Acebecker Posted July 15, 2011 Share Posted July 15, 2011 Yesterday I stayed late to finish some charts and ended up in radiology/lab to review something that I didn't think was quite right. I overhear the lab tech say my name so I wander over to see what's amiss and they hand me a printout of a CMP on a completely unrelated patient, someone I haven't seen in over a month who had labs ordered by a provider in a different state. The CMP shows a K+ of 6. All of the other providers have left the building (my preceptor is actually an NP and we all consult with one locum MD). The MD is the only one left - so I take the lab to him and give him as much background on the patient as I can - on Digoxin, Lasix, Enalapril... Last K+ was 4.8 about a month ago. He sees a nephrologist for chronic renal insufficiency and his nephrologist is actually the one who ordered the labs. I'm thinking we haul the patient back after hours and get another blood draw at the very least... Perhaps order Kayexalate and make sure it gets delivered ASAP (we are in a small community and personal visits occur often). He says, "This isn't so high that we should worry about it tonight. Why don't you just follow up with him in the morning and see what his nephrologist wants to do." What would you have done? Andrew Link to comment Share on other sites More sharing options...
Acebecker Posted July 15, 2011 Author Share Posted July 15, 2011 Lab techs went home right after handing me the printout. Link to comment Share on other sites More sharing options...
Just Steve Posted July 15, 2011 Share Posted July 15, 2011 Could you call the patient and see how they are doing? I don't know how many times I have responded to nursing homes to take patients to ERs for abnormal lab readings. Sometimes those labs were from that day...other times it was from labs more than a week old. My point is, perhaps talking with the patient you could suggest they find their way to an ER? I am not a big fan of using ERs as primary care sites, but a K of 6 isn't really a healthy thing. just my thoughts from the cheap seats. Link to comment Share on other sites More sharing options...
bradtPA Posted July 16, 2011 Share Posted July 16, 2011 Call the ordering provider, let him know you have a abnormal result to report. What abnormal finding would you expect to see on an EKG? What drug can be administered in a peripheral IV to correct the potassium? What nebulized medication can be used as an antidote? Link to comment Share on other sites More sharing options...
Contrarian Posted July 16, 2011 Share Posted July 16, 2011 I'm confused... How old is the lab... as in... what date was it collected...??? What abnormal finding would you expect to see on an EKG? What drug can be administered in a peripheral IV to correct the potassium? What nebulized medication can be used as an antidote? Also... how does ACEI contribute to HyperKalemia...???? Link to comment Share on other sites More sharing options...
HopefulPA Posted July 16, 2011 Share Posted July 16, 2011 Call the ordering provider, let him know you have a abnormal result to report. What abnormal finding would you expect to see on an EKG? What drug can be administered in a peripheral IV to correct the potassium? What nebulized medication can be used as an antidote? I agree not your pt. Call the nephrologist and find out what they want. Was there hemolysis? Don't want to be a spoiler to the above but to add to the questions ...................What can be given subQ? Link to comment Share on other sites More sharing options...
SCHMITTIE120 Posted July 16, 2011 Share Posted July 16, 2011 Also... how does ACEI contribute to HyperKalemia...???? this is ironic, I just had an exam question on this today. If no one answers soon I will. Link to comment Share on other sites More sharing options...
GeneValgene Posted July 16, 2011 Share Posted July 16, 2011 hmm...better safe than sorry...i'd probably try to get another lab draw and ekg. but as a student i guess sometimes nothing you can do :( What abnormal finding would you expect to see on an EKG? PR lengthening -> peaked T waves -> widening of the QRS -> flattening of P waves/sinusoidal -> bad news What drug can be administered in a peripheral IV to correct the potassium? sodium bicarb? What nebulized medication can be used as an antidote? a beta2 agonist like albuterol Also... how does ACEI contribute to HyperKalemia...???? blocks angiotensin ii which would in turn decrease aldosterone...aldosterone normally causes reabsorption of sodium/water and release of K Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted July 16, 2011 Administrator Share Posted July 16, 2011 What would you have done? Nothing. You "loaded the boat", gave the MD all the info that you have and articulated your professional concerns, and he's made the decision. If there is a bad outcome, you, as a PA student are not ethically, legally, or financially responsible for the decisions of an MD. Document what you did, then go get a good night's sleep and find out the outcome tomorrow. Link to comment Share on other sites More sharing options...
bradtPA Posted July 16, 2011 Share Posted July 16, 2011 sodium bicarb? The other answers were correct, good job. The rapid antidote for hyperkalemia is calcium. Calcium chloride will burn a peripheral vein up, and should be given through a central line. Calcium gulconate, however, can be given peripherally. Link to comment Share on other sites More sharing options...
MikeyBoy Posted July 16, 2011 Share Posted July 16, 2011 The other answers were correct, good job. The rapid antidote for hyperkalemia is calcium. Calcium chloride will burn a peripheral vein up, and should be given through a central line. Calcium gulconate, however, can be given peripherally. Good point- CaCl is what is usually supplied in the rapid response carts- Calcium Gluconate has to be ordered from the pharmacy usually. Link to comment Share on other sites More sharing options...
Acebecker Posted July 16, 2011 Author Share Posted July 16, 2011 Great teaching points - I'm taking the PANCE in 8 weeks, so I greatly appreciate it. Regarding what I actually could do about this... Not much at the time. The lab had been drawn earlier that day. I could and should have contacted the patient at that time... Will keep that in mind for future reference. Pt had not had ANY complaints earlier in the day when the lab was drawn, so that was reassuring. I managed to catch the clinic director and asked his opinion and he pointed out that on Digoxin the threshold for concerning elevation of K+ is a little higher. So we sat on it for 12 hours and I called him first thing the next morning - left a message with his family (he wasn't up yet) to come in ASAP to have it redrawn. It became afternoon and we hadn't seen him so our staff called again and he'd left town! I got on the phone with him instantly and gave him the choice of going to his provider in another state or coming back to the clinic immediately for redraw - he turned the car around and came back. Phew! Re-draw showed K+ of 5.8 so we started him on Kayexalate. We'll see him again Monday and adjust his meds at that time - he's been on Enalapril for over a year without any problems with K+. Don't recall how long he's been on Dig. Anyway, disaster averted/never occurred, so I feel a lot better today. Keep the teaching points coming! I gotta get ready for that exam. Link to comment Share on other sites More sharing options...
VictoriaO Posted July 16, 2011 Share Posted July 16, 2011 For what it's worth, here's a really interesting podcast about Kayexelate...is worth giving at all? http://www.blubrry.com/emcritlectures/988577/bonus-is-kayexalate-useless/ I might want to do some urine studies on Monday along with other lytes like Ca++, Mg++, maybe grab an EKG, potentially go with oral Ca++ supplementation over kayexelate, encourage a low-potassium diet over the weekend. Unfortunately you can't do much with diuretics in this guy, I'd be sure to chat with his nephrologist on Monday on the best way to handle this. Probably dialing back his ACE would be best, though leave him on a low-dose for cardioprotection (don't know what his heart hx is, but I'm assuming not great since he's on dig). Great case, thanks for sharing! Link to comment Share on other sites More sharing options...
bradtPA Posted July 16, 2011 Share Posted July 16, 2011 I use a lot of calcium carbonate instead of kayexalate myself.... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted July 16, 2011 Moderator Share Posted July 16, 2011 MORE ON HYPERK: calcium first(gluconate with a pulse, chloride without) d50/insulin sodium bicarb albuterol(each tx decreases k by 0.1) lasix kayexalate(last) I had a pt with a K of 6.7 last week after missing dialysis x 2. he had some early ekg changes. hospitalist wanted to send him home for dialysis in am(?WTF). I called pts nephrologist who admitted pt for emergent dialysis + all of the above meds.... Link to comment Share on other sites More sharing options...
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