DP15: A POTASSIUM SURGE: A CASE OF RAPID ONSET PERI-INDUCTION HYPERKALEMIA LEADING TO VENTRICULAR TACHYCARDIA IN END STAGE RENAL DISEASE
Kylie Schmitt, DO; Mariella Inoyatov, MD
HCA Florida Wesside
Background: Perioperative hyperkalemia presents a significant anesthetic challenge, particularly in patients with end-stage renal disease (ESRD). There are no established guidelines defining a maximum safe serum potassium level prior to induction of anesthesia, and electrocardiographic (ECG) changes do not reliably correlate with potassium concentration [1]. The absence of ECG abnormalities does not exclude the risk of sudden arrhythmia or cardiac arrest. In patients with potassium ≥5.5 mEq/L, clinicians often exercise caution, avoid succinylcholine, and consider nephrology consultation to determine the need for preoperative dialysis. In urgent cases where dialysis cannot be performed, close monitoring and readiness for rapid medical management are essential.
Case: A 71-year-old man with ESRD on hemodialysis, congestive heart failure, HIV, and hypertension presented for arteriovenous fistula revision. His last dialysis session was 48 hours prior, and his preoperative potassium was 5.5 mEq/L. After a supraclavicular block under minimal sedation, he was transported to the operating room. Following induction with fentanyl, lidocaine, and midazolam, he developed ventricular tachycardia with a palpable pulse. Intravenous calcium chloride was administered which resulted in nearly immediate conversion to normal sinus rhythm. Arterial blood gas analysis revealed severe hyperkalemia, potassium 8.8 mEq/L, and metabolic acidosis, pH 7.20. We administered insulin with dextrose and sodium bicarbonate to promote intracellular potassium shift. The procedure was aborted, and the patient was transferred to the intensive care unit for further management.
Discussion: This case highlights the dynamic and potentially catastrophic nature of perioperative hyperkalemia in ESRD patients. Despite mildly elevated preoperative potassium levels, rapid electrolyte shifts occurred shortly after induction. Contributing factors likely included impaired renal potassium excretion, peri-induction hypoventilation with hypercarbia, and metabolic acidosis promoting extracellular potassium shifts. ECG findings were not predictive of the severity of hyperkalemia, underscoring the importance of vigilance even in the absence of preoperative abnormalities. Management priorities include myocardial membrane stabilization with intravenous calcium, temporizing measures such as insulin with glucose and bicarbonate for acidosis, and continuous ECG and point-of-care potassium monitoring. In elective cases, interdisciplinary discussion regarding preoperative dialysis is critical, as even brief dialysis can significantly reduce serum potassium levels.
Conclusion: Borderline hyperkalemia in ESRD patients should not be considered low risk in the perioperative setting. Even modest potassium elevations may rapidly worsen during induction of anesthesia. Anesthesiologists must anticipate potential electrolyte shifts, maintain vigilant monitoring, and be prepared to initiate immediate treatment to prevent life-threatening arrhythmias.