Postoperative hyperkalemia

Electrolyte Imbalance in Acute Traumatic Brain Injury: Insights from the First 24 h

BACKGROUND/OBJECTIVES

Electrolyte disturbances are common in patients with traumatic brain injury (TBI), particularly affecting sodium, potassium, chloride, and calcium levels. This study aims to provide insights into these disturbances within the first 24 h post-injury.

METHODS

We conducted a cross-sectional analysis of 50 TBI patients, excluding those with conditions affecting electrolyte balance. Electrolyte levels were measured, and correlations with demographic data, trauma mechanisms, imaging findings, and Glasgow Coma Scale (GCS) scores were analyzed.

RESULTS

The results indicated that chloride levels inversely correlated with GCS scores (ρ = -0.515; p = 0.002), suggesting that elevated chloride may indicate severe neurological impairment. Potassium levels were significantly associated with subdural hematoma (p = 0.032) and subarachnoid hemorrhage (p = 0.043), highlighting their potential as markers for severe brain injuries. No significant associations were found between sodium or calcium levels and the studied variables.

CONCLUSIONS

These findings underscore the importance of early monitoring of chloride and potassium levels in TBI patients to improve management and outcomes. Future research should focus on larger, multi-center studies to validate these findings and develop comprehensive guidelines for managing electrolyte imbalances in TBI patients.

Severe Hyperkalemia During a Robot-Assisted Total Radical Prostatectomy in a Patient with Stage 3a Chronic Kidney Disease: A Case Report

A 63-year-old man with stage 3a chronic kidney disease (CKD) and mild hyperkalemia was scheduled for a robot-assisted prostatectomy. He was being treated with lisinopril. Owing to mild hyperkalemia (6.2 mmol/L), lisinopril was discontinued, and sodium polystyrene sulfonate was administered on the day before surgery. Three hours after incision, electrocardiographic signs of hyperkalemia manifested with the serum potassium concentration rising to 8 mmol/L. Although hyperkalemia is a common and well-documented side effect of angiotensin-converting enzyme inhibitors in patients with CKD, we report an extreme increase in potassium within a very short time period despite prior drug discontinuation.

Risk Factors for Postoperative Urinary Retention After Lumbar Fusion Surgery: Anesthetics and Surgical Approach

INTRODUCTION

Postoperative urinary retention (POUR) after lumbar fusion surgery can lead to longer hospital stays and thus increased risk of developing other postoperative complications. Therefore, we aimed to determine the relationship between POUR and (1) surgical approach and (2) anesthetic agents, including sugammadex and glycopyrrolate.

METHODS

After institutional review board approval, L4-S1 single-level lumbar fusion surgeries between 2018 and 2021 were identified. A 3:1 propensity match of patients with POUR to those without was conducted, controlling for patient age, sex, diabetes status, body mass index, smoking status, history of benign prostatic hyperplasia, and the number of levels decompressed. POUR was defined as documented straight catheterization yielding >400 mL. We compared patient demographic, surgical, anesthetic, and postoperative characteristics. A bivariant analysis and backward multivariable stepwise logistic regression analysis ( P -value < 0.200) were performed. Significance was set to P < 0.05.

RESULTS

Of the 899 patients identified, 51 met the criteria for POUR and were matched to 153 patients. No notable differences were observed between groups based on demographic or surgical characteristics. On bivariant analysis, patients who developed POUR were more likely to have been given succinylcholine (13.7% vs. 3.92%, P = 0.020) as an induction agent. The independent predictors of POUR identified by multivariable analysis included the use of succinylcholine {odds ratio (OR), 4.37 (confidence interval [CI], 1.26 to 16.46), P = 0.022} and reduced postoperative activity (OR, 0.99 [CI, 0.993 to 0.999], P = 0.049). Factors protective against POUR included using sugammadex as a reversal agent (OR, 0.38 [CI, 0.17 to 0.82], P = 0.017). The stepwise regression did not identify an anterior surgical approach as a notable predictor of POUR.

CONCLUSION

We demonstrate that sugammadex for anesthesia reversal was protective against POUR while succinylcholine and reduced postoperative activity were associated with the development of POUR. In addition, we found no difference between the anterior or posterior approach to spinal fusion in the development of POUR.

Perioperative water and electrolyte balance and water homeostasis regulation in children with acute surgery

BACKGROUND

Hospital-acquired hyponatremia remains a feared event in patients receiving hypotonic fluid therapy. Our objectives were to assess post-operative plasma-sodium concentration and to provide a physiological explanation for plasma-sodium levels over time in children with acute appendicitis.

METHODS

Thirteen normonatremic (plasma-sodium ≥135 mmol/L) children (8 males), median age 12.3 (IQR 11.5-13.5) years participated in this prospective observational study (ACTRN12621000587808). Urine was collected and analyzed. Blood tests, including renin, aldosterone, arginine-vasopressin, and circulating nitric oxide substrates were determined on admission, at induction of anesthesia, and at the end of surgery.

RESULTS

On admission, participants were assumed to be mildly dehydrated and were prescribed 50 mL/kg of Ringer's acetate intravenously followed by half-isotonic saline as maintenance fluid therapy. Blood tests, urinary indices, plasma levels of aldosterone, arginine-vasopressin, and net water-electrolyte balance indicated that participants were dehydrated on admission. Although nearly 50% of participants still had arginine-vasopressin levels that would have been expected to produce maximum antidiuresis at the end of surgery, electrolyte-free water clearance indicated that almost all participants were able to excrete net free water. No participant became hyponatremic.

CONCLUSIONS

The use of moderately hypotonic fluid therapy after correction of extracellular fluid deficit is not necessarily associated with post-operative hyponatremia.

IMPACT

Our observations show that in acutely ill normonatremic children not only the composition but also the amount of volume infused influence on the risk of hyponatremia. Our observations also suggest that perioperative administration of hypotonic fluid therapy is followed by a tendency towards hyponatremia if extracellular fluid depletion is left untreated. After correcting extracellular deficit almost all patients were able to excrete net free water. This occurred despite nearly 50% of the cohort having high circulating plasma levels of arginine-vasopressin at the end of surgery, suggesting a phenomenon of renal escape from arginine-vasopressin-induced antidiuresis.

[Anesthesia for patients suffering from neuromuscular diseases]

Neuromuscular diseases (NMD) are a heterogeneous group of motor unit disorders. Common to all is the main clinical symptom of muscle weakness. Depending on entity and phenotype, a broad range of disorders of neuronal, junctional or myocytic structures occurs. In addition to a weakness of the skeletal musculature, NMD can also affect throat musculature, respiratory and heart muscles. The possible consequences are immobility, deformities, tendency to aspiration as well as respiratory and cardiac insufficiency. In the context of surgery and anesthesia, complications that can result from the underlying disease and its interaction with anesthesia must be anticipated and averted. This article describes along the treatment pathway how preoperative evaluation, choice of the anesthetic procedure and postoperative care can be effectively and safely tailored to the needs of patients with NMD. Concise and practical recommendations for carrying out anesthesia for the most important NMDs are presented as well as relevant external sources of practice recommendations.

Incidence of hyperkalemia during hypertonic saline test for the diagnosis of diabetes insipidus

OBJECTIVE

Hyperkalemia has been reported upon different hypertonic saline infusion protocols. Since hypertonic saline test has recently been validated for the differential diagnosis of diabetes insipidus (DI), we aimed to investigate the course of plasma potassium during the test.

DESIGN

We analyzed data of 90 healthy volunteers and 141 patients with polyuria-polydipsia syndrome (PPS) from two prospective studies evaluating the hypertonic saline test. Our primary outcome was the incidence rate of hypertonic saline-induced hyperkalemia > 5 mmol/L.

METHODS

Participants received a 250 mL bolus of 3% NaCl solution, followed by 0.15 mL/min/kg body weight continuously infused targeting a plasma sodium level of 150 mmol/L. Blood samples and clinical data were collected every 30 min.

RESULTS

Of the 231 participants, 16% (n = 37/231) developed hyperkalemia. The incidence of hyperkalemia was higher in healthy volunteers and in patients with primary polydipsia (25.6% (n = 23/90) and 9.9% (n = 14/141), respectively), and only occurred in 3.4% (n = 2/59) of patients with diabetes insipidus. Hyperkalemia developed mostly at or after 90-min test duration (81.1%, n => 30/37). Predictors of hyperkalemia (OR (95% CI)) were male sex (2.9 (1.2-7.4), P => 0.02), a plasma potassium at baseline > 3.9 mmol/L (5.2 (1.8-17.3), P => 0.004), normonatremia at 30-min test duration (3.2 (1.2-9.5), P => 0.03), and an increase in potassium levels already at 30-min test duration as compared to baseline (4.5 (1.7-12.3), P => 0.003). Hyperkalemia was transient and resolved spontaneously in all cases.

CONCLUSION

The hypertonic saline test can lead to hyperkalemia, especially in patients with primary polydipsia who experience a longer test duration. Monitoring potassium levels in these patients is recommended.

Pre-Transplant Plasma Potassium as a Potential Risk Factor for the Need of Early Hyperkalaemia Treatment after Kidney Transplantation: A Cohort Study

INTRODUCTION

Plasma potassium (K+) abnormalities are common among patients with chronic kidney disease and are associated with higher rates of death, major adverse cardiac events, and hospitalization in this population. Currently, no guidelines exist on how to handle pre-transplant plasma K+ in renal transplant recipients (RTR).

OBJECTIVE

The aim of this study is to examine the relation between pre-transplant plasma K+ and interventions to resolve hyperkalaemia within 48 h after kidney transplantation.

METHODS

In a single-centre cohort study, we addressed the association between the last available plasma K+ level before transplantation and the post-transplant need for dialysis or use of K+-lowering medication to resolve hyperkalaemia within 48 h after renal transplantation using multivariate logistic regression analysis.

RESULTS

151 RTR were included, of whom 51 (33.8%) patients received one or more K+ interventions within 48 h after transplantation. Multivariate regression analysis revealed that a higher pre-transplant plasma K+ was associated with an increased risk of post-transplant intervention (odds ratio 2.2 [95% CI: 1.1-4.4]), independent of donor type (deceased or living) and use of K+-lowering medication within 24 h prior to transplantation).

CONCLUSIONS

This study indicates that a higher pre-transplant plasma K+ is associated with a higher risk of interventions necessary to resolve hyperkalaemia within 48 h after renal transplantation. Further research is recommended to determine a cutoff level for pre-transplant plasma K+ that can be used in practice.

Paradoxical Critical Hyperkalemia After Acetazolamide for Cerebrovascular Reactivity Study: A Case Report

We present the case of a 42-year-old man with moyamoya disease presenting for cerebral revascularization surgery who developed critical hyperkalemia following a single intravenous (iv) dose of 1000 mg of acetazolamide 1 day preoperatively for a cerebrovascular reactivity study. His potassium increased from 5.1 to 6.7 mmol/L. Prompt treatment of this abnormality allowed this patient to undergo surgery the next day uneventfully. A paradoxical, critical increase in potassium can result from a single 1000-mg iv dose of acetazolamide.

Abdominal Aortic and Junctional Tourniquet release after 240 minutes is survivable and associated with small intestine and liver ischemia after porcine class II hemorrhage

BACKGROUND

Uncontrolled hemorrhage is a leading cause of tactical trauma-related deaths. Hemorrhage from the pelvis and junctional regions are particularly difficult to control due to the inability of focal compression. The Abdominal Aortic and Junctional Tourniquet (AAJT) occludes aortic blood flow by compression of the abdomen. The survivability of tourniquet release beyond 120 minutes is unknown and fluid requirements to maintain sufficient blood pressure during prolonged application are undetermined. We therefore compared 60-minute and 240-minute applications and release of the AAJT for 30 minutes, with crystalloid fluid therapy, after a Class II hemorrhage.

METHODS

Sixty-kilogram anesthetized pigs were subjected to 900-mL hemorrhage and AAJT application for 60 minutes (n = 5), 240 minutes (n = 5), and fluid therapy only for 240 minutes (n = 5) and reperfusion for 30 minutes.

RESULTS

The AAJT application was hemodynamically and respiratory tolerable for 60 minutes and 240 minutes. Cumulative fluid requirements decreased by 64%, comparable to 3000 mL of crystalloids. Mechanical ventilation was impaired. AAJT increased the core temperature by 0.9°C compared with fluid therapy. Reperfusion consequences were reversible after 60 minutes but not after 240 minutes. A 240-minute application resulted in small intestine and liver ischemia, persisting hyperkalemia, metabolic acidosis, and myoglobinemia, suggesting rhabdomyolysis.

CONCLUSION

The AAJT application for 240 minutes with reperfusion was survivable in an intensive care setting and associated with abdominal organ damage. Long time consequences and spinal cord effects was not assessed. We propose an application time limit within 60 minutes to 240 minutes, though further studies are needed to increase the temporal resolution. The AAJT application may be considered as a rescue option to maintain central blood pressure and core temperature in cases of hemorrhagic shock from extremity bleedings, if fluid therapy is unavailable or if the supply is limited.

LEVEL OF EVIDENCE

Therapeutic study, level II.

Sudden Intraoperative Hyperkalemia during Laparoscopic Radical Nephrectomy in a Patient with Underlying Renal Insufficiency

We experienced a case of severe intraoperative hyperkalemia during laparoscopic radical nephrectomy in a 60-year-old male patient with renal insufficiency, whose hypertension had been managed by preoperative angiotensin II receptor blocker (ARB) and adrenergic beta-antagonist. After renal vessel ligation, his intraoperative potassium concentration suddenly increased to 7.0 mEq/L, but his electrocardiography (ECG) did not show any significant change. While preoperative ARB therapy has been regarded as a contributing factor for further aggravation of underlying renal insufficiency, we assumed that nephrectomy itself and rhabdomyolysis caused by surgical trauma also aggravated the underlying renal dysfunction and resulted in sudden hyperkalemia. Hyperkalemia was managed successfully with calcium gluconate, insulin, furosemide and crystalloid loading during the intraoperative and immediate postoperative periods, and potassium concentration decreased to 5.0 mEq/L at 8 hours after the operation. The patient’s hospital course was uncomplicated, but his renal function deteriorated further.

Considering Postoperative Functional Hypoaldosteronism after Unilateral Adrenalectomy

Conn's Syndrome is an uncommon condition. Patients who have undergone adrenalectomy in the early postoperative period can demonstrate biochemical hypoaldosteronism. Given the rare nature of this phenomenon we investigated its incidence and whether it translated to clinical findings. A single-institution retrospective review of all patients with biochemically proven hyperaldosteronism from 2005 to 2014 that underwent unilateral adrenalectomy. A total of 29 patients fit the inclusion criteria. Functional hypoaldosteronism had appreciated in 18/29 (62%) patients, whereas 11 patients (38%) had normal postoperative aldosterone. No significant differences between diagnostic groups were found in terms of clinical outcomes (length of stay, postoperative symptomatology, and readmissions P = 0.669, 0.154, and 0.268, respectively). Two (7%) patients required medical therapy. Biochemical evidence of functional hypoaldosteronism was identified in two-thirds of patients undergoing unilateral adrenalectomy. Although contralateral aldosterone suppression can be anticipated, the phenotypic response varied and the outcomes were similar to patients with normal aldosterone levels. Current guidelines make no formal recommendations for assessment of hypoaldosteronism after adrenalectomy, resulting in varying practice paradigms. Surgeons should consider the risk of postoperative hypoaldosteronism in these patients and counsel patients accordingly. Prospective investigations should be performed to assist in development of an outcomes-based care delivery model for these patients.

Rebound hyperkalemia after cessation of ritodrine in a parturient undergoing cesarean section

A 36-year-old parturient with a suspicion of placenta accreta under tocolytic therapy with ritodrine infusion underwent emergency cesarean section under general anesthesia with propofol, ketamine, and remifentanil because massive bleeding was anticipated. The ritodrine infusion was discontinued 1 h before cesarean section. The baby was delivered 6 min after induction of anesthesia. However, after the manual removal of the placenta from the uterus, the bleeding was massive and uncontrollable. We rapidly transfused crystalloid, colloid, and red blood cells through potassium removal filter. Hyperkalemia (5.8 mmol/L) was detected just before blood transfusion. One hour later, hemostasis was still difficult, and hyperkalemia was promoted (6.1 mmol/L). Thus, glucose insulin therapy started with intravenous furosemide to treat hyperkalemia. Gynecologists decided to induce the Bakri balloon tamponade for the treatment of postpartum hemorrhage. At the end of surgery, plasma potassium level also reduced to 5.5 mmol/L. In the ICU, the bleeding still continued, and then radiologists performed bilateral internal iliac artery embolization for full hemostasis. Postoperative plasma potassium level was stable and 3.3 mmol/L in the next morning. Although one of the common adverse reactions of ritodrine is hypokalemia, we should also beware of a rebound hyperkalemia after its cessation.

Lethal ventricular tachycardia triggered after femoral fracture repair in an obese man with insulin-resistant diabetes

An obese man (height, 178 cm; weight, 160 kg; body mass index, 50.5 kg/m²) with a history of recurrent ventricular tachycardia (VT), cardiomyopathy, coronary sclerosis, and insulin-resistant diabetes suffered a right femur fracture in a vehicular accident. His fracture was repaired the following day, but shortly after surgery, his serum potassium (K⁺) level increased, presumably due to K⁺ leakage from the injured muscles, leading to persistent VT and death. An autopsy revealed severe cardiac hypertrophy, moderate coronary sclerosis, and histological findings of myocardial hypercontraction, but not myoglobin-related renal failure, pulmonary thrombosis, lipid emboli, or inflammation. The hyperkalemia was not corrected by glucose-insulin infusion and led to the death of the patient due to the preexisting cardiomyopathy, coronary sclerosis, and a predisposition to VT. In addition to the autopsy, the analysis of the clinical course was indispensable for determining the cause of death as hyperkalemia-related VT.