Wang J C, Yao Y X, Guo X Y
Department of Anaesthesiology, Peking University Third Hospital, Beijing 100191, China.
Beijing Da Xue Xue Bao Yi Xue Ban. 2023 Feb 18;55(1):186-189. doi: 10.19723/j.issn.1671-167X.2023.01.029.
Severe hypokalemia is defined as the concentration of serum potassium lower than 2.5 mmol/L, which may lead to serious arrhythmias and cause mortality. We report an unusual case of potentially fatal ventricular arrhythmias induced by severe hypokalemia in a patient undergoing laparoscopic partial nephrectomy in Peking University Third Hospital due to irregular use of indapamide before operation. Indapamide is a sulfonamide diuretic with vasodilative and calcium antagonistic effects, which enhances sodium delivery to the renal distal tubules resulting in a dose-related increase in urinary potassium excretion and decreases serum potassium concentrations. The electrolyte disorder caused by the diuretic is more likely to occur in the elderly patients, especially those with malnutrition or long-term fasting. Hence, the serum potassium concentration of the patients under indapamide therapy, especially elderly patients, should be monitored carefully. Meanwhile, the potassium concentration measured by arterial blood gas analysis is different from that measured by venous blood or laboratory test. According to the previous research, the concentration of potassium in venous blood was slightly higher than that in arterial blood, and the difference value was 0.1-0.5 mmol/L. This error should be taken into account when rapid intravenous potassium supplementation or reduction of blood potassium level was carried out clinically. In the correction of severe hypokalemia, the standard approach often did not work well for treating severe hypokalemia. The tailored rapid potassium supplementation strategy shortened the time of hypokalemia and was a safe and better treatment option to remedy life-threatening arrhythmias caused by severe hypokalemia with a high success rate. Through the anesthesia management of this case, we conclude that for the elderly patients who take indapamide or other potassium excretion diuretics, the electrolyte concentration and the general volume state of the patients should be comprehensively measured and fully evaluated before operation. It may be necessary for us to reexamine the serum electrolyte concentration before anesthesia induction on the morning of surgery in patients with the history of hypokalemia. For severe hypokalemia detected after anesthesia, central venous cannulation access for individualized rapid potassium supplementation is an effective approach to reverse the life-threatening arrhythmias caused by severe hypokalemia and ensure the safety of the patients.
严重低钾血症定义为血清钾浓度低于2.5 mmol/L，这可能导致严重心律失常并造成死亡。我们报告了北京大学第三医院一名在腹腔镜下进行部分肾切除术的患者，因术前不规律使用吲达帕胺引发严重低钾血症，进而导致潜在致命性室性心律失常的罕见病例。吲达帕胺是一种具有血管舒张和钙拮抗作用的磺胺类利尿剂，它会增加肾远曲小管的钠输送，导致尿钾排泄呈剂量依赖性增加，并降低血清钾浓度。利尿剂引起的电解质紊乱更易发生在老年患者中，尤其是那些营养不良或长期禁食的患者。因此，接受吲达帕胺治疗的患者，尤其是老年患者，血清钾浓度应受到密切监测。同时，通过动脉血气分析测得的血钾浓度与静脉血或实验室检测测得的血钾浓度不同。根据以往研究，静脉血钾浓度略高于动脉血钾浓度，差值为0.1 - 0.5 mmol/L。在临床进行快速静脉补钾或降低血钾水平时应考虑到这一误差。在纠正严重低钾血症时，标准方法往往对治疗严重低钾血症效果不佳。量身定制的快速补钾策略缩短了低钾血症的持续时间，是一种安全且更好的治疗选择，可有效纠正由严重低钾血症引起的危及生命的心律失常，成功率高。通过对该病例的麻醉管理，我们得出结论，对于服用吲达帕胺或其他排钾利尿剂的老年患者，术前应全面测量并充分评估患者的电解质浓度和总体容量状态。对于有低钾血症病史的患者，在手术当天早晨麻醉诱导前重新检查血清电解质浓度可能是必要的。对于麻醉后检测出的严重低钾血症，通过中心静脉置管进行个体化快速补钾是逆转由严重低钾血症引起的危及生命的心律失常并确保患者安全的有效方法。
