AHRQ WebM&M: Morbidity and Mortality Rounds on the Web
Too Much, Too FastA patient with ALS was hospitalized with presumed pneumonia and sepsis. He was treated with broad-spectrum antibiotics and fluid resuscitation, and additional potassium was administered due to a persistently low potassium level. The patient went into cardiac arrest and resuscitation attempts were unsuccessful. In the accompanying commentary, Delphine Tuot, MDCM, MAS, of UCSF, provides an overview of potassium management and monitoring as well as factors that increase risk of hypokalemia and hyperkalemia.
Too Much, Too FastCommentary by Delphine Tuot, MDCM, MAS
A 68-year-old man with amyotrophic lateral sclerosis (ALS) was admitted to the intensive care unit (ICU) for fever, tachycardia, and increased respiratory secretions. His ALS was complicated by ventilator-dependence requiring a tracheostomy, along with comorbidities that included coronary artery disease and a prior bypass graft, insulin-dependent diabetes, hypertension, and hyperlipidemia. Initial physical examination and laboratory studies were suggestive of pneumonia with sepsis and poorly controlled hyperglycemia. His electrolytes were notable for sodium of 150 mEq/L, potassium of 3.7 mEq/L, and glucose of 421 mg/dL. He was treated with broad-spectrum antibiotics and fluid resuscitation while also being placed on an insulin infusion for his hyperglycemia.
Over the first few hours of hospitalization, his hemodynamics and glycemic control markedly improved. A repeat potassium level returned low at 2.7 mEq/L. Providers ordered 120 mEq of oral potassium replacement via a feeding tube and 60 mEq of intravenous potassium via a central line at 20 mEq/hour. While on the third bag of the potassium infusion, the patient went into cardiac arrest and advanced cardiovascular life support measures were delivered. Point-of-care testing showed potassium was critically elevated at greater than 9.0 mEq/L. Despite efforts to aggressively treat the hyperkalemia, resuscitation attempts were unsuccessful.