Spent a little more time in the hospital than need be..

[calypso]

So Wednesday was my fistula surgery in the upper left arm after a failed attempt at the lower left arm a few months ago.

The surgery went well, fistula worked great from the start, unlike the last one that failed before I even woke from the anesthesia.

I'm in recovery, the pain is not so bad like I thought it would be, and I'm thinkin I get to go home soon and sleep off the pain on some meds, when they tell me my potassium is too high (6.2) I don't eat fruits and all I had all week was chicken and pasta with meatballs but very little tomato sauce. But more on that later.

So they tell me I will have to go on D before I can go home but there aren't any chairs available for a couple of hours so they will get the potassium down by injecting the IV line with dextrose, insulin and bicarbonate. What that does is temporarily move the potassium out of the blood and into the cells. So they do that and I go on D and then go home...it's like 10pm before I get home but oh well.

Slept thursday, friday rolls around and when I wake up I notice it's black and blue all around the surgical site, from my bicep down to my wrist. It hurts but I expected that, but the black and blue concerned me and I thought if this thing fails...well look I'm going to the ER and getting this looked at real quick because I don't have a stethoscope and can't feel anything there (though it was swollen and it's new so it's not strong enough to feel yet anyway)

So I get to the ER and it takes like an hour to see a triage nurse who only takes vitals anyway and then 3 hours after that to see a PA (physician's assistant). They look at the fistula and decide to call the vascular surgeon's PA to come take a look at it. They put an IV on me and draw some blood.

Vascular PA comes down and changes the dressing which had dried blood in it. She says she can hear it's working and that the surgeon himself can come take a look at it since he is available.

He comes takes a look at it and says it's fine, some bruising is normal, as long as the bruit and thrill are there it's good.

Then the original PA comes along and says hey your bloodwork is back and your potassium is high. I was like yeah it was high Wed. too. They said you need to get treated for it ASAP it's 7.3

At that point I'm thinking......so this is not good. I ate NO potassium between Wed. and Friday. None. Not one tiny milligram. I'm sure of it.

Of course they don't believe me and give me that dextrose/insulin/bicarb treatment again and schedule me for D again before I realize what happened.

Because the dextrose/insulin/bicarb treatment only temporarily moves the K into the cells. The K was down when I was on D. So the D machine is cleaning clean blood and the K is hiding out in the cells.

A few hours after D the K must have come out of the cells and dumped into the blood causing my K to jump up again. Why it was even higher I don't know.

All I know is, if they try that bicarb crap again I don't want it, just D please! Thanks!

Of course they will insist because they don't want you coding before you get to D. I dunno. Just to have it bounce back up again? What would you do take the bicarb or wait till D to get the K down?

[boswife]

im a nobody as far as KNOWING, but i will say that as soon as you said they did that (insulun etc ) the first time, i thought geesh, why would they do that and then expect D to get rid of it. Again!! i dont know about it but seemed really wrong, and clear that that was not right..  I think you need to call your neph about it.  just sounds pretty off to me.  Take care.. That worries me so hope you get some answers quick!!!!!!!!!

[calypso]

im a nobody as far as KNOWING, but i will say that as soon as you said they did that (insulun etc ) the first time, i thought geesh, why would they do that and then expect D to get rid of it. Again!! i dont know about it but seemed really wrong, and clear that that was not right..  I think you need to call your neph about it.  just sounds pretty off to me.  Take care.. That worries me so hope you get some answers quick!!!!!!!!!

Well the reason they do it is to get the K down quickly because you can have a heart attack and die from it being that high. I'm young and my heart is strong so nothing bad happened to me but they worry so they are covering their ass from lawsuits in case they take too long to find you a seat at the D machine. Unfortunately it's not good for long term lowering of the K until you go back on dialysis again. I wound up getting D 2 days in a row its funny. I got it tues, then wed then thurs (but only 2 hours) then friday and saturday too before they let me out of the hospital.

If they hadn't have shoved it into the cells only to bounce back out again I would have been home sooner, but then you risk heart attack if you leave the K high while you wait for an opening at the hospital's D center because they only have like 6 machines. (they don't do outpatient treatments at that hospital only for admitted patients.)

[Restorer]

One things that comes immediately to my mind is rhabdomyolysis, which can cause very high potassium levels. I wouldn't expect muscle tissue to be especially damaged during a fistula surgery, but maybe there's another cause. The Wikipedia article mentions obstruction of blood supply, which could definitely happen during fistula surgery, or even be a result of creating the fistula.

I would expect them to check for that when your potassium was high after the surgery, and in the ER, but you never know what they might miss. If it continues to be a problem, you might want to ask about that.

Hope it's nothing that serious. 

[Riki]

I've never heard of being injected with anything to bring down K.  Here, if it's high, they give you Kayexalate to bring it down.  It's not immediate, it takes about an half hour to work, but it does work.  Basically you drink this gritty, sandy stuff, and then about a half hour to 45 minutes later, it all, um.. comes out.  Be sure to be near a toilet, cuz.. well, you know....

[calypso]

Kayexalate is nasty stuff, I wouldn't take that.

http://jasn.asnjournals.org/cgi/content/abstract/21/5/733

Sodium polystyrene sulfonate (SPS), an ion-exchange resin designed to bind potassium in the colon, was approved in 1958 as a treatment for hyperkalemia by the US Food and Drug Administration, 4 years before drug manufacturers were required to prove the effectiveness and safety of their drugs. In September 2009, citing reports of colonic necrosis, the Food and Drug Administration issued a warning advising against concomitant administration of sorbitol, an osmotic cathartic used to prevent SPS-induced fecal impaction and to speed delivery of resin to the colon, with the powdered resin; however, a premixed suspension of SPS in sorbitol, the only preparation stocked by many hospital pharmacies, is prescribed routinely for treatment of hyperkalemia. We can find no convincing evidence that SPS increases fecal potassium losses in experimental animals or humans and no evidence that adding sorbitol to the resin increases its effectiveness as a treatment for hyperkalemia. There is growing concern, however, that suspensions of SPS in sorbitol can be harmful. It would be wise to exhaust other alternatives for managing hyperkalemia before turning to these largely unproven and potentially harmful therapies.

Think about it, if the K is already in the blood or cells, how is a binder going to help? That would only be useful if I just ate something with high K and haven't digested it yet, right? I hadn't eaten anything high K as far as I'm aware for days prior to the procedure.

[calypso]

One things that comes immediately to my mind is rhabdomyolysis, which can cause very high potassium levels. I wouldn't expect muscle tissue to be especially damaged during a fistula surgery, but maybe there's another cause. The Wikipedia article mentions obstruction of blood supply, which could definitely happen during fistula surgery, or even be a result of creating the fistula.

I would expect them to check for that when your potassium was high after the surgery, and in the ER, but you never know what they might miss. If it continues to be a problem, you might want to ask about that.

Hope it's nothing that serious. 

That makes sense. Thank you. Yes they would likely clamp a blood vessel or 2 for a while for an upper arm fistula (and that's a sort of big artery too) otherwise I would bleed out in the time it take to meticulously sew the artery and vein together. Why no one mentioned that as a possible reason for the high K bothers me. Seems they may not know about it. I sure didn't! Thanks again for posting that!

[Restorer]

Think about it, if the K is already in the blood or cells, how is a binder going to help? That would only be useful if I just ate something with high K and haven't digested it yet, right? I hadn't eaten anything high K as far as I'm aware for days prior to the procedure.

Kayexalate isn't just a binder - it's an ion exchange resin. As it was explained to me, in addition to tying up the potassium in your intestines, it literally pulls potassium back out of the intestine wall (and your blood) and into your stool. I'm fairly sure the pumps can go both ways. Ever had high potassium for a long time? Often that results in chronic diarrhea as your body refuses to absorb potassium (and water along with it). If the difference is great enough, your colon will even pump water and potassium back out, which is what the kayexalate causes.

It'll pull out potassium even if you haven't eaten in a while, though I bet it would help to eat some crackers or something along with it.

[calypso]

I see. Thanks for the info. I still don't like the risk of colonic necrosis with it though.

[KICKSTART]

Ive had high potassium when my PD failed and over here we get a container of powder (sorry cant remember its name) to take home and mix a dose with water (several doses) and drink , its like trying to drink down diluted clay  Its strange you mentioning it jumping up despite not eating anything, we have just had out monthly bloods and mine is 6.2. The nurse asked me if i had been eating lots of chocolate the night before ! I said i hadnt eaten anything as i had spent the last 2 days being sick ! Be interesting to see what has caused this.

[calypso]

Ive had high potassium when my PD failed and over here we get a container of powder (sorry cant remember its name) to take home and mix a dose with water (several doses) and drink , its like trying to drink down diluted clay  Its strange you mentioning it jumping up despite not eating anything, we have just had out monthly bloods and mine is 6.2. The nurse asked me if i had been eating lots of chocolate the night before ! I said i hadnt eaten anything as i had spent the last 2 days being sick ! Be interesting to see what has caused this.

That's the Kayexalate, we mentioned earlier in this thread.

The cause, in my case I think may be because they told me not to eat 12 hours prior to surgery, perhaps if the body went into ketosis a bit and pulled potassium out of the cells and into the blood. (my monthly bloods show normal potassium levels usually)

Also could be due to rhabdomyolysis that Restorer mentioned, considering a blood vessel or 2 may likely need to be clamped during surgery. Going to have to find out how to pronounce that to talk to med staff about it! lol   rhabdo...rabbi...raddish.....rabbit...rhombusmusness...can I just call it rhombushead for short?

[Nephrologista]

Ah yes, the routine ER check of potassium when it has nothing to do with the presenting complaint - love it.   

The effect of the dextrose-insulin cocktail lasts about thirty minutes, the bicarb maybe two hours.  So while that's a good thought, I don't think it's the whole answer.

You had a lot of brusing?  That's a whole lot of red blood cells dying and leaking potassium.  Alternatively, the lab could have been wrong.  Did they leave the tourniquet on for a long time?  Use a tiny little butterfly needle?  Shake the tube on the way to the lab?  I routinely see high K levels that make no sense (ie patient had dialysis the day before) and when you recheck them, they are fine.

Kaexylate has been a reflex medication for so long.  I never use it any more - the data on it are terrible, and I have seen at least one colonic perforation.  Plus we HATE it when the ER gives it to our patients on the way down to dialysis - guaranteed bedpan use, no fun for anybody!  I've been working on the ER docs for about six months now.

[Restorer]

Oh man.

When I ended up in the hospital dehydrated and uremic, needing dialysis for the first time, the first thing they did was draw blood. Before the results were back, they rushed to give me Kayexalate, because they were sure my potassium would be high. Didn't matter that I'd be going on dialysis in the next hour.

When the blood results came back, my potassium was low, even before the Kayexalate (big surprise - I had been vomiting and hardly eating for days). So then I had to take big, grainy potassium tablets. Then I went on dialysis. Wouldn't dialysis have fixed my potassium if it were low anyway? 

And then, yes, in the middle of dialysis, I suddenly "had to go." 

I've avoided Kayexalate ever since.

[calypso]

You had a lot of brusing?  That's a whole lot of red blood cells dying and leaking potassium.  Alternatively, the lab could have been wrong.  Did they leave the tourniquet on for a long time?  Use a tiny little butterfly needle?  Shake the tube on the way to the lab?  I routinely see high K levels that make no sense (ie patient had dialysis the day before) and when you recheck them, they are fine.

A lot of bruising yes. From my bicep down to my wrist, black and blue. Pink butterfly IV is where they pulled the blood frrom in the ER. Shake the tube? Maybe a bit since they seem to be running around a lot. Thanks for the info, makes sense perhaps a number of factors led to the high K numbers and they make a big fuss over what was maybe nothing. I had no symptoms except a little tingling in my fingertips in the mornings (yes only in the mornings) after not eating all night, which is why I think it happens when I don't eat much.

I've literally felt the tingling before (months ago, even years ago), eaten breakfast and had it go away and not come back.

I know the feeling well, because when I was on PD they never told us to lower K intake, some PD patients are even on K supplements. And I ate a ton, and I mean a ton of tomato product and had that tingly feeling in my fingertips. Blood tested, high K, stop eating tomatoes and it went away quickly because PD is an everyday dialysis. (it was tomato harvest and we made gazpacho soup out of homegrown tomatoes and it was so good I ate a lot of it)

But that was years ago. I did PD for 6 years then when I got peritonitis I switched to hemo last year.