A physiologic-based approach to the treatment of acute hyperkalemia

Emergency Department Use of Heart Failure-Exacerbating Medications in Patients with Chronic Heart Failure

BACKGROUND

Use of heart failure-exacerbating medications (HFEMs) may lead to preventable episodes of acute decompensated heart failure (HF). HFEMs use is common in patients with HF, and there may be opportunities to reduce their use from the emergency department (ED).

METHODS

We performed an observational study on patients with HF presenting to EDs within a healthcare system between 1 January 2016 and 31 December 2020. Patients with chronic HF were identified using diagnostic codes within the electronic health record. The cohort was restricted to ambulatory (i.e., discharged to home) ED encounters. Medications, either ordered in the ED or prescribed at ED discharge, were extracted from the medication administration record and identified as potential HFEMs based on the 2016 American Heart Association Scientific Statement. Descriptive statistics were used to summarize the prevalence of HFEM use during ambulatory ED encounters. Exploratory analyses to identify correlates of HFEM use were performed.

RESULTS

The study cohort included 23,907 ED encounters. ED administration or prescription of HFEMs occurred during 20% of ambulatory ED encounters. HFEM administration in the ED (17%) was more common than HFEM prescription at ED discharge (6%). The most common HFEMs administered in the ED included nonsteroidal anti-inflammatory drugs (11%) and albuterol (7%).

CONCLUSION

HFEM use is common in patients with HF seeking ED care, occurring in roughly one-fifth of ambulatory ED encounters. There may be opportunities to optimize medication use among patients with HF in the ED.

Serum potassium changes during hypothermia and rewarming: a case series and hypothesis on the mechanism

Introduction

Hypokalemia is known to occur in association with therapeutically induced hypothermia and is usually managed by the administration of potassium (K+).

Methods

We reviewed data from 74 patients who underwent a therapeutic hypothermia protocol at our medical institution.

Results

In four patients in whom data on serum K+ and temperature were available, a strong positive correlation between serum K+ and body temperature was found. Based on the close positive relationship between serum K+ and total body temperature, we hypothesize that serum K+ decreases during hypothermia owing to decreased activity of temperature-dependent K+ exit channels that under normal conditions are sufficiently active to match cellular K+ intake via sodium/K+/adenosine triphosphatase. Upon rewarming, reactivation of these channels results in a rapid increase in serum K+ as a result of K+ exit down its concentration gradient.

Conclusion

Administration of K+ during hypothermia should be done cautiously and avoided during rewarming to avoid potentially life-threatening hyperkalemia. K+ exit via temperature-dependent K+ channels provides a logical explanation for the rebound hyperkalemia. K+ exit channels may play a bigger role than previously appreciated in the regulation of serum K+ during normal and pathophysiological conditions.

Hyperkalemia management in the emergency department: An expert panel consensus

Hyperkalemia is a common electrolyte abnormality identified in the emergency department (ED) and potentially fatal. However, there is no consensus over the potassium threshold that warrants intervention or its treatment algorithm. Commonly used medications are at best temporizing measures, and the roles of binders are unclear in the emergent setting. As the prevalence of comorbid conditions altering potassium homeostasis rises, hyperkalemia becomes more common, and hence there is a need to standardize management. A panel was assembled to synthesize the available evidence and identify gaps in knowledge in hyperkalemia treatment in the ED. The panel was composed of 7 medical practitioners, including 5 physicians, a nurse, and a clinical pharmacist with collective expertise in the areas of emergency medicine, nephrology, and hospital medicine. This panel was sponsored by the American College of Emergency Physicians with a goal to create a consensus document for managing acute hyperkalemia. The panel evaluated the evidence on calcium for myocyte stabilization and potassium shifting and excretion. This article summarizes information on available therapies for hyperkalemia and proposes a hyperkalemia treatment algorithm for the ED practitioner based on the currently available literature and highlights diagnostic pitfalls and evidence gaps.

Surprising Hyperkalemia of 10.2 mmol/L in a Patient with Hyperglycemia: A Case Report

Hyperkalemia is a life-threatening condition potentially leading to cardiac arrest. Here, we report a case of surprising severe hyperkalemia of 10.2 mmol/L in a diabetic patient with previously normal kidney function presenting without discernible clinical symptoms to our emergency department. The patient was admitted because of hyperglycemia of 32.8 mmol/L, which was detected during daily testing in her nursing home. The hyperkalemia was caused by prerenal failure due to hyperglycemic polyuria which led to volume depletion, and worsened by a combination of potassium-sparing drugs and potassium supplementation. The patient was treated conservatively. Eighteen hours later, the serum potassium concentration was 4.6 mmol/L. The patient could be released 6 days later. To our knowledge, this is the highest described hyperkalemia treated conservatively and survived without cardiopulmonary resuscitation.

Update on the prevention and treatment of tumor lysis syndrome

Tumor lysis syndrome is a constellation of metabolic derangements seen when tumor cells die and release their intracellular contents into the systemic circulation. Hyperkalemia, hyperphosphatemia, hypocalcemia, and hyperuricemia may lead to severe organ dysfunction and even death. Tumor lysis syndrome is classically considered a complication of successful cancer treatment, but it can also occur in untreated malignancies characterized by rapid proliferation. In this review, we cover the types of cancers and chemo- and immunotherapies associated with tumor lysis syndrome, the mechanisms by which severe metabolic derangements can develop, and the available treatments.

Repeated hyperkalaemia during two separate episodes of general anaesthesia in a nine-year-old, female neutered greyhound

There is an increasing awareness of the development of hyperkalaemia during anaesthesia in otherwise healthy veterinary patients. In the human literature 63 per cent of in-hospital hyperkalaemic episodes are associated with drug administration. Anecdotal veterinary reports have suggested that a genetic component may also play a role, with greyhounds seemingly more susceptible to the development of hyperkalaemia under anaesthesia. This case report identifies the repeated development of hyperkalaemia, and its treatment, during two separate episodes of general anaesthesia in a nine-year-old, female neutered greyhound. The first episode of hyperkalaemia (7.89 mmol/l) was identified due to bradycardia and second-degree atrioventricular block on electrocardiogram. Treatment was with intravenous calcium gluconate, insulin, glucose and fluid therapy. The second episode (6.60 mmol/l) was associated with spiked T-waves, and treatment was with insulin and glucose infusions to allow completion of the anaesthetic and surgery. Possible causes and treatments are discussed, and the need for reporting of such cases is highlighted.

Hyperkalemia and potential pitfalls of sodium polystyrene sulfonate

Sodium polystyrene sulfonate (SPS), FDA-approved more than 60 years ago for treating hyperkalemia, is an ion exchange resin that works by exchanging sodium for potassium in the colon. Though widely used in clinical practice, SPS use is not supported by well-designed clinical trials. In 2009, the FDA issued a warning that SPS was associated with colonic necrosis and other serious gastrointestinal adverse reactions. This article reviews the pros and cons of SPS therapy.

Renal and Gastrointestinal Considerations in Patients Undergoing Elective Orthopaedic Surgery

To minimize perioperative complications after orthopaedic procedures, patients may undergo medical optimization, which includes an assessment of their renal function and gastrointestinal (GI) system. The GI and renal systems are complex, and their proper optimization in the preoperative period can influence the success of any procedure. Several factors can prevent complications and reduce morbidity, mortality, and the cost of care, including a thorough evaluation and screening, with particular emphasis on anemia and its renal and GI causes; management of medications that are metabolized by the liver and excreted by the kidneys; and careful attention to the patient's nutritional status.

Cation Exchange Resins and colonic perforation. What surgeons need to know

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Cation Exchange Resins have been the mainstream treatment for chronic hyperkalemia.

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In 1987 the first case series of uremic patients with colonic perforations associated with the use of sodium polystyrene sulfonate was reported.

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The pathologic damage of Cation Exchange Resin in gastrointestinal tract goes from mucosal edema, ulcers, pseudomembranes, and the most severe transmural necrosis.

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Surgeons must avoid therapies with intestinal osmotic challenge implication in patients presenting gastrointestinal adverse reactions derived from Cation Exchange Resins.

Introduction

Since 1961 the use of Cation Exchange Resins has been the mainstream treatment for chronic hyperkalemia. For the past 25 years different kind of complications derived from its clinical use have been recognized, being the colonic necrosis the most feared and lethal of all.

Presentation of case

We report a case of a 72-year-old patient with chronic kidney disease, treated with calcium polystyrene sulfonate for hyperkalemia treatment who presented in the emergency department with constipation treated with hypertonic cathartics. With clinical deterioration 48 h later progressed with colonic necrosis requiring urgent laparotomy, sigmoidectomy and open abdomen management with subsequent rectal stump perforation and dead. The histopathology finding: calcium polystyrene sulfonate embedded in the mucosa, consistent with the cause of perforation.

Discussion

Lillemoe reported the first case series of five uremic patients with colonic perforation associated with the use of SPS in sorbitol in 1987 and in 2009 the FDA removed from the market the SPS containing 70% of sorbitol.

The pathophysiologic change of CER goes from mucosal edema, ulcers, pseudomembranes, and the most severe case transmural necrosis.

Up to present day, some authors have questioned the use of CER in the setting of lowering serum potassium. Despite its worldwide use in hyperkalemia settings, multiple studies have not demonstrated a significant potassium excretion by CER.

Conclusion

Despite the low incidence of colonic complication and lethal colonic necrosis associated with the CER clinical use, the general surgeon needs a high index of suspicion when dealing with patients treated with CER and abdominal pain.

Accuracy of point-of-care serum creatinine devices for detecting patients at risk of contrast-induced nephropathy: a critical overview

Contrast-induced nephropathy (CIN) is a common event in hospitals, with reported incidences ranging from 1 to 30%. Patients with underlying kidney disease have an increased risk of developing CIN. Point-of-care (POC) creatinine devices are handheld devices capable of providing quantitative data on a patient's kidney function that could be useful in stratifying preventive measures. This overview aims to synthesize the current evidence on diagnostic accuracy and clinical utility of POC creatinine devices in detecting patients at risk of CIN. Five databases were searched for diagnostic accuracy studies or clinical trials that evaluated the usefulness of POC devices in detecting patients at risk of CIN. Selected articles were critically appraised to assess their individual risk of bias by the use of standard criteria; 13 studies were found that addressed the diagnostic accuracy or clinical utility of POC creatinine devices. Most studies incurred a moderate to high risk of bias. Overall concordance between POC devices and reference standards (clinical laboratory procedures) was found to be moderate, with 95% limits of agreement often lying between -35.4 and +35.4 µmol/L (-0.4 and +0.4 mg/dL). Concordance was shown to decrease with worsening kidney function. Data on the clinical utility of these devices were limited, but a significant reduction in time to diagnosis was reported in two studies. Overall, POC creatinine devices showed a moderate concordance with standard clinical laboratory creatinine measurements. Several biases could have induced optimism in these estimations. Results obtained from these devices may be unreliable in cases of severe kidney failure. Randomized trials are needed to address the clinical utility of these devices.

A physiologic-based approach to the evaluation of a patient with hyperkalemia

Hyperkalemia generally is attributable to cell shifts or abnormal renal potassium excretion. Cell shifts account for transient increases in serum potassium levels, whereas sustained hyperkalemia generally is caused by decreased renal potassium excretion. Impaired renal potassium excretion can be caused by a primary decrease in distal sodium delivery, a primary decrease in mineralocorticoid level or activity, or abnormal cortical collecting duct function. Excessive potassium intake is an infrequent cause of hyperkalemia by itself, but can worsen the severity of hyperkalemia when renal excretion is impaired. Before concluding that a cell shift or renal defect in potassium excretion is present, pseudohyperkalemia should be excluded.