Introduction: Hyperkalemia (HK) is known to be associated with increased risk of adverse outcomes related to anesthesia and surgery. The overall impact of hyperkalemia on surgery delay or cancellation is not known. This study was designed to assess the impact of HK on surgery case cancellation and to determine if any standards existed with respect to the management of surgical patients with HK in a large health system.

Methods: There were two phases of the study. Phase 1 was a structured survey was distributed to electronically to clinicians within the 26-hospital health system regarding HK knowledge and treatment paradigms. Phase 2 consisted of electronic health record data of patients treated between 1/1/2015-12/31/2020 who had an elevated serum K+ (> 5 mEq/L) ≤ 24 hours (an indication of preoperative HK) prior to a scheduled surgery.

Results: HK was clinically significant by 47% of respondents with a serum K+ level at 5.6-5.9 mEq/L and by 39% at K+ > 6 mEq/L thresholds. Only 50% of respondents recognized Renin-angiotensin-aldosterone system inhibitors as a risk factor for HK. Of 645,073 surgical cases 1.4% (n = 9,166) had a documented pre-operative HK. Black and Hispanic patients were more likely to have preoperative HK (≥ 6.0 mEq/L) compared to White (p = 0.01). Patients with a K+ value ≥ 6.0 mEq/L within 24 hrs. Of a scheduled surgery were 2.40 times more likely to have a cancelled surgery compared to patients with a K+ between 5.1-5.9 mEq/L (p < 0.0001).

Conclusion: There is a lack of consensus as to what constitutes significant preoperative HK, and whether to cancel or delay elective surgery due to HK, and no standard treatment when preoperative HK was identified. This study indicates a need for improved perioperative standards and greater reliability in the approach to surgical patients with HK.