J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website http://www.journalmc.org

Case Report

Volume 11, Number 6, June 2020, pages 152-156

Etiology and Treatment of Intraoperative Hyperkalemia During Posterior Spinal Fusion in an Adolescent

**Table 1.** Intraoperative Laboratory Results and Clinical Care
Point-of-care testing results (normal values)	8:57 am	10:24 am	11:23 am	11:46 am	12:16 pm	1:09 pm
Laboratory results from arterial blood. After the results at 10:24 am, minute ventilation was increased by 20%. After the results at 11:23 am, the following steps were taken: esmolol infusion discontinued, Normosol^® changed to 0.9% normal saline, sodium bicarbonate administered (50 mEq), furosemide (10 mg) administered, and the inhalational agent (desflurane) was discontinued and propofol started. It was verified that none of the infusions had inadvertently been mixed in high potassium containing fluids.
pH	7.37	7.39	7.39	7.46	7.47	7.43
PaCO₂ (mm Hg)	42	40	38	36	34	36
Base deficit/excess	-1	-1	-2	+2	0	0
Hemoglobin (13.5 - 17.5 g/dL)	12.6	12.9	12.6	12.2	12.9	12.9
Ionized calcium (1.22 - 1.35 mEq/L)	1.14	1.18	1.18	1.10	1.17	1.19
Sodium (135 - 145 mEq/L)	140	136	134	138	138	139
Potassium (3.7 - 5.3 mEq/L)	3.9	5.3	5.9	5.7	5.3	4.7

Table 1. Intraoperative Laboratory Results and Clinical Care

Point-of-care testing results (normal values)

8:57 am

10:24 am

11:23 am

11:46 am

12:16 pm

1:09 pm

Laboratory results from arterial blood. After the results at 10:24 am, minute ventilation was increased by 20%. After the results at 11:23 am, the following steps were taken: esmolol infusion discontinued, Normosol^® changed to 0.9% normal saline, sodium bicarbonate administered (50 mEq), furosemide (10 mg) administered, and the inhalational agent (desflurane) was discontinued and propofol started. It was verified that none of the infusions had inadvertently been mixed in high potassium containing fluids.

7.37

7.39

7.46

7.47

7.43

PaCO₂ (mm Hg)

Base deficit/excess

-1

-2

Hemoglobin (13.5 - 17.5 g/dL)

12.6

12.9

12.6

12.2

12.9

Ionized calcium (1.22 - 1.35 mEq/L)

1.14

1.18

1.10

1.17

1.19

Sodium (135 - 145 mEq/L)

140

136

134

138

139

Potassium (3.7 - 5.3 mEq/L)

3.9

5.3

5.9

5.7

5.3

4.7

**Table 2.** Potential Etiologies of Hyperkalemia
ACE: angiotensin-converting enzyme.
Spurious
Hemolysis
Exogenous administration
Medications (antibiotics: penicillin)
Parenteral nutrition
Intravenous fluids (lactated ringers, Normosol^®, Plasmalyte^®)
Blood and blood products
Cardioplegia solution
Medication error (diluents)
Intracellular-extracellular shift
Acidosis
Beta adrenergic blockade
Increased production
Malignant hyperthermia
Rhabdomyolysis
Tumor lysis
Hemolysis (cell saver, cardiopulmonary bypass)
Succinylcholine
Decreased excretion
Decreased cardiac output
Medications (aldosterone antagonist, ACE inhibitor)
Renal insufficiency
Adrenal failure or insufficiency
Hydrocortisone
Aldosterone

Table 2. Potential Etiologies of Hyperkalemia

ACE: angiotensin-converting enzyme.

Spurious

Hemolysis

Exogenous administration

Medications (antibiotics: penicillin)

Parenteral nutrition

Intravenous fluids (lactated ringers, Normosol^®, Plasmalyte^®)

Blood and blood products

Cardioplegia solution

Medication error (diluents)

Intracellular-extracellular shift

Acidosis

Beta adrenergic blockade

Increased production

Malignant hyperthermia

Rhabdomyolysis

Tumor lysis

Hemolysis (cell saver, cardiopulmonary bypass)

Succinylcholine

Decreased excretion

Decreased cardiac output

Medications (aldosterone antagonist, ACE inhibitor)

Renal insufficiency

Adrenal failure or insufficiency

Hydrocortisone

Aldosterone

**Table 3.** Treatment of Hyperkalemia
ECG: electrocardiogram.
Resuscitation as needed according to guidelines
Consider extracorporeal support for refractory hemodynamic instability
Administration of calcium gluconate or chloride if ECG changes are noted
Enhanced extracellular-to-intracellular shift
Increase pH (hyperventilation or administration of sodium bicarbonate)
Glucose and insulin
Beta adrenergic agonists
Inhaled albuterol
Intravenous epinephrine or terbutaline
Enhanced elimination
Hydrocortisone in setting of adrenal insufficiency
Loop diuretics
Kayexalate
Hemodialysis or renal replacement therapies

Table 3. Treatment of Hyperkalemia

ECG: electrocardiogram.

Resuscitation as needed according to guidelines

Consider extracorporeal support for refractory hemodynamic instability

Administration of calcium gluconate or chloride if ECG changes are noted

Enhanced extracellular-to-intracellular shift

Increase pH (hyperventilation or administration of sodium bicarbonate)

Glucose and insulin

Beta adrenergic agonists

Inhaled albuterol

Intravenous epinephrine or terbutaline

Enhanced elimination

Hydrocortisone in setting of adrenal insufficiency

Loop diuretics

Kayexalate

Hemodialysis or renal replacement therapies