if they had already started to sedate him yet or not. I was just told they hadn't even started working on him yet. Before they called the code they paged the anesthesiologist to the OR so my guess is that he hadn't received any sedation yet. I wasn't down there so really it's just speculation.

[rn undisclosed name]

Tweety said:

I think you did everything you could for this patient. There was no way to predict such an outcome. Interesting that the primary said he needed dialysis yet he went to surgery first. He didn't' sound medically clear.

I have had a patient's go from 6.0 to 8.0 rather quickly, so it is possible. This patient died as well.

He couldn't get dialysis due to his nonfunctioning graft. They would have had to get him some other access prior to this revision of his graft. I think in a situation like this they were planning to fix his graft and if they couldn't they were going to place a pc and then do dialysis. The nephrologist was aware of all this too.

I am thinking this surgeon wasn't expecting this. In fact if I were having sx I would want this particular surgeon doing my surgery. I don't like him as a person because he is so cocky but he is a great surgeon (and several of us have told him we don't like his attitude but think he is a great surgeon). I wouldn't want anyone else in his group since I have seen some of their surgeries go bad.

Kelly

[ebear, BSN, RN]

Tweety

he couldn't get the dialysis until the AV graft was addressed.

ebear