Hyperkalemia
Background
- Defined as >6.0 mEq/L
- Consider pseudohyperkalemia (e.g. from hemolysis)
- Potassium secretion is proportional to flow rate and sodium delivery through distal nephron
- This is how loop & thiazide diuretics cause hypokalemia
ECG
Changes NOT always predictable and sequential
- 6.5 - 7.5 mEq/L: peaked T waves, prolonged PR interval, shortened QT interval
- 7.5 - 8.0 mEq/L: widened QRS interval, flattened P waves
- 10 - 12 mEq/L: sine wave, ventricular fibrillation, heart block
Differential Diagnosis
- Pseudohyperkalemia: hemolyzed specimen, prolonged tourniquet use prior to blood draw, thrombocytosis or leukocytosis
- Redistribution
- Acidemia (see (DKA))
- Cellular breakdown: see Rhabdomyolysis/crush injury, hemolysis, see Tumor Lysis Syndrome
- Increased total body potassium
- Inadequate excretion: Acute or chronic renal failure, hypoaldosteronemia
- Drug-induced: potassium-sparing diuretic (spironolactone), angiotensin converting enzyme inhibitors (ACE-I), nonsteroidal anti-inflammatory drugs (NSAIDs)
- Excessive intake: diet, blood transfusion
- Other causes: succinylcholine, digitalis, beta-blockers
Treatment
Stabilize Cardiac Membranes: give if ECG changes, consider if K >7 mEq/L
- Intravenous calcium: only if QRS interval prolonged
- Can give as calcium gluconate or calcium chloride
- Calcium gluconate 2 - 3 grams IV
- Only 1/3 the calcium compared to calcium chloride
- Give over 10 minutes: can cause hypotension due to osmotic shift
- Calcium chloride 1 gram IV
- Give over 1 - 2 minutes
- Extravasation is bad: use a good IV
- Usually given in code situations
- Duration of action: 30 - 60 minutes
- Use caution if patient digitalis toxic
- Do serial EKGs to track progress: may need to give multiple doses
- Calcium gluconate 2 - 3 grams IV
Force Intracellular Shift
- Intravenous insulin + dextrose
- Give 10 units regular insulin intravenously with 25 to 50 grams (1 - 2 50 mL ampules) of 50% dextrose (D50)
- May withhold dextrose if blood sugar >300 mg/dl
- Duration of effect: 4 - 6 hours
- Give 10 units regular insulin intravenously with 25 to 50 grams (1 - 2 50 mL ampules) of 50% dextrose (D50)
- Nebulized albuterol 5 - 20 mg
- Response is dose-dependent
- Peak effect: 30 minutes
- Duration of effect: 2 hours
- Intravenous sodium bicarbonate 50 ml of 8.4% solution (1 ampoule) given over 5 minutes
- Duration of effect: 1 - 2 hours
- More effective if patient is acidemic
Remove from System
- Intravenous furosemide (Lasix) 40 - 80 mg
- Sodium polystyrene sulfonate (Kayexylate): 30 gm oral or per rectum
- Unreliable, slow, potential complications: falling out of favor
- Intravenous normal saline solution for volume expansion if dehydrated, rhabdomyolysis, diabetic ketoacidosis or other acidosis
- Definitive: hemodialysis
See Also
Source
Tintinalli Management Severe Hyperkalemia. Crit Care Med, 2008, 36:12 EMCrit Podcast #32