Intra‐operative hyperkalemia: a serious but under recognised complication of renal parathyroidectomy – a prospective study: how we do it

Abstract

Dear Editor, Approximately 29% of patients with long-term chronic renal failure (CRF) undergo parathyroidectomy to control secondary hyperparathyroidism that occurs as a result of chronic parathyroid stimulation caused by failure of adequate Vitamin D synthesis. 1 Patients with renal failure have associated metabolic complications and electrolyte disturbance. 2 The senior authors (RJE, SR) in this study were involved with a 20year-old patient with renal failure undergoing total parathyroidectomy, who had a cardiac arrest intra-operatively. Despite aggressive resuscitation, the patient died. At the commencement of the resistant ventricular fibrillation arrest, the patient's serum potassium level had risen from 3.3 mm at induction to 7.8 mm over 1 h. After such a devastating complication, potassium levels were subsequently monitored in these patients during the operation. On reviewing the literature, there is no mention of this intraoperative complication during renal parathyroidectomy. Hyperkalemia is recognised as a complication within the first 24 h post-operatively after parathyroidectomy. 3 This study is a prospective analysis of intra-operative monitoring of potassium levels for patients with CRF undergoing parathyroidectomy under the care of the senior author (RJE). , all patients with CRF undergoing parathyroidectomy at Hull Royal Infirmary were included in the study. All the parathyroidectomies were performed by a single surgeon (RJE). Four-gland parathyroidectomy was planned and achieved in every patient. Typically, the patients had received multiple anaesthetics in the past. Anaesthesia for parathyroidectomy did not differ significantly from the previous anaesthetics. The drugs used at induction of anaesthesia were propofol, fentanyl, ondansteron and atracurium as laid down by a previously agreed anaesthetic protocol; maintenance with oxygen ⁄ nitrous oxide ⁄ sevoflurane mixture; morphine intra-operatively for further analgesia and reversal of neuromuscular blockade with glycopyrrolate ⁄ neostigmine at the end. If the pre-operative post-dialysis potassium levels were above 5.3 mm, the planned parathyroidectomy procedure was cancelled. As there was no mention in the literature of similar problems, after discussion with the nephrologists, it was decided that a rise of more than 0.5 mm of potassium levels from the post-induction level to intra-operative would be considered significant.Twenty-nine patients are included in the study (Table 1), and no patients were excluded. All the operations were performed on a morning operating list. All patients had a post-dialysis pre-operative potassium level check on the morning of the surgery, at least two potassium checks in theatre and one post-operative potassium level measurements (Fig. 1). The first potassium check was immediately after induction, and the second potassium level was checked after the second parathyroid gland had been removed (earlier if ECG changes became evident). Intra-operative potassium was measured using a venous sample in a blood-gas machine ...

Severe Hyperkalaemia Complicating Parathyroidectomy in Patients with End-Stage Renal Disease

“…Consequently, the rate of operative parathyroidectomy in ESRD patients in our centre has increased from occasional surgery to now over one-third of our centre's parathyroidectomy case-mix. A small study recently suggested a superiority of subtotal parathyroidectomy over cinacalcet for the management of tertiary hyperparathyroidism in renal transplant patients, with improved correction of hypercalcaemia 13 .…”

Predictors of hyperkalemia after total parathyroidectomy in patients with drug-refractory secondary hyperparathyroidism

“…Hyperkalemia is currently defined as a higher-thannormal range of serum potassium levels, with various arbitrary cutoff values used to indicate different levels of severity (14). Despite there being no single cutoff value for defining hyperkalemia, many papers studying SHPT and hyperkalemia have used serum potassium levels >5.3 mmol/L to define hyperkalemia (15)(16)(17). Therefore, this criterion was also used to define hyperkalemia in our study.…”

Intraoperative and postoperative hyperkalaemia after total parathyroidectomy following exposure to cinacalcet in sixteen patients for renal hyperparathyroidism

“…The risk to patients of sudden hyperkalaemia and hypocalcaemia cannot be underestimated. A literature review returned two recent reports of intraoperative parathyroidectomy‐related hyperkalaemia . In the report of the mortality, it was not clear whether the patient was medicated with cinacalcet.…”