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 [[Hyperkalemia smart algorithm

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

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

Management

Shown below is an algorithm summarizing the approach to hyperkalemia.

High potassium level

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

No changes in EKG, stable patient

Use rapidly acting transient agents, e.g Insulin, Dextrose, IV Calcium; with Ca gluconate generally preferred over Ca chloride, 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 for potential fatal arrhythmias, esp. with levels higher than 6.5.
• 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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