Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access
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Case Report

Volume 11, Number 6, June 2020, pages 152-156

Etiology and Treatment of Intraoperative Hyperkalemia During Posterior Spinal Fusion in an Adolescent


Table 1. Intraoperative Laboratory Results and Clinical Care
Point-of-care testing results (normal values)8:57 am10:24 am11:23 am11:46 am12:16 pm1:09 pm
Laboratory results from arterial blood. After the results at 10:24 am, minute ventilation was increased by 20%. After the results at 11:23 am, the following steps were taken: esmolol infusion discontinued, Normosol® changed to 0.9% normal saline, sodium bicarbonate administered (50 mEq), furosemide (10 mg) administered, and the inhalational agent (desflurane) was discontinued and propofol started. It was verified that none of the infusions had inadvertently been mixed in high potassium containing fluids.
PaCO2 (mm Hg)424038363436
Base deficit/excess-1-1-2+200
Hemoglobin (13.5 - 17.5 g/dL)12.612.912.612.212.912.9
Ionized calcium (1.22 - 1.35 mEq/L)
Sodium (135 - 145 mEq/L)140136134138138139
Potassium (3.7 - 5.3 mEq/L)


Table 2. Potential Etiologies of Hyperkalemia
ACE: angiotensin-converting enzyme.
Exogenous administration
  Medications (antibiotics: penicillin)
  Parenteral nutrition
  Intravenous fluids (lactated ringers, Normosol®, Plasmalyte®)
  Blood and blood products
  Cardioplegia solution
  Medication error (diluents)
Intracellular-extracellular shift
  Beta adrenergic blockade
Increased production
  Malignant hyperthermia
  Tumor lysis
  Hemolysis (cell saver, cardiopulmonary bypass)
Decreased excretion
  Decreased cardiac output
  Medications (aldosterone antagonist, ACE inhibitor)
  Renal insufficiency
  Adrenal failure or insufficiency


Table 3. Treatment of Hyperkalemia
ECG: electrocardiogram.
Resuscitation as needed according to guidelines
  Consider extracorporeal support for refractory hemodynamic instability
Administration of calcium gluconate or chloride if ECG changes are noted
Enhanced extracellular-to-intracellular shift
  Increase pH (hyperventilation or administration of sodium bicarbonate)
  Glucose and insulin
  Beta adrenergic agonists
    Inhaled albuterol
    Intravenous epinephrine or terbutaline
Enhanced elimination
  Hydrocortisone in setting of adrenal insufficiency
  Loop diuretics
  Hemodialysis or renal replacement therapies