Hypokalemia Leading to Postoperative Critical Arrhythmias: Case Reports and Literature Review

Abstract

Perioperative arrhythmias can develop due to many reasons, rarely life-threatening, but hypokalemia plays an important role in their development. We report two cases of severe postoperative hypokalemia leading to ventricular fibrillation (VF). Case 1: A young healthy lady developed perioperative severe hypokalemia leading to repeated episodes of VF requiring cardiopulmonary resuscitation (CPR), direct current (DC) shock and anti-arrhythmic therapy, apart from rapid replacement of intravenous potassium. She recovered fully without any neurological or cardiac sequelae. Case 2: A 78-year-old male patient, a known case of hypertension controlled with medications developed postoperative repeated VF due to hypokalemia requiring 210 mmol of potassium chloride, antiarrhythmic therapy, DC shock, and CPR. He recovered, but complicated into acute myocardial infarction requiring therapy. Perioperative severe hypokalemia can lead to life-threatening cardiac arrhythmias. Early recognition and aggressive correction are essential for better outcomes.

Arrhythmogenic Mechanisms in Hypokalaemia: Insights From Pre-clinical Models

“…Hypokalaemia is associated with increased risks of atrial fibrillation amongst hospitalized patients ( 108 ). Moreover, hypokalaemia is common in patients presenting with VT/VF, and those with severe hypokalaemia have found to be associated with preceding gastrointestinal illness, higher doses of diuretics ( 109 ), use of drugs such as anti-depressants ( 110 ), as well as post-operative settings ( 111 ). In patients with implantable cardioverter-defibrillators (ICDs), hypokalaemia but not hyperkalaemia has been linked with increasing risk of recurrent ventricular tachyarrhythmias and appropriate ICD therapies ( 112 ).…”

2024 RECOVER Guidelines: Monitoring. Evidence and knowledge gap analysis with treatment recommendations for small animal CPR

“…113 Five case reports in people describe CPA associated with severe hypokalemia ranging from 0.9 to 2.9 mmol/L, the administration of potassium, and its contribution to recovery. [118][119][120][121][122] Allen et al report a dog that developed CPA due to severe hypokalemia (1.5 mmol/L) associated with leptospirosis; this dog received periarrest potassium at 0.9-2.0 mmol/kg/h, IV, and survived to discharge with good neurologic function. 123 Five further case reports or case series document successful CPR in individuals with severe hyperkalemia due to kidney disease, rhabdomyolysis, and other conditions.…”

Causes of Perioperative Cardiac Arrest: Mnemonic, Classification, Monitoring, and Actions

“…109 Life-Threatening Electrolyte Abnormalities Hypokalemia can cause POCA. [110][111][112] One case described a 78-year-old man undergoing laparoscopic cholecystectomy. 110 The patient remained intubated and was transported to the intensive care unit after surgery for observation.…”

“…[110][111][112] One case described a 78-year-old man undergoing laparoscopic cholecystectomy. 110 The patient remained intubated and was transported to the intensive care unit after surgery for observation. One hour later, he developed tachycardia, progressing into pulseless ventricular tachycardia.…”

“…In the perioperative setting, pulseless ventricular tachycardia and ventricular fibrillation result from a variety of causes, including, but not limited to, direct surgical stimulation, electrocautery, 130 myocardial ischemia and infarction, 131 coronary artery occlusion, 132 graft spasm, 133 hypothermia, 134 electrolyte abnormality, 110 acidosis, 135 hypoxemia, 136 hypovolemia, 137 drugs, 83,138 and coexisting diseases. 139 Ondansetron, for example, can cause dose-dependent QT prolongation––clinically relevant when other proarrhythmic factors are present.…”