Hyperkalemia resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]; Mahmoud Sakr, M.D. [3] Jogeet Singh Sekhon, M.D. [4]

Overview

Hyperkalemia is defined as a serum potassium concentration greater than 5.5 mEq/L in adults. Levels higher than 7 mEq/L can lead to significant hemodynamic compromise.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Management

Shown below is an algorithm summarizing the approach to hyperkalemia.[1][2][3]

 
 
 
 
 
 
 
 
Potassium > 5.5 mEq/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If repeated potassium level is normal, check potassium level in 24 hours
 
 
R/O Pseudohyperkalemia
(Artifact, hemolysis, elevated WBC, elevated RBC, elevated platelets)

Repeat potassium level
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check vital signs
ABC's
Order an EKG
Obtain a concise history and physical exam
Order BUN, creatinine, glucose, ABG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Assess EKG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Presence of EKG changes
Loss of P waves, peaked T waves and wide QRS
EKG hyperkalemia.gif
 
 
 
 
 
 
 
 
 
Absence of EKG changes

and

Hemodynamically stable patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do the following steps simultaneously:
1. Myocardial stabilization
IV Ca gluconate (1-2 amps)
Contraindicated in digoxin toxicity and hypercalcemia

2. Shift potassium from blood into cells
Insulin (0.2 units for every gram of glucose administered) and 20% dextrose ( 2.5-5 ml/kg/h)
(D50 1 ampule/10unit insulin)
Glucose level monitoring is needed

Beta2 agonists (albuterol is given 10-20mg via nebulizer or 0.5 mg IV)

3. Lower total body potassium
Cation exchange resin (kayexalate 30-90g given P.O. or P.R.)

Loop diuretics (furosemide 1-2 mg/kg)

Hemodialysis if refractory
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Potassium > 6 mEq/L
 
 
 
 
 
 
 
 
 
 
5.5mEq/L<Potassium<6mEq/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do the following steps simultaneously:
1. Monitor for cardiac arrhythmia
Place the patient on a closely monitored bed for potential arrhythmias

2. Shift potassium from blood into cells
Insulin (0.2 units for every gram of glucose administered) and 20%dextrose ( 2.5-5 ml/kg/h)
Glucose level monitoring is needed

Beta2 agonists (albuterol is given 10-20mg via nebulizer or 0.5 mg IV)

3. Lower total body potassium
Cation exchange resin (kayexalate 30-90g given P.O. or P.R.
Loop diuretics (furosemide 1-2 mg/kg)

Hemodialysis if refractory
 
 
 
 
 
 
 
 
 
 
Lower total body potassium
Cation exchange resin (kayexalate 30-90g given P.O. or P.R.)

Loop diuretics (furosemide 1-2 mg/kg)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
D/C any offending medications that is associated with hyperkalemia

D/C oral or parenteral potassium

Correct acidosis with bicarb if pH<7.2

Restrict dietary potassium intake

Review potassium levels every 2-4 hours until stabilized

Check levels of other electrolytes such as magnesium and phosphorus
 
 
 
 
 
 
 
 
 
 
 
 
 

Diagnostic criteria

 
 
 
 
 
 
 
 
 
 
 
 
 
Potassium >5.1meq/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ECG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If no changes,rule out pseudohyperkalemia
 
If changes present then start urgent treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine sodium <25 meq/L
 
 
 
 
 
 
urine sodium >25 meq/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ARF
CKD
Heart failure,
Volume depletion
 
Decreased K+secretion(Urine K+<20meq/L
 
 
 
 
 
 
 
Transcellular shift(measure serum osmolarity and pH)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low aldosterone(TTG<3)
 
 
 
 
 
Normal aldosterone(TTG>7)
 
 
 
 
Diabetic ketoacidosis,
Metabolic acidosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low renin
 
Normal renin
 
 
 
Tissue breakdown,
Pseudohypoaldosternism type 1 and type 2,
Type 1 RTA
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Interstital nephritis,
Obstructive uropathies,
Diabetic nephropathy,
ACE inhibitors,Angiotensin 2 receptors
 
Primary hypoaldosteronism,
Congenital adrenal hyperplasia,
Aldosterone receptor antagonists,
RTA type 4
 
 
 
 
 
 
 
 


Do's

1) Calcium, insulin with glucose, beta-2-adrenergic agonists, and sodium bicarbonate (in certain group of patients) can rapidly decrease the serum potassium levels. These should be the first line in patients with hyperkalemia related electrocardiographic changes, potassium levels > 6.5, and rapidly increasing less severe hyperkalemia.

2) Cation exchange resins are effective in lowering the serum potassium after multiple doses and are not effective immediately. Thus, they should always be combined with rapidly acting agents when used. They can produce severe side effects like intestinal necrosis.

References

  1. Lehnhardt A, Kemper MJ (2011). "Pathogenesis, diagnosis and management of hyperkalemia". Pediatr Nephrol. 26 (3): 377–84. doi:10.1007/s00467-010-1699-3. PMC 3061004. PMID 21181208.
  2. Ahee P. The management of hyperkalaemia in the emergency department. J Accid Emerg Med 2000;17:188-191 doi:10.1136/emj.17.3.18
  3. Weisberg L. Management of severe hyperkalemia. Crit Care Med 2008 Vol. 36, No. 12.

References

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