Replying to Kathryn B. 23/10/2022 - 20:13
Hello again!
I’m this case you would definitely treat the potassium regardless. Depending on the underlying condition, IVFT is often enough to treat some cases. We were worried about the cardiac consequences in this case.
Calcium infusions are considered “cardioprotective” in severe hyperkalaemia, even though they do not change the circulating potassium concentration. Hyperkalaemia raises the resting membrane potential, and providing additional calcium raises the threshold for depolarization, re-establishing a more normal ionic gradient across the cell membrane. IV calcium gluconate (50 mg/kg slow IV over 10-30 minute period, given to effect) is a logical first-line treatment for severe hyperkalaemia in these patients.
If severe hyperkalemia persists following 6-8 hours of fluid therapy or if bradycardia is profound, IV dextrose can be administered. Glucose stimulates insulin secretion, which moves K from the extracellular fluid into cells, quickly decreasing circulating K concentrations. If dextrose administration alone fails to decrease the K, IV insulin can be safely administered. When insulin is administered, glucose must be monitored closely to ensure that hypoglycaemia can be quickly identified and treated, if needed. Severe hypoglycaemia at admission or after insulin administration should be addressed with adequate glucose added to the IV saline to create a 5% dextrose solution. Alternatively, a dextrose bolus (0.25-0.5 g/kg, diluted 1 : 3) can be given IV. It is important to remember that glucose administration may cause transient hyperglycaemia. Hyperglycaemia, in turn, causes serum Na concentrations to measure low because the increasing glucose concentration results in fluid shifting to the extracellular space, diluting Na. In the very unlikely event that acidosis is severe (pH < 7.1) and does not correct with fluid therapy, bicarbonate can be administered at increments of 1/4 (0.3 × base deficit × body weight in kg) every 20 minutes while monitoring venous pH.
We did do an ACTH stim in this case...
https://ibb.co/MZv0WrB
Addison's indeed! But for me the big learning point was the crazy potassium!
Scott 🙂
