Hyperkalemia resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; associate editor-in-chief: Mahmoud Sakr, M.D. [2]

Definition

Hyperkalemia is best 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

Immediate life-threatening causes are conditions which result in immediate death or disability if left untreated.

• Acute Renal Failure
• Rhabdomyolysis
• Rapid tissue necrosis
• Tumor Lysis syndrome
• Metabolic acidosis, diabetic ketoacidosis
• Massive hemolysis
• large IV doses of Calcium chloride or calcium gluconate
• Adrenal insufficiency

Common Causes

• Pseudoyperkalemia
• Renal insufficiency
• Adrenal insufficiency
• Medications; ACE inhibitors, Angiotensin receptor blockers, amiloride,spironolactone, NSAIDS, ciclosporin, Tacrolimus, Trimethoprim, Pentamidine
• Renal tubular acidosis
• Iatrogenic

Management

Please find below an algorithm that summarizes the approach to hyperkalemia

Check vital signs Stabilize the patient Order an EKG Concise history and physical exam

Assess EKG

EKG changes;e.g. hyperacute T waves, widened QRS,

EKG not changed, patient stable

use rapidly acting transient agents,e.g Insulin, Dextrose, IV calcium, inhaled Beta2 agonists

Kayexalate, orally, and also can be given rectally in unconscious patients to avoid risks of aspiration

IV hydration

stop potential causative medications

use carefully in potential heart failure patients, consider diuresis when clinically appropriate

consult with nephrology for resistant and severe cases of hyperkalemia may require urgent dialysis, yet rare

Do's and Don'ts

• Place the patient on a closely monitored bed
• Repeat basic metabolic panels frequently
• Be ware when using kayexalate, as it has been reported to cause colonic transmural necrosis
• Remove the offending medications that are associated with Hyperkalemia
• Keep the patient well hydrated
• Check levels of other electrolytes such as Magnesium and phosphorus as it may be abnormal as well.
• Avoid over treating with IV Bicarbonate as it may lead to rebound metabolic alkalosis
• Consider consultation with nephrology

References

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