Hot Seat #148: Denouement

Posted on: March 26, 2020, by :

The case: a 4 mo with history of bilateral nephrectomies on daily dialysis presenting with hyperkalemia that is worsening over ED course with evidence of repolarization abnormalities on EKG.

Here’s how you answered the questions:

Discussion: In a child with chronic hyperkalemia and a normal EKG with plans for upcoming dialysis, how aggressively (if at all) do you treat the elevated potassium? Some  argued for no treatment, while others voted to initiate the least invasive/lowest risk intervention (i.e. albuterol). Given this patient’s history of bilateral nephrectomies, insulin runs the risk of fluid overload as as well as delayed metabolism. Bicarb in the absence of an acidosis would also be less than effective at moving potassium into the cells.

The other dilemma in this case, is how do you deal with consultant recommendations that you do not agree with? Dr. Donnelly raised the point of being very concrete with consultants, as they often do not know how the flow in the ED works. Others argued that while the patient is under our care, it is ultimately our call on the best course of action, even when it means going against what the ‘experts’ say. 

Denouement: You have Nephrology on the phone when POC K+ results, you push further and he explains that bicarb would have little effect absent acidosis. Insulin would be dangerous given lack of renal metabolism and potential inability to dialyze out therefore he refuses to give you an adjusted insulin dose.

Bicarb is given immediately; continuous albuterol is started. PICU fellow updated and patient promptly transferred on continuous albuterol, and given insulin/glucose and later dialyzed without complications.

The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.

Mary Beth Howard
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