High-dose potassium resuscitation in a peritoneal dialysis patient with severe hypokalemia and torsades de pointes

Background: The American Heart Association (AHA) recommends to treat cardiac arrest due to Torsade de Pointes (TdP) with 1–2 grams of intravenous (IV) magnesium over 5 minutes. A second dose can be repeated within 5–15 minutes, and a continuous infusion may be considered. In cases of TdP due to severe hypokalemia, the doses and rate of administration of IV potassium chloride (KCL) are not described explicitly in the guidelines. Methods: In this case report, we describe a peritoneal dialysis (PD) patient who had a prolonged history of hospital stay with infected diabetic foot. He was on the medical ward, but recently admitted to the Intensive Care Unit with septic shock needing inotropic support. He developed a TdP cardiac arrest with a serum potassium of 2.4 millimol/litre. We managed the cardiac arrest according to AHA guidelines and also administered a total of 120 milliEquivalent (mEq) of KCL over 2 hours. The severe refractory hypokalemia improved, and the recurrent TdP subsequently stopped only after we urgently drained the PD fluid during the resuscitation as a last resort. We also avoided administration of sodium bicarbonate even though he was severely acidotic during and after the resuscitation. Results: To compliment this case report, we reviewed the literature available on hypokalemia in PD patient, and also on the established treatment of TdP. Conclusion: In cardiac arrest situation secondary to hypokalemia, repeated high doses of IV KCL, up to a total of 120 mEq may be required, provided point of care testing is available. Draining the PD fluid during resuscitation, might expedite the correction of the refractory hypokalemia and malignant arrhythmias.