Abstract Surgeons are increasingly faced with patients suffering from complicated pathology in multiple organ systems, to which multiple therapeutic agents with complex adverse effects are often prescribed. We face a daily challenge in maintaining an up-to-date knowledge of these complications. Heparin is widely used in surgical practice, yet our awareness of its adverse effects, other than bleeding and thrombocytopenia, remains poor. We will present an example of heparin-induced hyperkalemia following administration for cardiopulmonary bypass and intraaortic balloon pump prophylaxis. This is a rare but serious complication of heparin therapy, not usually reported in the context of a cardiac surgical patient. We will also discuss the renal physiology leading to hyperkalemia and the options available for its management.