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Severe hyperkalemia with refractory ventricular fibrillation: successful resuscitation using extracorporeal membrane oxygenation
American Journal of Emergency Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Severe hyperkalemia with refractory ventricular fibrillation: successful resuscitation using extracorporeal membrane oxygenation☆,☆☆,★ Abstract Refractory ventricular fibrillation caused by severe hyperkalemia is a rare condition. We report a case of a 66-year-old man presenting with prolonged cardiac arrest and refractory ventricular fibrillation due to severe hyperkalemia caused by his having taken an unknown herbal medicine and in which cardiac arrest was refractory to prolonged conventional cardiopulmonary resuscitation. Extracorporeal membrane oxygenation was initiated approximately 90 minutes after prolonged cardiopulmonary resuscitation; this provided cardiopulmonary life support for prolonged cardiac arrest and termination of refractory ventricular fibrillation, achieving a sustained return of spontaneous circulation, which permitted adequate time for continuous venovenous hemofiltration with the promotion of potassium excretion and enabled a good recovery with intact cerebral performance. A 66-year-old man with end-stage renal disease presented to the emergency department complaining of chest tightness and a cough producing foamy pink sputum, over a 2-hour duration. His wife reported that he had taken an unknown herbal medication earlier. A chest x-ray taken on arrival showed pulmonary edema. The electrocardiogram showed a wide QRS complex and an irregular ventricular rhythm with no regular, distinct atrial activity (Fig.), and severe hyperkalemia was highly suspected. The treatment included calcium gluconate, sodium bicarbonate, dextrose with regular insulin, and oral kayexalate. Cardiac arrest with ventricular fibrillation occurred without warning, and advanced cardiopulmonary life support was provided. The duration of cardiopulmonary resuscitation (CPR) was approximately 38 minutes, and the first return of spontaneous circulation (ROSC) was achieved. During resuscitation, ventricular fibrillation developed repeatedly, and CPR was performed again for approximately 33 minutes. Although ROSC was achieved, it lasted for less than 20 minutes, and refractory ventricular fibrillation returned. A decision was made to resuscitate the patient with extracorporeal membrane oxygenation (ECMO) for cardiopulmonary life support in our emergency department. The laboratory data were significant for a high potassium level of 8.6 mEq/L. Venoarterial ECMO catheters were inserted into the left femoral vessels for resuscitation. Sustained ROSC was achieved, and prompt continuous venovenous hemofiltration was performed for severe hyperkalemia.
☆ Grant support: The authors have no grant support for this manuscript. ☆☆ Conflict of interest disclosures: The authors have no conflict of interest to disclose. ★ Author contributions: All authors contributed equally to the care of the patient and final drafting of the manuscript.
During continuous venovenous hemofiltration with ECMO, an occasional pulsatile ventricular rhythm was noted and ventricular fibrillation did not recur. Follow-up laboratory data revealed a troponin level of 5.0 ng/mL, and electrocardiography revealed normal sinus rhythm with T-wave inversion in II, III, and aVF. Coronary angiography revealed insignificant stenosis. The 5-, 11-, and 17-hour serial serum potassium levels obtained after continuous venovenous hemofiltration with ECMO were 8.3, 6.2, and 4.3 mEq/L, respectively. After the above procedures, serial echocardiography revealed gradual recovery of heart contractility (left ventricular ejection fraction increased from 12% to 45% in 2 days). The patient was weaned off ECMO on day 2 but later developed complications including pneumonia and gastrointestinal bleeding, which required prolonged hospitalization. He was discharged on day 14 without any serious sequelae or neurologic deficits. Severe hyperkalemia is associated with irregular ventricular rhythm and sudden cardiac arrest if left untreated. Urgent treatment includes administration of calcium gluconate, sodium bicarbonate, glucose plus insulin, kayexalate, and hemodialysis. In most patients, hyperkalemia is reversible, but either the potassium source is continuously absorbed from the gastrointestinal tract or severe rhabdomyolysis occurs after succinylcholine administration [1,2]. Because of the persistence of refractory ventricular fibrillation, we considered that the patient was having concomitant acute coronary syndrome. The clinical challenge is how to treat a patient with refractory ventricular fibrillation due to severe hyperkalemia or acute coronary syndrome. Hemodialysis and percutaneous coronary intervention were impossible at the time because of ongoing CPR; therefore, resuscitation with extracorporeal life support as a bridge to diagnosis and treatment was necessary for this patient. We suspected that serum potassium levels in this case were too high to be reversed to normal because potassium was continuously being absorbed from the digestive tract after ingestion of an unknown herbal medicine. During interventions, serial serum potassium decreased only to 8.3 and 6.2 mEq/L despite the application of continuous venovenous hemofiltration for 5 and 11 hours, respectively, which was compatible with the clinical course. In our patient, cardiac arrest with ventricular fibrillation was secondary to severe hyperkalemia, and this life-threatening dysrhythmia was refractory to conventional CPR. Extracorporeal membrane oxygenation was initiated approximately 90 minutes after prolonged CPR, and continuous venovenous hemofiltration in combination with ECMO was successfully implemented to provide cardiopulmonary life support for prolonged cardiac arrest, resulting in sustained ROCS, which allowed adequate time for promotion of
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Chiu C-C, et al, Severe hyperkalemia with refractory ventricular fibrillation: successful resuscitation using extracorporeal membrane oxygenation, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.016
2
C-C. Chiu et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Fig. The electrocardiography revealed loss of P waves, widening of the QRS complex, irregular ventricular rhythm, and peaked T waves over precordial leads (arrows).
Yao-Li Chen MD Department of Surgery Changhua Christian Hospital Changhua, Taiwan
potassium excretion. Extracorporeal membrane oxygenation support can extend the duration of CPR, but prolonged CPR may lead to multiple-organ failure and neurologic deficits as major complications [2-4]. Although some complications developed after prolonged CPR in this case, he recovered completely with intact cerebral performance. In cases of severe hyperkalemia with refractory ventricular fibrillation, health care providers should study ECMO as a cardiopulmonary support and bridge to diagnosis and treatment.
Chun-Chieh Chiu MD Department of Emergency Medicine Changhua Christian Hospital Changhua, Taiwan Hsu-Heng Yen MD Department of Internal Medicine Changhua Christian Hospital Changhua, Taiwan
Fu-Yuan Siao MD Department of Emergency Medicine Changhua Christian Hospital Changhua, Taiwan E-mail address: [email protected] References [1] Czuriga D, Barta J, Rácz I, et al. ST-segment elevation followed by progressive widening of the QRS complex. JAMA Intern Med 2013;173(7):490 discussion 491–2. [2] Al-Takrouri H, Martin TW, Mayhew JF. Hyperkalemic cardiac arrest following succinylcholine administration: the use of extracorporeal membrane oxygenation in an emergency situation. J Clin Anesth 2004;16(6):449–51. [3] Chen YS, Yu HY, Huang SC, et al. Extracorporeal membrane oxygenation support can extend the duration of cardiopulmonary resuscitation. Crit Care Med 2008;36(9):2529–35. [4] Massetti M, Tasle M, Le Page O, et al. Back from irreversibility: extracorporeal life support for prolonged cardiac arrest. Ann Thorac Surg 2005;79(1):178–83.
Please cite this article as: Chiu C-C, et al, Severe hyperkalemia with refractory ventricular fibrillation: successful resuscitation using extracorporeal membrane oxygenation, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.016
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Severe hyperkalemia with refractory ventricular fibrillation: successful resuscitation using extracorporeal membrane oxygenation☆,☆☆,★ Abstract Refractory ventricular fibrillation caused by severe hyperkalemia is a rare condition. We report a case of a 66-year-old man presenting with prolonged cardiac arrest and refractory ventricular fibrillation due to severe hyperkalemia caused by his having taken an unknown herbal medicine and in which cardiac arrest was refractory to prolonged conventional cardiopulmonary resuscitation. Extracorporeal membrane oxygenation was initiated approximately 90 minutes after prolonged cardiopulmonary resuscitation; this provided cardiopulmonary life support for prolonged cardiac arrest and termination of refractory ventricular fibrillation, achieving a sustained return of spontaneous circulation, which permitted adequate time for continuous venovenous hemofiltration with the promotion of potassium excretion and enabled a good recovery with intact cerebral performance. A 66-year-old man with end-stage renal disease presented to the emergency department complaining of chest tightness and a cough producing foamy pink sputum, over a 2-hour duration. His wife reported that he had taken an unknown herbal medication earlier. A chest x-ray taken on arrival showed pulmonary edema. The electrocardiogram showed a wide QRS complex and an irregular ventricular rhythm with no regular, distinct atrial activity (Fig.), and severe hyperkalemia was highly suspected. The treatment included calcium gluconate, sodium bicarbonate, dextrose with regular insulin, and oral kayexalate. Cardiac arrest with ventricular fibrillation occurred without warning, and advanced cardiopulmonary life support was provided. The duration of cardiopulmonary resuscitation (CPR) was approximately 38 minutes, and the first return of spontaneous circulation (ROSC) was achieved. During resuscitation, ventricular fibrillation developed repeatedly, and CPR was performed again for approximately 33 minutes. Although ROSC was achieved, it lasted for less than 20 minutes, and refractory ventricular fibrillation returned. A decision was made to resuscitate the patient with extracorporeal membrane oxygenation (ECMO) for cardiopulmonary life support in our emergency department. The laboratory data were significant for a high potassium level of 8.6 mEq/L. Venoarterial ECMO catheters were inserted into the left femoral vessels for resuscitation. Sustained ROSC was achieved, and prompt continuous venovenous hemofiltration was performed for severe hyperkalemia.
☆ Grant support: The authors have no grant support for this manuscript. ☆☆ Conflict of interest disclosures: The authors have no conflict of interest to disclose. ★ Author contributions: All authors contributed equally to the care of the patient and final drafting of the manuscript.
During continuous venovenous hemofiltration with ECMO, an occasional pulsatile ventricular rhythm was noted and ventricular fibrillation did not recur. Follow-up laboratory data revealed a troponin level of 5.0 ng/mL, and electrocardiography revealed normal sinus rhythm with T-wave inversion in II, III, and aVF. Coronary angiography revealed insignificant stenosis. The 5-, 11-, and 17-hour serial serum potassium levels obtained after continuous venovenous hemofiltration with ECMO were 8.3, 6.2, and 4.3 mEq/L, respectively. After the above procedures, serial echocardiography revealed gradual recovery of heart contractility (left ventricular ejection fraction increased from 12% to 45% in 2 days). The patient was weaned off ECMO on day 2 but later developed complications including pneumonia and gastrointestinal bleeding, which required prolonged hospitalization. He was discharged on day 14 without any serious sequelae or neurologic deficits. Severe hyperkalemia is associated with irregular ventricular rhythm and sudden cardiac arrest if left untreated. Urgent treatment includes administration of calcium gluconate, sodium bicarbonate, glucose plus insulin, kayexalate, and hemodialysis. In most patients, hyperkalemia is reversible, but either the potassium source is continuously absorbed from the gastrointestinal tract or severe rhabdomyolysis occurs after succinylcholine administration [1,2]. Because of the persistence of refractory ventricular fibrillation, we considered that the patient was having concomitant acute coronary syndrome. The clinical challenge is how to treat a patient with refractory ventricular fibrillation due to severe hyperkalemia or acute coronary syndrome. Hemodialysis and percutaneous coronary intervention were impossible at the time because of ongoing CPR; therefore, resuscitation with extracorporeal life support as a bridge to diagnosis and treatment was necessary for this patient. We suspected that serum potassium levels in this case were too high to be reversed to normal because potassium was continuously being absorbed from the digestive tract after ingestion of an unknown herbal medicine. During interventions, serial serum potassium decreased only to 8.3 and 6.2 mEq/L despite the application of continuous venovenous hemofiltration for 5 and 11 hours, respectively, which was compatible with the clinical course. In our patient, cardiac arrest with ventricular fibrillation was secondary to severe hyperkalemia, and this life-threatening dysrhythmia was refractory to conventional CPR. Extracorporeal membrane oxygenation was initiated approximately 90 minutes after prolonged CPR, and continuous venovenous hemofiltration in combination with ECMO was successfully implemented to provide cardiopulmonary life support for prolonged cardiac arrest, resulting in sustained ROCS, which allowed adequate time for promotion of
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Chiu C-C, et al, Severe hyperkalemia with refractory ventricular fibrillation: successful resuscitation using extracorporeal membrane oxygenation, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.016
2
C-C. Chiu et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Fig. The electrocardiography revealed loss of P waves, widening of the QRS complex, irregular ventricular rhythm, and peaked T waves over precordial leads (arrows).
Yao-Li Chen MD Department of Surgery Changhua Christian Hospital Changhua, Taiwan
potassium excretion. Extracorporeal membrane oxygenation support can extend the duration of CPR, but prolonged CPR may lead to multiple-organ failure and neurologic deficits as major complications [2-4]. Although some complications developed after prolonged CPR in this case, he recovered completely with intact cerebral performance. In cases of severe hyperkalemia with refractory ventricular fibrillation, health care providers should study ECMO as a cardiopulmonary support and bridge to diagnosis and treatment.
Chun-Chieh Chiu MD Department of Emergency Medicine Changhua Christian Hospital Changhua, Taiwan Hsu-Heng Yen MD Department of Internal Medicine Changhua Christian Hospital Changhua, Taiwan
Fu-Yuan Siao MD Department of Emergency Medicine Changhua Christian Hospital Changhua, Taiwan E-mail address: [email protected] References [1] Czuriga D, Barta J, Rácz I, et al. ST-segment elevation followed by progressive widening of the QRS complex. JAMA Intern Med 2013;173(7):490 discussion 491–2. [2] Al-Takrouri H, Martin TW, Mayhew JF. Hyperkalemic cardiac arrest following succinylcholine administration: the use of extracorporeal membrane oxygenation in an emergency situation. J Clin Anesth 2004;16(6):449–51. [3] Chen YS, Yu HY, Huang SC, et al. Extracorporeal membrane oxygenation support can extend the duration of cardiopulmonary resuscitation. Crit Care Med 2008;36(9):2529–35. [4] Massetti M, Tasle M, Le Page O, et al. Back from irreversibility: extracorporeal life support for prolonged cardiac arrest. Ann Thorac Surg 2005;79(1):178–83.
Please cite this article as: Chiu C-C, et al, Severe hyperkalemia with refractory ventricular fibrillation: successful resuscitation using extracorporeal membrane oxygenation, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.016