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
• Blood transfusion
• Diabetic ketoacidosis
• Potassium supplementation (oral or IV)
• Potassium rich diet
• 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

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, hyperacute T waves and widened QRS)

Absence of EKG changes and Stable patient

1. Myocardial stabilization IV Ca gluconate 10% (contraindicated in digoxin toxicity and hypercalcemia) 2. Shift potassium from blood into cells Insulin and dextrose (glucose level monitoring is needed) Beta2 agonists by nebulizer (can cause tachycardia) 3. Lower total body potassium Cation exchange resin (kayexalate) Loop diuretics (furosemide) Hemodialysis if refractory

Potassium > 6 mEq/L

5.5mEq/L<Potassium<6mEq/L

1. Monitor for cardiac arrhythmia Place the patient on a closely monitored bed for potential arrhythmias 2. Shift potassium from blood into cells Insulin and dextrose Beta2 agonists by nebulizer 3. Lower total body potassium Cation exchange resin (kayexalate) Loop diuretics (furosemide) Hemodialysis if refractory

Lower total body potassium Cation exchange resin (kayexalate) Loop diuretics (furosemide)

Stop any offending medications that is associated with hyperkalemia Stop oral or parenteral potassium Review potassium levels every 2-4 hours until stabilized Check levels of other electrolytes such as magnesium and phosphorus

References

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