Emergent Management of Severe Hyperkalemia and Volume Overload in a Maintenance Hemodialysis Patient With Castor Oil and Enemas in the Absence of Accessible Hemodialysis

To the Editor:

The COVID-19 pandemic resulted in substantial medical and social upheaval.^1,2 In Colombia, a social crisis ensued when the Colombian government made the decision to close economic gaps by increasing taxes. In protest, counter-government groups took control of the main roads and intermunicipal highways, completely blocking traffic, including medical missions,3, 4, 5 resulting in an inability of patients, including those dependent on hemodialysis, to receive essential medical care.

An anuric hemodialysis-dependent man in his late 60s presented with fluid overload and hyperkalemia to a community hospital where dialysis was unavailable 4 days after his last hemodialysis session. He usually received dialysis in the inaccessible city of Cali, Colombia. At the time of hospitalization, his serum potassium was 7.9 mEq/L (Table 1). Of note, most blood pressure medications and all potassium binders also were unavailable at this hospital.

Table 1.

Key laboratory and examination data

Time	Weight (kg)	SpO2	K (mEq/L)	Blood Pressure (mm Hg)	ECG
Admission	82	92%	7.9	198/112	Peaked T waves in V1-V2
Day 1 of enemas	83	76%	8.8	212/116	—
+12 h	81	84%	—	186/110	—
+20 h	80	—	—	—	—
+24 h	—	86%	7.4	174/106	—
+30 h	78	94%	6.4	168/94	Resolved

Abbreviations: ECG, electrocardiogram; K, potassium; SpO₂, oxygen saturation.

After a phone consultation, we implemented the following interventions, recognizing that these were the only options available at the time. These included β-agonists via nebulizer, a dihydropyridine calcium channel blocker, and minoxidil. Despite this, hypertension and hypervolemia persisted with potassium increasing to 8.8 mEq/L and oxygen saturation dropping. In this setting, we initiated enemas every 15 minutes as well as oral castor oil, 1 ounce every 12 hours, RRM. With the enemas and oral castor oil, we were able to temporize him for 5 days, with marked improvement in blood pressure and volume status as well as potassium dropping to 6.4 mEq/L with a resolution of electrocardiogram changes after 30 hours of treatment initiation. Nine days after his last hemodialysis session, he was able to resume hemodialysis.

These measures, although representing a desperate measure, proved effective in allowing our patient sufficient time until he could receive hemodialysis.