When Treatment Poses a Danger

Medication can save a life, but medication can also take one. Today’s clinicians need to be aware of not just the benefits of these medications, but also their hazards. Today we look at a case where a physician ordered what he believed to be the best treatment, with tragic results.

Clinical Scenario

It was a cold March afternoon when the patient was brought to the hospital by ambulance for complaints of weakness in his arms and legs. The 63-year-old man had hepatitis C, cirrhosis of the liver, end-stage liver disease, renal failure, and congestive heart failure. He had already been hospitalized 2 other times that year, for a total of 28 days. Upon admission, the doctor in question was assigned as the treating physician.

The primary admission diagnoses were rhabdomyolysis, chronic kidney disease, and hepatitis C cirrhosis. The nephrology department was consulted and for the next 3 days the patient underwent daily hemodialysis for his kidney failure. During this time, his bloodwork showed that his rhabdomyolysis was continuing to worsen. Dialysis was stopped.

The following day, he experienced a precipitous drop in heart rate. The physician immediately ordered an EKG which showed bradycardia and life-threating heart rhythms. He made a preliminary diagnosis of hyperkalemia.

The physician ordered blood work stat to evaluate the patient's potassium level but given the emergency nature of the situation he decided to begin the treatment protocol for hyperkalemia while awaiting the lab results. The blood work later confirmed the diagnosis of hyperkalemia. As part of the treatment, the doctor ordered the patient be given Kayexalate (sodium polystyrene sulfonate) oral suspension with sorbitol. The physician did not specifically inform the patient about the risks and benefits of the protocol before administering the Kayexalate.

The patient’s wife stayed with him overnight at the hospital. During the night, he had 7 bowel movements, some of them bloody, and began experiencing severe abdominal pain. Over the course of the next morning, his blood pressure dropped precipitously and could not be raised with fluid boluses. He was transferred to the intensive care unit (ICU) and prepped for exploratory surgery. The physician wrote a discharge summary in the notes when the patient was transferred to the ICU. In it, he noted that the patient’s differential diagnosis included intestinal ischemia due to hepatitis C-related vasculitis versus intestinal ischemia due to Kayexalate use versus hepatic decompensation with lower GI bleed.

The patient's surgery lasted over 6 hours and confirmed the diagnosis of ischemic colitis, requiring the removal of almost all of the patient’s colon. In a post-operative note, the surgeon wrote “…the patient had significant mucosal level ischemic colitis. Given the overall state of the patient’s perfusion, this may have likely been induced by the Kayexalate.”

The patient never regained consciousness and died the following day. His death certificate listed the cause of death as “ischemic colitis.” On autopsy, the pathologist noted that ischemic necrosis was seen in the patient’s residual small intestine, consistent with recent Kayexalate use. “The findings may be suggestive of Kayexalate colitis, which could have exacerbated the patient’s underlying medical disease,” noted the pathologist in the notes.

The patient’s family sued the doctor and the hospital.

NEXT: The Lawsuit and The Takeaway