[HSF] Hyperkalemia

[Shahid Mahmud Malik]

Manoj,
The insulin dependent diabetics in my experience always require a lot of extra management issues.Exactly why the sequence of events happened in your case, I cannot comment with any certaininty.However following are my general obsevations,
1) They over years of regular Insulin use,have a very high total body potassium.
2) Most IDDM patients usuallly have an abnormal serum creatinine and low GFRs.The GFRs may not be calculated in every patient and giving them drugs like Vancomycin may further knock off their excretory reserve.
3) Many IDDM patients have compromized LV functions (low EFs) and may not have adequate cardiac output in the immediate post op period which may further complicate renal output.
4) Use of pressor agents in higher doses, further add to the renal insult.
5) Generally some patients would go through a period of severe oliguria or anuria before recovering to some extent.Some would require dialysis.(Your patient was on dialysis)
6) To over come the generally low output in these patients we are now liberally using hemofilteration during surgery on these paients.
7) I have also started to use IABP on any IDDM with abnormal serum creatinine and low EFs(even 35%-that I would not consider in a non-diabetic pt) for a post op period of 24-36hrs.
8) Using IABP reduces the need for pressor agents that is helpful and in our very limited experience provided adequate urine output.
9) I maintain the blood sugar in the initial periods to around 200 and avoid large K supplements if possible.
!0) Sometimes,even Heparin in the post operative period used in the flushes causes inappropriate rise in serum K.Not too long ago Dr Prassana provided a no.of referances for it.
  Like I said these are obsevations and not necessarily an explantion to your patients demise.
Shahid Malik