[HSF] Hyperkalemia

[A]

Shahid Malik:

What do you think the cause of Hyperkalemia in spite of the adequate
dialysis?  Your input please 

Ahmed
-----Original Message-----
From: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] On Behalf Of Shahid Mahmud
Malik
Sent: Sunday, April 01, 2007 3:57 AM
To: OpenHeart-L at lists.hsforum.com
Subject: [HSF] Hyperkalemia



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
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