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Management of Hyperkalemia

Mike Weinstock, MD and Mizuho Morrison, DO
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Miz and Mike discuss diagnosis and management of hyperkalemia in the UC setting.

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Brent W. -

Couple questions:
1)You didn't address testing for GC/chlamydia. My understanding is that urine is superior in both male and females. The question is how long do they need to have NOT urinated prior to dirty catch to make it valid?
2)You didn't address blood antibody screen for HSV. I find it useless and only creates anxiety (except in very rare case it is negative, uncommon today with 90% of adults positive for Simplex 1 and now cross-over between 1 and 2 with oral sex). Do you ever do the test?
3)Going back a few episodes: is it ever OK to send a very low risk patient home with troponin pending assuming near normal EKG and low risk? Perhaps if the chest pain/discomfort resolved more than 12 hours ago?
4) New flu assays are said to be both specific AND sensitive (98%) , does this change your practice? It is the FLOQ RNA molecular test.

Mike W., MD -

1. Yes, urine testing is a good option for gc/chl. Will need to check on timing of urination relative to test
2. Agree HSV blood screening is not the best initial approach to dx of HSV. In fact, usually this is a clinical dx which is confirmed w a swab. I don't think I have ever ordered a blood test for HSV!
3. Regarding trops, a very involved topic, but yes. If long duration of pain (generally over 6 hours of constant pain) and negative trop, the pt can be further eval as an outpt. Of course, the big question then is your pretest prob. If low with neg trop, it would make ACS very unlikely. Of course... there's always PE and dissection!
4. I have not seen these high of numbers, but if that is the case, I will likely be doing more of these. Still, after 48 hours (and even before), the efficacy of temiflu is limited. In summary, good news, but probably won't affect outcomes that much
Thx for the comments!!

Mike W., MD -

Brent, here is some additional info from Matt DeClerk:
1) For male GC/Chlamydia urine is superior to urethral swab. The recommendation is that they should not have urinated within the past 2 hours for a reliable test but you can catch it earlier in a majority of cases b/c the NAATs testing is so sensitive. For women urine can be used but it not superior to direct cervical/vaginal swab b/c GC/Chlamydia is more commonly a crevicitis rather than a urethritis. The problem with women is that vaginitis/cervicitis is more common and often missed b/c no one is actually looking/doing a pelvic exam. Assuming a negative urine test in a female means she doesn't have GC or Chlamydia without doing a pelvic exam is problematic and can miss these infections (up to 10% missed).

From the CDC Guidelines:
For female screening, specimens obtained with a vaginal swab are the preferred specimen type. Vaginal swab specimens are as sensitive as cervical swab specimens, and there is no difference in specificity (82–87). Self-collected vaginal swabs are equivalent in sensitivity and specificity to those collected by a clinician (83,88). Cervical samples are acceptable when pelvic examinations are done, but vaginal swab specimens are an appropriate sample type, even when a full pelvic exam is being performed. Cervical specimens collected into a liquid cytology medium for Pap screening are acceptable for NAATs that have been cleared by FDA for such specimen types (Table 2). However, following Pap screening, there should be a clinical indication for reflex additional testing of liquid cytology specimens for chlamydia and gonorrhea since these specimen types are more widely used in older populations at low risk for infection. First catch urine from women, while acceptable for screening, might detect up to 10% fewer infections when compared with vaginal and endocervical swab samples.

2) I do not do blood test for HSV for typing in the majority of pts. It is a clinical dx. If they have lesions c/w HSV then I start empiric treatment, the treatment is similar for both HSV 1 and HSV 2. While there has been an increase incidence of HSV 1 cross over from oral sex practices there is no benefit in determining the serotype as both are equally infectious and treated similarly. In the majority of cases pts can be screened for HSV1/HSV2 infection based on history of oral/genital lesions. Appropriate sexual precautions are reinforced in this pt population.

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