Nate Jones, MD Children’s National Medical Center

CC: Elevated potassium

HPI: Patient is a 4 mo ex-34-week female with a complex medical history including ARPKD requiring daily peritoneal dialysis, congenital hypothyroidism, and GT dependence who is referred hyperkalemia. Per mother, the family recently moved from another state and is in the process of transferring care. Patient was recently discharged from OSH 2 week ago after bilateral nephrectomy and G-tube placement.  She reports patient has been in her usual state of health over the past two weeks. Denies any recent illnesses, fever, or vomiting. However, she does report the child has had chronic medication-induced diarrhea. Patient continues to receive peritoneal dialysis daily, she has not received dialysis yet today. She continues to feed with Similac PM 60/40 both PO and G-tube, no changes in volume. She reports initially being concerned with poorer weight gain however patient’s weight has increased 900g since being discharged. Of note she does not remember the exact potassium level drawn at clinic just that it “was high” which she states isn’t unusual for her daughter.

ROS:

CONSTITUTIONAL: +Wt gain, denies  fever or recent illnesses
SKIN: Denies rash or hives
EYES: Denies redness, discharge, or swelling
RESPIRATORY: Denies cough, wheeze, stridor
CV: Denies edema
GI: +Diarrhea, denies vomiting, or decreased PO intake
NEURO:  Denies AMS or decreased tone  

Birth Hx: Born 34 weeks

PMHx:  

ARPKD s/p bilateral nephrectomy on daily peritoneal dialysis

Catheter related thrombus

Congenital Hypothyroidism

PSHX:

Bilateral nephrectomy

G-tube placement

SHx: Patient lives at home with caretaker

FHx: Non-contributory

Meds:
Enoxaparin
Lactulose  
Sodium Phosphate  
Sodium Chloride
Senna
Amlodipne
Levothyroxine
Poly-Vi-Sol
Cholecalciferol Calcitriol Ferrous Sulfate
Famotidine
Epogen

PE

T 37.6  HR155 BP112/64 RR 42 SpO2 98% on RA

GEN: Appears comfortable feeding in mother’s arms

HEENT: Normocephalic. PERRL. EOMI. Conjunctiva clear. Nares patent. Moist oral mucosa. No pharyngeal erythema.
Neck: Supple, no lymphadenopathy
Resp: Clear to auscultation bilaterally, no wheezes
CV: Regular rate. Regular rhythm. Normal S1, S2. No murmur appreciated.
GI: Abd soft NT/ND, PD catheter and G-tube in place c/d/i,
Integumentary: Warm, intact, no rash. mildly mottled
MSK: Full range of motion, Normal strength, No edema
Neuro: Alert

An EKG is obtained which shows NSR, normal intervals and QRS, normal t-waves.

The BMP results: Na 140, K 6.4 (without hemolysis), Cl 104, CO2 25, Glucose 94,  BUN 54,  Cr 2.8, Phos 8.4. iSTAT/EPOC was obtained and correlated with BMP. 

Calcium gluconate is given. Nephrology fellow is paged. Attempts to contact the patient’s private nephrologist is unsuccessful.

Patient is immediately started on a round of albuterol. Bicarb along with insulin/glucose are ordered. Nephrology calls and is adamant that the patient does not receive either bicarb or insulin/glucose, as the level of hyperkalemia is mild and patient is due for dialysis which Nephrology will arrange as an inpatient.

An hour has gone by and the albuterol is completed. A repeat EKG and repeat POC K+ are ordered.

IV team arrives roughly 45 minutes later. Prior to their arrival the EKG demonstrates peaked T-waves. Nephrology is updated with EKG findings and continues to recommend against bicarb and insulin/glucose citing they are temporizing measures and is actively arranging for inpatient PD.

IV access is obtained, repeat POC K+ is >9 however there are no beds in the PICU with multiple PICU boarders in the ED.

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