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Hyperkalemia

Definition

  • Serum K+ >5.3-5.5

Etiology:

  • Pseudohyperkalemia- K release from cells after blood draw, IVF with K
  • Impaired excretion
  • Low GFR (AKI or CKD)
  • Drugs (spironolactone, ACEi, ARB, TMP-SMX, NSAIDs, digitalis overdose, heparin, chemo therapeutic agents)
  • Shift from intracellular to extracellular compartment
  • Excessive K intake
  • Hemolysis
  • Marked thrombocytosis or leukocytosis
  • Ingestion (K Supplements, dietary salt substitutes)
  • Iatrogenic
  • Low mineralocorticoid state (adrenal insufficiency, type IV RTA)
  • Acidosis
  • Insulin deficiency or resistance including DKA
  • Cell death (rhabdomyolysis, burns, tumor lysis)
  • Retroperitoneal hemorrhage
  • Old (hemolyzed) pRBC transfusion

Clinical manifestations:

  • Weakness, nausea, paresthesia, palpitations

Evaluation:

  • Repeat serum K+ and assess renal function studies including serum Cr and BUN
  • Order stat ECG to evaluate for hyperkalemia related changes (Tall peaked “tented” T waves, PR interval prolongation followed by loss of P waves, QRS widening, sinus wave pattern, VF/asystole/PEA
  • Review medications for offending drugs and stop as appropriate/indicated

Management: PowerChart “Hyperkalemia (TH) Protocol”

Approach to Rx:

  • Order ECG for serum K >5.5 and treat emergently if ECG changes noted. Rx any K >6.5 emergently regardless of ECG changes

  • Repeat ECG every 30-60 mins to ensure resolution of ECG abnormalities and consider telemetry for monitoring.

  • Check and treat concurrent electrolyte abnormalities as they increase risk for arrythmias

  • Check if sample is hemolyzed and repeat serum K measurement to verify

Treatment aims:

  1. Stabilize the myocardial membrane
  2. Temporarily shift K into cells
  3. Eliminate K from body

Cardiac membrane stabilization:

  • Calcium chloride 0.5-1g IV (more potent, but must be given via central line)
  • Calcium gluconate 1-2g IV
  • No effect on serum K level. Should normalize ECG. If not, re-dose.

Temporarily shift K into cells:

  • Regular Insulin 10 units IV + D50 100ml IV. If high risk for hypoglycemia, monitor blood glucose closely. If hyperglycemic, insulin can be given alone.
  • Beta2-agonists (albuterol 10-20mg in 4mL saline nebulized)
  • NaHCO3 50-100 mEq

Eliminate K from body:

  • Preferably renal elimination
  • IVF with NS or NaHCO3- First line in hypovolemic patients
  • Loop diuretic: Furosemide 40-160 mg IV- First line in hypervolemic patients and given with IVF if euvolemic
  • Thiazide diuretic: Adjunct use with loop diuretic may be useful
  • GI cation exchangers- Exchange Na+ for K+ in the GI tract
  • Sodium zirconium cyclosilicate (Lokelma)- 10 g TiD for up to 48hr, then 5-15g q.other daily-daily as maintenance
  • Kayexalate (sodium polystyrene sulfonate)- 15-30 g PO (slow onset and controversial use; associated with bowel necrosis and contraindicated in post-op patients and those with risk of/obstruction
  • Dialysis-can be used in patients with acute/chronic renal failure who fail medical management; improves serum K relatively quickly but lengthy process to initiate therapy (nephrology consult, machine and catheter placement)
  • Continues renal replacement therapy-slow correction and requires ICU setting

Key Points:

  • Hyperkalemia protocol can be initiated/ordered from PowerChart

  • Serum K level >6.5 or hyperkalemia with ECG changes warrant emergent treatment with calcium gluconate or CaCl

  • Strategy to shift K into cells is useful acutely as it works fast but is only a temporary measure and it should be accompanied by therapies to eliminate K from the body

  • K elimination renally is most efficient and takes into consideration patient’s volume status

 

 

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