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Emergency
Mangement
Hyperkalaemia
Author: A McKie, D Ellis
Date of Review: Oct 2012
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Version: 1
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Contents
1.
2.
3.
4.
5.
6.
7.
8.
Methodology
Background
Management
Review
Monitoring
Implementation
References
Treatment Algorithm
Page Number(s)
2-3
3-8
9-14
14
14
15
15-16
17
1 Methodology
1. Rationale/Purpose/Objective
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2. Scope
4. Evidence
Emergency
Mangement
Hyperkalaemia
Author: A McKie, D Ellis
Date of Review: Oct 2012
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5. Methods
2. Background
Potassium is a mostly intracellular cation with approximately 98% of the
total being within the intracellular fluid (ICF) compartment (mainly
muscle) and only 2% in the extracellular fluid (ECF). This ratio of ECF:ICF
potassium is a primary determinant of resting membrane potential in all
electrically active cells and a small absolute change in extracellular
potassium can alter the resting membrane potential of these cells. This
can have dramatic effects on cell function including altering myocardial
cell conduction velocity, repolarisation, preventing normal muscle
contraction and nerve functioning. Therefore the body maintains tight
control of extracellular potassium in a variety of ways including altering
renal and gut excretion and the flux of potassium into or out of the
intracellular compartment (mainly via the sodium potassium pump).
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Fig. 1
Fig. 2
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Aetiology of hyperkalaemia
The most common cause of hyperkalaemia in paediatric practice is
pseudo-hyperkalaemia or a spuriously elevated result. The clearest
indicators of probable spurious hyperkalaemia are clinical context and
renal function [7]. Therefore, if the patient has normal renal function and
no risk factors for hyperkalaemia it is likely that the result is spurious.
(1) Pseudo-hyperkalaemia may be due to:
Marked leucocytosis/leukaemia
Thrombocytosis (potassium released during clot formation-plasma
levels normal serum levels raised)
Hereditary and acquired red cell disorders causing in vivo
haemolysis
Tumour lysis syndrome
Trauma, burns, surgery, crush injury, rhabdomyolysis
Emergency
Mangement
Hyperkalaemia
Author: A McKie, D Ellis
Date of Review: Oct 2012
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Compartment syndrome
Acidosis
*
Some drugs e.g. -blockers, suxamethonium , propofol
Digoxin toxicity
Insulin deficiency
Cessation of -adrenergic agonists, followed by leaching of K+ out
of cells
Suxamethomium can cause a transient rise in serum potassium of 0.51mmol/l for up to half an hour [8][9][10]
(6) Rare conditions such as:
Patient Assessment
Hyperkalaemia may be entirely asymptomatic and detected coincidentally
during blood testing for another reason or the patient may have
symptoms such as tiredness, nausea, vomiting, muscle weakness,
palpitations or very rarely flaccid paralysis.
Even in the absence of symptoms a high potassium level particularly in
conjunction with supportive ECG changes is a medical emergency. A
Emergency
Mangement
Hyperkalaemia
Author: A McKie, D Ellis
Date of Review: Oct 2012
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Version: 1
Page 6 of 19
ECG Monitoring:
Whilst confirming the diagnosis and during therapy, the patient should
have continuous ECG monitoring, to detect any of the classic changes
associated with hyperkalaemia. Whilst there is a recognised progression of
ECG changes from mild through to severe hyperkalaemia, there is a poor
correlation between ECG changes and serum potassium concentration,
and the progression of rhythm abnormalities is unpredictable in any
individual. ECG changes are dependent on both the absolute value and the
rate of increase of potassium levels. Some patients with severe
hyperkalaemia may have no identifiable ECG changes and others may
have changes at surprisingly low potassium levels. The absence of ECG
changes in cases of moderate or severe hyperkalaemia does not obviate
the need for therapy. The presence of ECG changes, even in mild
hyperkalaemia, should encourage prompt and aggressive treatment.
Emergency
Mangement
Hyperkalaemia
Author: A McKie, D Ellis
Date of Review: Oct 2012
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Version: 1
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Investigations
Regular monitoring of serum potassium, electrolytes, glucose and blood
gas are useful especially as hyperkalaemia is frequently associated with
acidosis and hyperglycaemia. In some cases it may be useful to perform:
Full blood count with differential and film to look for haemolysis,
leucocytosis and thrombocytosis
Creatinine kinase in cases of possible tissue injury, trauma, burns
Urinary potassium excretion
Bilirubin, reticulocytes and haptoglobin in suspected haemolysis
Renal ultrasound if suggestion of renal dysfunction or obstruction
Emergency
Mangement
Hyperkalaemia
Author: A McKie, D Ellis
Date of Review: Oct 2012
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These investigations depend upon the individual clinical situation and must
never delay acute treatment once it is deemed necessary.
3. Management
Airway, Breathing, Circulation.
Repeat serum potassium should be ordered urgently, especially if
hyperkalaemia is an unexpected or isolated finding and there are no ECG
signs of hyperkalaemia, to exclude pseudohyperkalaemia. This can be run
on the gas machine and should not preclude starting preparation of
definitive therapy.
Hypoxia potentiates the risk of cardiac dysrhythmia, so all patients (unless
there is an associated cardiac lesion requiring low FiO2) should be
administered oxygen.
The response of an individual patient to any of the following proposed
therapies is unpredictable, so frequent repeated monitoring of potassium
is mandatory.
ECG monitoring should be continuous once hyperkalaemia is suspected
and treatment is commenced. Emergency treatment is required in any
patient with ECG changes, is symptomatic or who has a true potassium
level above 6.5mmol/l regardless of ECG appearance. Between 6 and
6.5mmol/l calcium may be withheld at the discretion of senior medical
staff but other therapy should be commenced. Even lower levels of
hyperkalaemia may require treatment particularly in the setting of a rapid
or acute rise when it is less well tolerated. Arrhythmia control is difficult
without lowering the serum potassium level.
Ideally calcium and glucose 50% should be administered centrally. If
central access is unavailable then it may be appropriate to give larger
volumes of a more dilute concentration. Preparation time and risk of
injuries secondary to extravasation must be weighed against the risk of
cardiac instability.
Bradycardia secondary to hyperkalaemia presents a conundrum and
mandates the PICU consultant being informed. It is unlikely to resolve
without correcting the hyperkalaemia but therapy with calcium salts may
Emergency
Mangement
Hyperkalaemia
Author: A McKie, D Ellis
Date of Review: Oct 2012
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These interventions buy time for more definitive therapy but they do not
remove potassium from the body. Beta-blockers and digoxin may reduce
the effectiveness of insulin-glucose and beta-2 agonists.
Emergency
Mangement
Hyperkalaemia
Author: A McKie, D Ellis
Date of Review: Oct 2012
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a)
Insulin
The onset of action is around 15 minutes and the effect lasts for over 1
hour. Potassium levels have been shown to fall by up to 0.5mmol/l in
20minutes and 1mmol/l by an hour, so it is an effective temporising
manoeuvre [11] [14]. Dosing can be repeated after 30 minutes. The
effect lasts up to 4 hours.
Theoretically one could give a dextrose load alone as this will increase the
childs own insulin production and promote intracellular uptake of
potassium, however the potassium lowering effect is likely to be greater if
glucose and insulin are used in combination. Also the endogenous insulin
response may be inadequate and the resultant hypertonic state may
exacerbate hyperkalaemia due to solvent drag with efflux of water from
the intracellular to extracellular compartment.
Glucose may not need to be given if the serum glucose is > 16mmol/dl,
this should be discussed with the consultant.
b)
-adrenergic agonist.
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3.
a)
Cation exchange resins e.g. calcium resonium and Resonium A
the degree of benefit of these treatments in hyperkalaemia remains
controversial.
Cation exchange resins remove potassium directly from the body through
the gut mucosa of the large bowel and ileum. Approximately one gram of
resin exchanges 1mmol sodium or 2mmol calcium for 1mmol of
potassium. This potassium is then bound by the resin in the intestinal
lumen and excreted. The onset of action is slow, in the order of 1-2
hours, with peak of 4-6 hours so the temporising steps in point 2 must be
undertaken in the first instance.
The resins can be administered rectally or orally. The preferred route is
oral (except in neonates) if administered rectally the resin should be
mixed with methylcellulose and retained for at least 60 minutes.
Recommended doses are: 250mg/kg (max 15g) 3-4 times per day orally
or rectally, repeated every 6-8 hours if required for children over 1 month
of age. [13] The resin must not be combined with fruit juices as they
contain high levels of potassium. If the rectal route is used the colon
must be irrigated 6-12 hourly to prevent faecal impaction. Side effects
include rectal mucosal irritation and ulceration, faecal impaction,
constipation and rarely bowel perforation. Hypercalcaemia may occur
especially in patients on dialysis.
The data regarding the effectiveness of exchange resins is conflicting. It
is possible to excrete up to 12 mmol/l potassium via the gastro-intestinal
tract in healthy adults however this is limited by stool volume. This is
especially pertinent in a paediatric population who obviously have much
lower stool volumes. Some authors also suggest that resins do not
contribute to faecal potassium excretion above the effect of laxatives
alone [24]
Emergency
Mangement
Hyperkalaemia
Author: A McKie, D Ellis
Date of Review: Oct 2012
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These drugs increase urine flow and delivery of sodium to distal tubular
potassium excreting sites. This is likely to be less effective in patients
with renal dysfunction who may have limited response to diuretics
c)
Haemodialysis
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4. Review:
This guideline should be reviewed every 2 years from date of approval
5. Monitoring
An audit of adherence to the guidelines can be performed.
6. Implementation plan
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Emergency
Mangement
Hyperkalaemia
Author: A McKie, D Ellis
Date of Review: Oct 2012
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Version: 1
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7. References
1. Shaffer SG, Kilbride HW, Hayen LK, Meade VM, Warady
BA. Hyperkalemia in Very Low Birth Weight Infants. J Pediatr,
1992;121:275-9.
2. Brenner: Brenner & Rector's The Kidney, 7th ed.
Copyright 2004 Saunders, An Imprint of Elsevier
3. Mandal AK. Hypokalemia and hyperkalemia. Med Clin North Am
1997;81:61139
4. Guidelines for the Treatment of Hyperkalaemia in Adults GAIN
(Guidelines and Audit Implementation Network- Northern Ireland)
December 2008
5. Webster A, Brady W, Morris F. Recognising Signs of Danger: ECG
Changes Resulting From an Abnormal Serum Potassium Concentration.
Emerg Med J 2002;19:7477
6. Martinez-Vea A, Bardaji A, Garcia C, Oliver J A. Severe Hyperkalemia
With Minimal Electrocardiographic Manifestations. Journal of
Electrocardiology1999 32 1 45-49
7. Stuart W, Smellie A. Spurious Hyperkalaemia. BMJ 2007;334:693-5
8. Day S. Plasma Potassium Changes Following Suxamethonium And
Suxethonium In Normal Patients And In Patients In Renal Failure
Br.J. Anaesth. 1976;48: 1011-15
9. List W F. Serum Potassium Changes During Induction Of Anaesthesia.
Brit. J. Anaesth. 1967;39: 480-484
10. Weintraub H D, Heisterkamp D V, Cooperman L H. Changes In
Plasma Potassium Concentration After Depolarizing Blockers In
Anaesthetized Man. Brit. J. Anaesth. 1969;41:1048-105
11. Ahee P, Crowe AV. The Management Of Hyperkalaemia In The
Emergency Department. J Accid Emerg Med 2000;17:188191
12. Noyan A, Anarat A, Pirti M, et al. Treatment Of Hyperkalemia In
Children With Intravenous Salbutamol. Acta Paediatr Jpn 1995;37:3557
13. Martin J (ed) BNF for Children 2010. London: Pharmaceutical Press
2010
14. Lens XM, Montoliu J, Cases A, et al. Treatment Of Hyperkalemia In
Renal Failure: Salbutamol V Insulin. Nephrol Dial Transplant 1989;4:228
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Mangement
Hyperkalaemia
Author: A McKie, D Ellis
Date of Review: Oct 2012
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Emergency
Mangement
Hyperkalaemia
Author: A McKie, D Ellis
Date of Review: Oct 2012
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Emergency
Mangement
Hyperkalaemia
Author: A McKie, D Ellis
Date of Review: Oct 2012
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Hyperkalaemia Algorithm
(PICU)
K+ > 5.5
mmol/l
(Genuine Result)
No
Asymptomatic and
Normal ECG
Symptomatic or
abnormal ECG
Discuss with renal and
ICU consultant , follow
patient protocol
K+ 6mmol/l
or abnormal ECG
or symptomatic
K+ <6mmol/l and
normal ECG
and asymptomatic
Discuss with
consultant
IV Furosemide 0.5mg/kg