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]

For hyperkalemia smart algorithm click here

Definition

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 result in death or permanent disability within 24 hours if left untreated.

• Acute renal failure
• Adrenal insufficiency
• Diabetic ketoacidosis
• Large IV doses of calcium chloride or calcium gluconate
• Massive hemolysis
• Metabolic acidosis
• Rapid tissue necrosis
• Rhabdomyolysis
• Tumor lysis syndrome

Common Causes

• Adrenal insufficiency
• Diabetic ketoacidosis
• Iatrogenic
• Medications: ACE inhibitors, angiotensin receptor blockers, amiloride, spironolactone, NSAIDS, ciclosporin, tacrolimus, trimethoprim, pentamidine, succinylcholine
• Pseudohyperkalemia
• Renal insufficiency
• Renal tubular acidosis type 4

Management

Shown below is an algorithm summarizing the approach to hyperkalemia.

Potassium > 5.5 mEq/L

R/O Pseudohyperkalemia Repeat potassium level

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

Assess EKG

EKG changes, e.g. loss of P waves, hyperacute T waves and widened QRS

IV Ca gluconate Rapidly acting transient agents: Insulin and glucose Beta2 agonists by nebulizer

No changes in EKG Stable patient

Potassium > 6

5.5mEq/L < Potassium < 6 mEq/L

Rapidly acting transient agents: Insulin and glucose Beta2 agonists by nebulizer

Kaexalate (orally, and also can be given rectally in unconscious patients to avoid risks of aspiration) Furosamide

Stop the offending medications that are associated with hyperkalemia Order spot urine potassium, osmolality, creatinine

Do's

• Place the patient on a closely monitored bed for potential fatal arrhythmias, esp. with levels higher than 6.5.
• Repeat basic metabolic panels frequently.
• Stop 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.
• Consider consultation with nephrology.

Dont's

• Don't over use kayexalate, as it has been reported to cause colonic transmural necrosis.
• Don't over treat with IV bicarbonate as it can lead to rebound metabolic alkalosis.

References

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