Pharmacotherapeutics Seminar – Spring 2014

Case 1B

CC:
Weakness, malaise

HPI:
DS is a 55-year-old African American male with a history of heart failure who has been
treated with furosemide and digoxin for several years. He has also been taking an oral
potassium supplement for the past two years. His physician recently started him on
lisinopril and increased his furosemide. After learning that he should restrict the amount
of sodium in his diet, DS decided to start using a salt substitute. DS presents with
complaints of weakness, malaise, and skin tingling that started three days ago. He also
notes a decrease in his urine output over the past few days.

PMH:
Heart failure
Diabetes
Hypertension

Allergies:
Penicillins – reaction unknown
Latex – reaction unknown

Meds:
Furosemide 80 mg po daily (recently increased from 40 mg po daily)
Digoxin 250 mcg po daily
Potassium chloride SR 40 mEq daily
Lisinopril 10 mg po daily
Metformin 1000 mg po bid.

ROS:
+ weakness, malaise, skin tingling

Physical Examination:
General: A&O x 2, follows commands, dry mucous membranes
Vital Signs: Temperature 98.8, HR 108, BP 78/43, RR 14, O2 sat 100% on room air; Ht:
70 in, Wt: 105 kg
HEENT: eyes sunken
Lungs: clear bilaterally
Heart: sinus tachycardia, no rubs or gallop
Abdomen: soft, non-tender, non-distended, normal bowel sounds
Skin: poor skin turgor, no edema
Extremities: slow capillary refill
Labs:
Na 138 mEq/L Hgb 10.2 g/dL Phos 2.6 mg/dL
K 6.3 mEq/L Hct 30.8%
Cl 102 mEq/L Plt 423 x 103/mm3
CO2 25 mEq/L WBC 4.5 x 103/mm3
BUN 74 mg/dL Alb 4.3 gm/dL
SCr 2.3 mg/dL Ca 8.9 mg/dL
Glu 102 mg/dL Mg 2 mg/dL

Tests:
EKG: Sinus tachycardia, peaked T waves and shortened QT interval

Assessment
Electrolyte imbalance / dehydration

Identify this patient’s problem list and the correct electrolyte imbalance. Provide a
SOAP note for the primary problem ONLY.
Pharmacotherapeutics Seminar – Spring 2014
Case 1B Facilitator’s Guide

Problem List:
1. Hyperkalemia / dehydration
2. Acute renal failure
3. Heart failure
4. Diabetes
5. Hypertension

1. Hyperkalemia
Subjective:
 Weakness, malaise, and skin tingling that started three days ago
 Decrease in his urine output over the past few days
 Started using a salt substitute

Objective:
 HR 108, BP 78/43
 EKG: Sinus tachycardia, peaked T waves and shortened QT interval
 A&O x 2
 Dry mucous membranes, eyes sunken, poor skin turgor, slow capillary refill
 Relevant home meds: Furosemide 80mg po daily (recently increased from 40mg
po daily), digoxin 250mcg po daily, potassium chloride SR 40mEq daily, lisinopril
10mg po daily, metformin 1000mg bid
 PMH: Congestive heart failure, diabetes, hypertension.
 K 6.3, BUN 74, SCr 2.3

Assessment:
55 year old male presenting with weakness and malaise secondary to hyperkalemia
and acute renal failure. Hyperkalemia may be due to adverse effects of medications,
which were recently increased. It may also be related to initiation of salt substitutes.

Plan:
Goals of Therapy:
 Prevent effects of hyperkalemia, particularly arrhythmias
 Relieve symptoms
 Normalize total body potassium content
 Avoid side effects related to treatment

Recommendations:
 Hold furosemide, digoxin, potassium, lisinopril.
 Give calcium gluconate 1 gm/10 mL IV push over 5 min x 1
o This will stabilize myocardial cells and prevent immediate worsening of
arrythmias
o Onset: 2 min, duration: 30-60 min
o Unlikely to cause significant ADRs unless total calcium level exceeds 13
mg/dL
 Shift potassium intracellularly through use of one of the following therapies:
o Sodium bicarbonate 50 meq/50ml over 5 min, MR x 1
 Onset < 30 min, duration 1-2 hrs
o Insulin 10 Units IV + dextrose 50% 25 gm
 Onset: 30 min, duration: 4-6 hrs
o Albuterol should not be recommended as this is rarely used in adults
because of ADRs (agitation, tachycardia) and short duration
 Remove potassium from body
o Initiate sodium polystyrene sulfonate (SPS) 30-45 gm PO q3-4 hrs
 Onset: 1-12 hours, duration: < 6 hours, ADRs: constipation
 BM needed for efficacy
 PR administration is an option but not necessary in this patient
o Other options to remove potassium include loop diuretic or dialysis
 Loop diuretic should not be used alone because of variable effect.
This patient is hypovolemic already, so loop diuretic is
inappropriate.
 Dialysis, even with no net fluid removal, is not indicated in this
patient because medical management will likely be effective for
this degree of hyperkalemia. If clinical status deteriorates, dialysis
would be an option.
 Initiate fluids
o Crystalloids should be chosen over colloids since the two classes of fluids
result in equivalent mortality outcomes in non-trauma patients and
crystalloids have fewer ADRs (such as immunosupression, transfusion
related acute lung injury) and are more cost effective. Because many
colloids are blood products, their supply is more limited.
o Normal saline should be chosen because it does not contain potassium
like lactated ringers and is an isotonic fluid.
o Do not choose hypotonic fluids such as D5W or 0.45% sodium chloride
because they will not stay intravascular as well.
o Since the patient does not exhibit symptoms of organ hypoperfusion, an
initial infusion rate of 200-300 mL/hr would be reasonable. Boluses of 500
mL q30-60 min could be considered if the patient becomes more
tachycardic, urine output drops (<0.5 mL/kg/hr), or other signs of organ
hypoperfusion develop.
o No matter which initial fluid strategy is chosen, fluids should be quickly
reduced once the patient becomes more euvolemic (lower HR, moist
mucous membranes, faster capillary refill) and BUN/SCr improve.
o Avoid excessive fluid administration due to history of CHF.
o Once hydrated and able to eat, a diet should be initiated and fluids should
be discontinued. This will prevent iatrogenic volume overload.

Monitoring Parameters:
 K, Na, bicarbonate, acid-base status, BUN, SCr
 Insulin and dextrose – hypo-/hyperglycemia
 Fluids - HR, UOP, Chem-7, I/Os, lactate, H/H, wt, BP, JVD, lung sounds,
peripheral edema

References:
 Mahoney BA, Smith WAD, Lo DS, et al. Emergency interventions for
hyperkalemia. Cochrane Database Syst Rev 2005;18:CD003235.