Hyperkalemia

Hyperkalemia
  • >6.0 mmol/L
  • EKG changes (not necessarily in order, especially if chronic renal failure patient)
    • Peaked T waves
    • PR prolongation
    • Short QT (<350 ms)
    • Widened QRS
    • Flat P waves
    • Heart Block
    • Sine wave
    • V. Fib.
  • Treatment: Stabilize, Shift, Excrete
    • Stabilize: Calcium stabilizes myocardial membrane with onset in 15-30 minutes.
      • Calcium gluconate IV
        • 10 ml of 10% solution over 10 minutes
        • may cause hypotension
      • Calcium chloride contains 3x more calcium
        • 10 ml of 10% solution (1 gram) IV over 1-2 minutes
        • Scleroses veins and extravasation can cause necrosis. Be sure IV is good, preferably central access.
      • Digoxin “Stone Heart” syndrome in patient given IV calcium is best addressed here.8
    • Shift: Several agents can shift potassium into the intra-cellular compartment.
      • Insulin – 10 units regular IV (5 units IV if renal insufficiency 5)
        • Administer with glucose if serum glucose < 300 mg/dL
        • Glucose 25-50 gm IV (D50 = 50% dextrose in a 50 ml syringe = 25 grams)
        • Onset: 30 minutes
        • Duration of effect 4-6 hours, lowers level by 1 mmol/L
      • Albuterol nebulized 5-20mg (note: typical dose for bronchospasm is 2.5mg /3ml)
        • Onset: 30 minutes
        • Duration: 2 hours
      • Sodium Bicarbonate IV (50 ml of 8.4% = 1 amp)
        • Only effective if patient is acidotic
        • Given over 5 minutes
        • Onset 30-60 min
        • Duration 1-2 hours
    • Excrete:
      • Lasix diuresis, 40-80 mg IV if urine output is proven
      • Kayexalate (sodium polystyrene sulfonate) 30 gm orally
        • There is increasing opinion that kayexalate is not as effective as we believe 6,7
        • Given risk of necrotizing colitis, rectal use is best avoided.
      • IV hydration / resuscitation for patients with dehydration, DKA, sepsis, rhabdomyolysis, etc.
      • Hydrocortisone therapy for patients with adrenal insufficiency
      • Dialysis
  • Symptoms
    • Lethargy and fatigue
    • Muscle weakness
    • Tingling
    • Vomiting
    • Shortness of breath
    • Palpitations
    • Chest pain
  • Causes
    • Renal failure
    • Addison’s disease (adrenal insufficiency)
    • ACE inhibitors
    • Beta blockers
    • Dehydration
    • Trauma / burns / tissue destruction
    • Excessive oral intake
References:
  1. Tse G, Chan YW, Keung W, Yan BP. Electrophysiological mechanisms of long and short QT syndromes. Int J Cardiol Heart Vasc. 2017;14:8-13. PubMed Full Article
  2. Larue HA, Peksa GD, Shah SC. A Comparison of Insulin Doses for the Treatment of Hyperkalemia in Patients with Renal Insufficiency. Pharmacotherapy. 2017;37(12):1516-1522. PubMed
  3. Sterns RH, Rojas M, Bernstein P, Chennupati S. Ion-exchange resins for the treatment of hyperkalemia: are they safe and effective?. J Am Soc Nephrol. 2010;21(5):733-5. PubMed
  4. Erickson CP, Olson KR. Case files of the medical toxicology fellowship of the California poison control system-San Francisco: calcium plus digoxin-more taboo than toxic?. J Med Toxicol. 2008;4(1):33-9. Full Text

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