1/ An important one folks.
Elderly man p/w subacute worsening chest pressure and dizziness.
Elderly man p/w subacute worsening chest pressure and dizziness.
2/
Our focus should be his chest pressure. The subacute nature significantly lowers likelihood of ACS, PE, and aortic dissection.
Our focus should be his chest pressure. The subacute nature significantly lowers likelihood of ACS, PE, and aortic dissection.
3/
Exam normal (including vitals and BMI).
Labs w/ potassium 6.4, HCO3 30, and Cr 0.8!! CBC pending.
EKG quickly obtained w/o any abnormality.
Exam normal (including vitals and BMI).
Labs w/ potassium 6.4, HCO3 30, and Cr 0.8!! CBC pending.
EKG quickly obtained w/o any abnormality.
4/
What diagnosis can you make?
What diagnosis can you make?
5/
There is only one acid-base d/o that can be diagnosed on BMP and that is AG acidosis. Why? The body never compensates for an alkalosis w/ AG acidosis. It is always pathologic. We need VBG (pH/pCO2). And just to ANGER half the ICU doctors - don't need ABG for this!!
There is only one acid-base d/o that can be diagnosed on BMP and that is AG acidosis. Why? The body never compensates for an alkalosis w/ AG acidosis. It is always pathologic. We need VBG (pH/pCO2). And just to ANGER half the ICU doctors - don't need ABG for this!!
6/
VBG show pH 7.36, pCO2 55. What is the acid-base d/o?
VBG show pH 7.36, pCO2 55. What is the acid-base d/o?
7/
The bicarb of 30 reflects comp for the retained pCO2. Primary resp acidosis is just prox dx, you need terminal dx. Why are they retaining? Start from brain (respiratory center) and work your way down to lung and then the surface - thoracic cavity. But let's focus on the K!
The bicarb of 30 reflects comp for the retained pCO2. Primary resp acidosis is just prox dx, you need terminal dx. Why are they retaining? Start from brain (respiratory center) and work your way down to lung and then the surface - thoracic cavity. But let's focus on the K!
8/
It is rare to have hyperkalemia w/ normal kidney function. Normal kidneys brilliant at peeing out excess K. This should make you pause and have 2 thoughts: (1) Rare cause of hyperkalemia or (2) Pseudo-hyperkalemia.
It is rare to have hyperkalemia w/ normal kidney function. Normal kidneys brilliant at peeing out excess K. This should make you pause and have 2 thoughts: (1) Rare cause of hyperkalemia or (2) Pseudo-hyperkalemia.
9/
My favorite approach to hyperkalemia from the MESSI of diagnosis @rabihmgeha. No joke, his work has made me tear up @ times. The clarity is unmatched.
My favorite approach to hyperkalemia from the MESSI of diagnosis @rabihmgeha. No joke, his work has made me tear up @ times. The clarity is unmatched.
10/
Before you consider a rare cause you must make sure it is not pseudo-hyperkalemia. Can you imagine reacting to pseudo-hyperkalemia w/ insulin, diuretics, and Lokelma? You might kill the patient. Also review the meds to make sure they are not contributing to hyperK!
Before you consider a rare cause you must make sure it is not pseudo-hyperkalemia. Can you imagine reacting to pseudo-hyperkalemia w/ insulin, diuretics, and Lokelma? You might kill the patient. Also review the meds to make sure they are not contributing to hyperK!
11/
Pseudo-hyperK happens because of in vitro (test tube) lysis. But before landing on in vitro lysis must consider in vivo (in the body). It most often is IN VITRO. Check out this case. nejm.org
Pseudo-hyperK happens because of in vitro (test tube) lysis. But before landing on in vitro lysis must consider in vivo (in the body). It most often is IN VITRO. Check out this case. nejm.org
12/
Clues to in vivo lysis include other findings to support muscle (rhabdo), RBC (hemolysis), and tumor cell (TLS) lysis. This pt did not have any other findings to support in vivo lysis. But it can be tricky to tease these apart. Read NEJM paper above.
Clues to in vivo lysis include other findings to support muscle (rhabdo), RBC (hemolysis), and tumor cell (TLS) lysis. This pt did not have any other findings to support in vivo lysis. But it can be tricky to tease these apart. Read NEJM paper above.
13/
Quick summary, elderly man w/ worsening of subacute chest pressure w/ normal Cr not on any medications but severely elevated potassium likely d/t in vitro lysis.
Quick summary, elderly man w/ worsening of subacute chest pressure w/ normal Cr not on any medications but severely elevated potassium likely d/t in vitro lysis.
14/
Most often in vitro lysis is b/c the way blood was collected - tourniquet on too long, sample shaken too aggressively, vein difficult to find. BUT his CBC finally came back
Most often in vitro lysis is b/c the way blood was collected - tourniquet on too long, sample shaken too aggressively, vein difficult to find. BUT his CBC finally came back
15/
Hgb 24, Plt > 1 million. You see these extra RBCs and Plt were lysing in test tube releasing their intracellular potassium. STELLAR resident Cam sent plasma sample (w/o cells) and K returned 4.1 confirming hypothesis of pseudohyperK. Important to confirm...
Hgb 24, Plt > 1 million. You see these extra RBCs and Plt were lysing in test tube releasing their intracellular potassium. STELLAR resident Cam sent plasma sample (w/o cells) and K returned 4.1 confirming hypothesis of pseudohyperK. Important to confirm...
16/
This pt had P. Vera. @Anand_88_Patel and I will simplify understanding leukemia, especially, MPNs in later threads. Be cautious b/c patients w/ leukemia might have TLS but normal kidney function made it unlikely and plasmaK ruled it out. Study @rabihmgeha schema.
This pt had P. Vera. @Anand_88_Patel and I will simplify understanding leukemia, especially, MPNs in later threads. Be cautious b/c patients w/ leukemia might have TLS but normal kidney function made it unlikely and plasmaK ruled it out. Study @rabihmgeha schema.
17/
🫵HyperK w/ normal eGFR is RARE - Ask "is it real?"
🫵HyperK from lysis might be IN VIVO or IN VITRO - other clues help prioritize
🫵Erroneously treating in vitro aka pseudohyperK may kill the patient
🫵PseudohyperK most often d/t collection technique but not always!
🫵HyperK w/ normal eGFR is RARE - Ask "is it real?"
🫵HyperK from lysis might be IN VIVO or IN VITRO - other clues help prioritize
🫵Erroneously treating in vitro aka pseudohyperK may kill the patient
🫵PseudohyperK most often d/t collection technique but not always!
18/
OMG forgot. Chest pressure was likely from increased viscosity of blood from all cells. It resolved w/ phlebotomy and aspirin.
OMG forgot. Chest pressure was likely from increased viscosity of blood from all cells. It resolved w/ phlebotomy and aspirin.
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