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 (Artifact, hemolysis, elevated WBC, elevated RBC, elevated platelets) Repeat potassium level

Check vital signs Stabilize the patient Order an EKG Obtain a concise history and physical exam

Assess EKG

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

1. Myocardial stabilization IV Ca gluconate 2. Shift potassium from blood into cells Insulin and dextrose Beta2 agonists by nebulizer 3. Lower total body potassium Kayexalate Furosemide<Hemodialysis if refractory

No changes in EKG And Stable patient

Potassium > 6

5.5mEq/L < Potassium < 6 mEq/L

Rapidly acting transient agents: Insulin and glucose Beta2 agonists by nebulizer Place the patient on a closely monitored bed for potential arrhythmias

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 Check levels of other electrolytes such as magnesium and phosphorus as it may be abnormal as well

References

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