LAUSR

A 71-year-old male underwent laparoscopic cholecystectomy with basket extraction of a bile duct stone. Intravenous glucagon (1 mg) was administered to relax the ampulla to allow flushing of stone debris. Because of frailty, he was a planned admission to intensive care unit, where electrocardiogram (ECG) showed peaked T-waves. Arterial blood gas, 40 min after glucagon administration demonstrated marked hyperkalaemia (6.7 mmol/L). With treatment (intravenous calcium gluconate, insulin, glucagon and hydrocortisone) both the ECG and serum potassium returned to baseline, within 5 and 90 min, respectively. We concluded that the hyperkalaemia was secondary to intraoperative glucagon. Causes of hyperkalaemia such as other medications, cell necrosis, acute kidney injury, acidosis and blood transfusion were excluded. Preoperatively he had received a two-week course of prednisone (25 mg) for an exacerbation of chronic obstructive pulmonary disease. He was not diabetic and had normal renal function and potassium levels, preoperatively. Intravenous glucagon is utilised in a variety of medical, surgical and radiological procedures and is regarded as being safe with minimal adverse effects. Physiological doses of glucagon in a healthy patient produce no change in serum potassium due to an increase in insulin. In insulin deficient patients, glucagon should be used cautiously because it may elevate serum potassium. A single previous case report has described glucagon induced hyperkalaemia after an ERCP in a 45-year-old man with diabetes and chronic kidney disease. Steroid therapy can suppress the surgical stress response which can help regulate potassium homeostasis. We postulate that in this setting glucagon stimulated hepatic release of potassium and catecholamine induced transcellular shifts can result in hyperkalaemia. This case demonstrates cardio-toxic hyperkalaemia secondary to intravenous glucagon in a patient on oral steroid therapy. Although such a complication is rare, clinicians should be aware of the potentially severe side effect. Additionally, to consider increased postoperative biochemical monitoring in those with diabetes, kidney disease, steroid use and acidosis.