Extreme Hyperkalemia

H A. Tran, MD


South Med J. 2005;98(7):729-732. 

In This Article

Case Report

A 55-year-old male presented with a sudden onset of chest pain and collapse while in the ward. The patient had been admitted 2 days prior with acute cholecystitis. He had been previously well with no known history of cardiac disease and was a smoker of 20 to 30 cigarettes daily. There was no prior medical, surgical, family, or allergy history. He was receiving 5,000 U subcutaneous heparin twice daily as part of thromboprophylaxis and intravenous ampicillin, gentamicin, and metronidazole.

The patient was found to be in ventricular tachycardia, with no recordable blood pressure and no cardiac output. Resuscitation was promptly instituted. The condition was intractable, with periods of ventricular tachycardia and fibrillation. Cardiopulmonary resuscitation was performed continuously for 30 minutes, including six episodes of defibrillation of increasing voltage to a maximum of 360 J, before the resumption of sinus (tachycardia) rhythm. During this time, the patient was given intravenous normal saline of 0.9% sodium chloride. No potassium or noradrenalin was given at any stage. Medications administered during the resuscitation included intravenous lignocaine and amiodarone.

His intraarrest blood samples were collected through a femoral venipuncture with a 20F gauge needle. Fortunately, his prearrest tests were available to be analyzed retrospectively.[1] Results are listed in Table 1 .[2]

The patient remained in sinus tachycardia but was stable, with blood pressure of 110/80 mm Hg. He did not require any inotropic or ventilatory support but was monitored closely. His urinary output was satisfactory. An amiodarone infusion was given for the ensuing 24 hours, followed by an oral maintenance dose. His 12-lead electrocardiogram (ECG) showed sinus tachycardia with clear evidence of an inferior myocardial infarction. Surprisingly, there were no features of hyperkalemia. The extreme hyperkalemia was treated with a calcium gluconate, insulin, and glucose infusion for the following 24 hours until his potassium level normalized (see Table 1 ).[2] His serum troponin-1 was 15.1 ng/mL, supporting the ECG evidence of a myocardial infarction. He was treated expectantly and made a satisfactory recovery. At the 1-month review, the patient remained well, with a serum potassium (K+) level of 4.2 mmol/L, normal serum bicarbonate, and otherwise normal renal function. His fasting glucose level was 5.2 mmol/L.