Disclosures none Nilsson E, Gasparini A, Arnlov J, Xu H, - PowerPoint PPT Presentation

To do or not to do? Pro /Con Debate on Hyperkalemia for the Elective Cataract Patient By: Melissa Kreso Associate Professor of Anesthesiology & Perioperative Medicine Ophthalmic Anesthesia Society September 2018

Disclosures none

• Nilsson E, Gasparini A, Arnlov J, Xu H, Henriksson KM, Coresh J, Grams ME, Carrero JJ. Incidence and determinants of hyperkalemia and hypokalemia in a large healthcare system. Int J of Card 2017; 245:277- 84. Incidence of Hyperkalemia?

365,955 • Nilsson E, Gasparini A, Arnlov J, Xu H, Henriksson people KM, Coresh J, Grams ME, Carrero JJ. Incidence and determinants of hyperkalemia and hypokalemia in a large healthcare system. Int J of Card 2017; 245:277- 84. Incidence of Hyperkalemia?

Number of People • Nilsson E, Gasparini A, Arnlov J, Xu H, Henriksson KM, Coresh J, Grams ME, Carrero JJ. Incidence and determinants of hyperkalemia and hypokalemia in a large healthcare system. Int J K+ wnl K+ >5.0 mmol/L of Card 2017; 245:277- 84. Incidence of Hyperkalemia?

Number of People • Nilsson E, Gasparini A, Arnlov J, Xu H, Henriksson KM, Coresh J, Grams ME, Carrero JJ. Incidence and determinants of hyperkalemia and K+ wnl K+>5.0mmol/L hypokalemia in a large healthcare system. Int J K+ >5.5 mmol/L of Card 2017; 245:277- 84. Incidence of Hyperkalemia?

• Nilsson E, Gasparini A, Arnlov J, Xu H, Henriksson KM, Coresh J, Grams ME, Carrero JJ. Incidence and determinants of hyperkalemia and hypokalemia in a large healthcare system. Int J of Card 2017; 245:277-84. Factors for having hyperkalemia

• Nilsson E, Gasparini A, Arnlov J, Xu H, Henriksson KM, Coresh J, Grams ME, Carrero JJ. Incidence and determinants of hyperkalemia and hypokalemia in a large healthcare system. Int J of Card 2017; 245:277-84. Factors for having hyperkalemia

What does this mean for outcomes?

What does these mean on outcomes? The influence of potassium disorders especially hyperkalemia on outcomes has not been established

Potassium & Intraoperative dysrhythmias correlated with preoperative dysrhythmias Arrhythmias If present, there was a higher incidence intraop But NOT correlated to HIGH potassium levels Vitez TS, Soper LE, Wong KC, Soper P. Chronic hypokalemia and Intraoperative Dysrhythmias. Anesthesiology 1985; 63: 130-3.

Absence of adverse outcomes? • Olson RP, Schow AJ, McCann R, Lubarsky DA, Gan TJ. Absence of adverse outcomes in hyperkalemic patients undergoing vascular access surgery. Can J Anesth 2003; 50(6): 553-7.

Absence of adverse outcomes? • Olson RP, Schow AJ, McCann R, Lubarsky DA, Gan TJ. Absence of adverse outcomes in hyperkalemic patients undergoing vascular access surgery. Can J Anesth 2003; 50(6): 553-7.

People going for vascular Absence of surgery adverse outcomes? • Olson RP, Schow AJ, McCann R, Lubarsky DA, Gan TJ. Absence of adverse outcomes in hyperkalemic patients undergoing vascular access surgery. Can J Anesth 2003; 50(6): 553-7. potassium <5 mmol/L potassium>5 mmol/L

People going for vascular Absence of surgery adverse outcomes? • Olson RP, Schow AJ, McCann R, Lubarsky DA, Gan TJ. Absence of adverse outcomes in hyperkalemic patients undergoing vascular access surgery. Can J Anesth 2003; 50(6): 553-7. potassium <5 mmol/L potassium>5 mmol/L

Absence of adverse outcomes? No • Olson RP, Schow AJ, Adverse McCann R, Lubarsky DA, Gan TJ. Absence of adverse outcomes in Outcomes! hyperkalemic patients undergoing vascular access surgery. Can J Anesth 2003; 50(6): 553-7.

Risk of serious arrhythmias Hirsch IA, Tomlinson DL, et al. The overstated risk of preoperative hypokalemia. Anesth Analg 1988; 67(2):131-6.

Risk of serious • Cardiac/Vascular surgery arrhythmias • Associated with • Hx of CHF • Ventricular aneurysm • Digoxin usage Hirsch IA, Tomlinson DL, et al. The overstated risk of preoperative hypokalemia. Anesth Analg 1988; 67(2):131-6.

• Cardiac/Vascular surgery Risk of • Associated with • Hx of CHF serious • Ventribular aneurysm • Digoxin usage arrhythmias • BUT NOT • Potassium nor Hirsch IA, Tomlinson DL, et al. The overstated diuretic usage risk of preoperative hypokalemia. Anesth Analg 1988; 67(2):131-6.

• Retrospective review • 1861 patients with CRF Another for 8456 surgeries • 13 (2%) had potassiums > study 6.0 mEq/L immediately prior to surgery • 17 had potassiums >6.5mEq/L within 6M of having surgery (which were not repeated) • Underwent planned operations • No difference in adverse Ehrenfeld JM, Sedykh A, Furman W,. events amongst patients Management of Potassium abnormalities on the day of Surgery: A Retrospective Review. (A1652) Abstract presented at ASA Annual Meeting; 2011 Chicago, IL

• 61 patient Does ROC • Sux group vs rocuronium- suggamadex group • Median time rock? • 406 seconds to spon vent, sux group • 216 seconds to spon vent, roc-sugga group • Median time TOF 90 recovery • 518s with sux • 168s with roc-suga Sorensen MK, Bretlau C, Gatke MR, Sorensen AM, Rasmussen LS. Rapid sequence induction and intubation with rocuronium-sugammadex compared with succinylcholine: a randomized trial. BJA 2012; 108(4): 682-9

Does ROC rock? Sorensen MK, Bretlau C, Gatke MR, Sorensen AM, Rasmussen LS. Rapid sequence induction and intubation with rocuronium- sugammadex compared with succinylcholine: a randomized trial. BJA 2012; 108(4): 682-9

Does ROC • Rapid sequence induction rock? with rocuronium f/b sugammadex = earlier re- establishment of spontaneous ventilation than with succinylcholine alone! Sorensen MK, Bretlau C, Gatke MR, Sorensen AM, Rasmussen LS. Rapid sequence induction and intubation with rocuronium-sugammadex compared with succinylcholine: a randomized trial. BJA 2012; 108(4): 682-9