Rapid potassium repletion in a pericoding patient with severely low K of 1.5 due to mismanaged DKA at outside hospital. How fast would you replete it? What is the fastest you have ever repleted K?

[u/Little_Blackberry588]

I repleted 40 meq via central line in less than an hour, bringing it up to 1.9. The pharmacist is reporting me for dangerously fast repletion. What I can tell you is the patient was able to breath much better shortly after the potassium was given. Pretty sure the potassium was so low he was losing function of his diaphragm. Any thoughts from docs or crit care who have experience with a similar case?

[u/dMwChaos]

https://emcrit.org/ibcc/hypokalemia/

Have a read through this, rather than me copy pasting stuff here. There is a section on high-dose IV potassium administration.

My personal opinion -

This an area where you are acting outside of evidence. It is thus easy for others to criticise you from afar, especially as they were not with you and the patient at that moment.

We often have to make time-sensitive decisions in the critically ill, and base these upon a combination of knowledge, available evidence, and experience. This is a core part of Emergency Medicine.

As long as you are able to explain and defend your decisions, and in this case why you might have veered off of normal practice, I don't see a problem. To me the justification of peri-arrest with potential significant contribution from hypokalaemia (we do not want our severe DKA patient's struggling to ventilate) is sufficient.

Of course, sometimes our professional bodies and/or legal systems might not fully agree with us. I think this will vary depending on where you practice, but yes I can imagine things getting messy from time to time, unfortunately.

[u/Little_Blackberry588 → u/dMwChaos]

Thank you. It was given over approximately 30 mins and the patient improved significantly after. No arrhythmias. The EKG improved. Breathing improved significantly. This is definitely a grey area in the literature for obvious reasons.

I think his diaphragm was becoming paralyzed from hypokalemia and DKA. The outside hospital had given him a bolus of insulin and started the patient on a drip without checking the K and repleting. He was flown to me with a K of 1.7 and looked worse than I expected when he arrived. I was worried DKA w coma impending or resp failure from low K. I put a central line in right away knowing what the K was and was ready for rapid repletion.

[u/bearstanley → u/Little_Blackberry588]

so you were reported for fixing the patient? easiest complaint review of all time.

[u/dMwChaos → u/Little_Blackberry588]

It sounds reasonable to me. Sick DKA patients are usually maximally ventilating to compensate for their acidaemia. Hypoventilation can certainly be lethal, and this is what you're trying to address. This is of course also why we don't want to RSI these patients unless they will die without a tube anyway...

[u/biobag201 → u/dMwChaos]

Thank you! I had this conversation with an icu doc after he criticized me intubating a dka and hhs (bsg was 1000) with a ph of 7.16 and a rr of a peaceful 8. I literally said “dude this guy is pre arrest, his rr rate should be in the 20’s minimum”

[u/No-Association-7005 → u/biobag201]

'Peaceful 8'....lol, that's a great way of putting it

[u/dMwChaos → u/biobag201]

Damned if you do, damned if you don't.

Sometimes we just have to make difficult decisions.

[u/Eh_for_Effort → u/dMwChaos]

Some specialities aren’t comfortable rolling the dice when you have to

[u/MrPBH → u/Eh_for_Effort]

God I feel this in my bones.

Sometimes I feel that EM drives the tempo of most medical decision making in this country.

Maybe Canada is right to make it a five year post-graduate program. We are the deciders in modern medicine, as former president Bush would say.

[u/[deleted] → u/Eh_for_Effort]

I don't even see that as rolling the dice. How much minute ventilation are you actually losing for the tube with a resp rate of 8?

Now tubing the patient breathing at 30 because "they're going to tire out..." Uncool.

[u/skywayz → u/biobag201]

Idk if I would intubate that guy, unless you really thought his RR of 8 was due to impending respiratory failure due to his underlying acidosis. For example if the dude had a RR of 40 for like the last 2 hours, and now is suddenly 8, yea I am tubing him as well 100%. But BSG of 1000 screams HHS like you said, and honestly would think the dude is just really altered and wasn't breathing very fast, a pH of 7.16 is low, but not crazy low.

[u/Mediocre_Daikon6935 → u/biobag201]

Man because since they were intubated he had to be an icu admission.

Basically pissed he had to do this job.

[u/Little_Blackberry588 → u/dMwChaos]

Exactly.

[u/Acudx → u/dMwChaos]

Is using NIV with these patients actually an option? With the goal to assist them with positive pressure in order to take stress from their respiratory muscles.

[u/metamorphage → u/Acudx]

HFNC is first line. DKA patients tend to start vomiting and you don't want a bipap mask on when that happens.

[u/MuscIeChestbrook → u/Little_Blackberry588]

How is potassium management not etched into DKA management in all ER settings?! That's wild.

[u/travelinTxn → u/MuscIeChestbrook]

I had an argument with a Family Medicine doc about a DKA pt on insulin drip who thought we could best manage it by giving D5 1/2NS and then KCl 20 meq bags every time the lab resulted with a K<3.7 (I think that was the number seemed arbitrary to me at the time).

Insisted this was what we were going to do after I repeatedly explained this is bad management even if this pt wasn’t my 5th pt that was in a hallway bed while I was also getting pulled in to help in med resus.

Eventually I got it out of him that he wasn’t sure how to order D5 1/2 c/ K…. Gods I wish we had a standardized DKA insulin drip order set.

[u/Mediocre_Daikon6935 → u/MuscIeChestbrook]

….

As a paramedic I was completely unaware potassium could be critically low, as were all the ER nurses. Had never been taught to me, or apparently anyone else in the ER except the physician.

Thankfully the Dr was on point. Other then my IO, couldn’t get a line, doc had to toss a central line to even get labs.

[u/tokekcowboy → u/MuscIeChestbrook]

I’m a medical student. It’s wild to me that nobody checked or repleted K.

[u/MuscIeChestbrook → u/[deleted]]

Haha, why not troll on your original account /u/hangedman_reversed?

[u/MrPBH → u/Little_Blackberry588]

It sounds like you did the correct thing. Brave in fact, as your action was correct but goes against the dogma that everyone accepts as gospel fact.

This is one of the few scenarios where rapid infusion of potassium is indicated and absolutely life-saving.

Everyone learns the "rule" (ie no more than 10 per hour by PIV and 20 per hour by CVL) but they don't bother remembering the exceptions to the rule. Honestly hard to fault them, as they did not go to medical school so why should they be required to know that?

At the same time, if you wanna make clinical decisions, pick up the text and get some library reading in! In the words of a famous man (paraphrasing): "everybody want to treat patients but don't want to read those heavy books."

[u/Anonymous_Chipmunk → u/Little_Blackberry588]

Given the impending respiratory paralysis and hypoventilation and insuring acidemia, would it not be prudent to intubate the patient, optimize the ventilator settings for hypocapnia and then follow up with ABGs to guide ventilator management?

[u/PABJJ → u/Anonymous_Chipmunk]

Last resort - they are maximally ventilating and paralyzing them could kill them. Hard to say without being there I suppose. 

[u/[deleted] → u/PABJJ]

Why would paralysis kill this patient?

[u/PABJJ → u/[deleted]]

Respiratory compensation for severe metabolic acidosis, they are blowing off CO2 as fast as they can. If you paralyze them, and screw around with a tube, you get rid of the compensation. Sometimes you have to if their respiratory effort is shutting down, because it beats the alternative, but you want to avoid this if possible. 

[u/[deleted] → u/PABJJ]

I agree with the claim that it should be a last resort but disagree specifically that paralysis could kill them. Are you assuming that the intubation step would be so protracted that it would send them into arrest?

There is a lot I am assuming here so wanted to clarify your position

[u/PABJJ → u/[deleted]]

If you're breathing 60 breaths per minute, and you're still decompensated, and CO2 is the quickest way to compensate, what do you think happens to your average breathing rate if you suspend it for any amount of time. I'm not assuming. This is a well documented phenomena. It isn't protracted either. This would be standard RSI. 

I'm a PA, so I'm not typically handling folks that are about to arrest, so doc's feel free to chime in, but that's my understanding. 

[u/[deleted] → u/PABJJ]

If you’re breathing 60/min there is a minimal amount of gas exchange actually happening distally in the alveoli. And, I believe the patient is effectively creating a pseudo-shunt here.

In the scenario you’ve presented, the patient is actively decompensating because they are breathing so quickly. Their bodies are attempting to compensate by increasing their minute ventilation through increased RR but their volumes simply cannot keep up. Left to their own mechanical devices - they die. Full stop.

The scenario you’ve outlined is hypoxic respiratory failure and absolutely would demand emergent intubation. In the hands of a skilled operator, the procedure would take less than 30s from drug push to circuit connection.

[u/PABJJ → u/[deleted]]

Just out of curiosity, what's your background? 

[u/No_Wind_8234 → u/PABJJ]

Looks like they are a CAA based on their comment history (which is quite scary given the context of the conversation).

[u/Anonymous_Chipmunk → u/PABJJ]

Agreed as a last resort, but it sounds as if this patient wasn't maximally ventilating, hence the peri-arrest from worsening acidosis.

[u/AcanthocephalaReal38 → u/Anonymous_Chipmunk]

You can't ventilate a patient to get CO2 much lower than 20. Healthy people can ventilate better than that.... For awhile.