What is it about?
Conventionally, physiology teaches that respiratory acidosis causes minimal or no elevation in serum potassium, unlike metabolic acidosis. However, in clinical practice during prone-position esophagectomy, we frequently observe significant hyperkalemia. This article presents a protocol for a multicenter study designed to investigate this contradiction. We view this surgery—specifically with intrathoracic carbon dioxide insufflation—as a unique, artificial model of "hyperacute respiratory acidosis." In this planned study, our primary objective is to prove that potassium levels do significantly rise in this specific context. Furthermore, using multivariate analysis, we aim to disentangle the respective contributions of respiratory and metabolic factors to reveal the true drivers of this phenomenon.
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Why is it important?
Updating safety standards and physiology: First, if our hypothesis is correct, current monitoring practices for prone esophagectomy are insufficient. Proving that respiratory acidosis drives hyperkalemia would mandate arterial blood gas analysis for these patients, preventing life-threatening arrhythmias. Broader implications for ICU care: Second, this research extends beyond the operating room. It challenges the safety of "permissive hypercapnia" strategies used in ICUs for respiratory failure. By using this surgery as an artificial model of extreme acidosis, we can define the safe limits of carbon dioxide retention, potentially saving critically ill patients from overlooked electrolyte imbalances.
Perspectives
As an anesthesiologist, I have always been intrigued by the gap between textbook physiology and clinical reality. We are generally taught that respiratory acidosis does not significantly raise potassium levels. Yet, in the operating room, I consistently witnessed the opposite during these specific procedures. My core research theme is to explore physiological truths hidden in special, non-physiological ventilation scenarios that are rarely encountered in standard practice. I view this surgery as a valuable opportunity to observe these extreme conditions. I designed this protocol to investigate these unmapped areas of physiology. My goal is to clarify how the body truly responds in these artificial environments, potentially revealing mechanisms that standard textbook physiology overlooks.
Sakura Okamoto
Aichi Ika Daigaku
Read the Original
This page is a summary of: Association between acute respiratory acidosis and hyperkalemia during esophageal cancer surgery in the prone position: A multicenter retrospective observational study protocol, PLOS One, January 2026, PLOS,
DOI: 10.1371/journal.pone.0337018.
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