Extracorporeal Membrane Oxygenation Support for Hypokalemia-induced Cardiac Arrest: A Case Report and Review of the Literature

Hypokalemic Cardiac Arrest: Narrative Review of Case Reports and Current State of Science

PURPOSE

Hypokalemic cardiac arrest is an uncommon occurrence in the emergency department. Electrocardiogram findings related to hypokalemic cardiac arrest include prolonged QT, U waves, and preventricular contractions leading to Torsades de Pointes and then arrest. Literature evaluating the prevalence of hypokalemic cardiac arrest is scarce, and its management is lacking. This review provides a summary of current literature, recommendations from current guidelines, and proposed management strategies of hypokalemic cardiac arrest.

SUMMARY

Intravenous potassium administration is the treatment for hypokalemic cardiac arrest. Although the treatment for hypokalemic cardiac arrest is known, there is limited evidence on the proper procedure for administering intravenous potassium appropriately and safely. Owing to the time-sensitive nature of treating hypokalemic cardiac arrest, rapid administration of intravenous potassium (10 mEq/100 mL of potassium chloride over 5 minutes) is warranted. Concerns regarding rapid potassium administration are not without merit; however, a risk-benefit analysis and potential mitigation strategies for unwanted side effects need to be considered if hypokalemic cardiac arrest is to remain a reversible cause. It is imperative to identify hypokalemia as the cause for arrest as soon as possible and administer potassium before systemic acidosis, ischemia, and irreversible cell death.

CONCLUSIONS

More evidence is necessary to support treatment recommendations for hypokalemic cardiac arrest; however, it is the authors' opinion that, if identified early during cardiac arrest, intravenous potassium should be administered to treat a reversible cause for cardiac arrest.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Extracorporeal Membrane Oxygenation for Hypokalemia and Refractory Ventricular Fibrillation Associated with Caffeine Intoxication

BACKGROUND

Caffeine has been reported as a cause of cardiac arrest after massive overdose. Here, we report the case of a patient with caffeine intoxication, which can cause fatal dysrhythmias and severe hypokalemia. They were successfully treated with extracorporeal membrane oxygenation (ECMO).

CASE REPORT

A 43-year-old woman with a history of bipolar disorder presented to the emergency department after suicidal drug ingestion (caffeine and amitriptyline). Immediately after arrival, she experienced multiple episodes of ventricular fibrillation with severe hypokalemia requiring cardiopulmonary resuscitation and medical therapy. However, conventional treatment was not successful. We instituted ECMO early during resuscitation because prolonged hypokalemia refractory to aggressive potassium replacement precluded the use of antidysrhythmic medications for refractory circulatory compromise with ventricular fibrillation. The use of ECMO provided time to correct hypokalemia (19.3 g potassium) and reduce the caffeine level with hemodialysis. Although she had sustained cardiac arrest, she recovered fully and was discharged home. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case indicates the potential effectiveness of ECMO in severely poisoned patients with fatal dysrhythmias. ECMO could provide time for removal of toxic drugs and correction of electrolyte abnormalities.

Development and validation of a dynamic inpatient risk prediction model for clinically significant hypokalemia using electronic health record data

Purpose

The purpose of this study was to develop a dynamic risk prediction model for inpatient hypokalemia and evaluate its predictive performance.

Methods

A retrospective cohort included all admissions aged 18 years and above from 2 large tertiary hospitals in Florida over a 22-month period. Hypokalemia was defined as a potassium value of less than 3 mmol/L, and subsequent initiation of potassium supplements. Twenty-five risk factors (RF) identified from literature were operationalized using discrete electronic health record (EHR) data elements. For each of the first 5 hospital days, we modeled the probability of developing hypokalemia at the subsequent hospital day using logistic regression. Predictive performance of our model was validated with 100 bootstrap datasets and evaluated by the C statistic and Hosmer-Lemeshow goodness-of-fit test.

Results

A total of 4511 hypokalemia events occurred over 263 436 hospital days (1.71%). Validated C statistics of the prediction model ranged from 0.83 (Day 1 model) to 0.86 (Day 3), while p-values for the Hosmer-Lemeshow test spanned from 0.005 (Day 1) to 0.27 (Day 4 and 5). For the Day 3 prediction, 9.9% of patients with risk scores in the 90th percentile developed hypokalemia and accounted for 60.4% of all hypokalemia events. After controlling for baseline potassium values, strong predictors included diabetic ketoacidosis, increased mineralocorticoid activity, polyuria, use of kaliuretics, use of potassium supplements and watery stool.

Conclusion

This is the first risk prediction model for hypokalemia. Our model achieved excellent discrimination and adequate calibration ability. Once externally validated, this risk assessment tool could use real-time EHR information to identify individuals at the highest risk for hypokalemia and support proactive interventions by pharmacists.

Extracorporeal membrane oxygenation (ECMO) for critically ill adults in the emergency department: history, current applications, and future directions

Extracorporeal membrane oxygenation (ECMO) is a mode of extracorporeal life support that augments oxygenation, ventilation and/or cardiac output via cannulae connected to a circuit that pumps blood through an oxygenator and back into the patient. ECMO has been used for decades to support cardiopulmonary disease refractory to conventional therapy. While not robust, there are promising data for the use of ECMO in acute hypoxemic respiratory failure, cardiac arrest, and cardiogenic shock and the potential indications for ECMO continue to increase. This review discusses the existing literature on the potential use of ECMO in critically ill patients within the emergency department.