Hyperkalemia

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 Hyperkalemia

Elevation of potassium level in the

blood.
 Immediate Questions
A. Is the lab result correct? Consider
pseudohyperkalemia, especially if the ECG shows
no changes of hyperkalemia. There are a number of
causes of factitious hyperkalemia, the most
common being the tourniquet method of drawing
blood. A tight tourniquet around an extremity can
elevate the potassium. Hemolysis of a blood sample
prior to the chemical determination is another
source of error. Extreme leukocytosis (>70,000) or
thrombocytosis (>1,000,000) can elevate the serum
potassium. If there is a question, obtain a plasma
potassium.
 Immediate Questions

B. What are the vital signs?

C. What is the patient's urine

output?
 Immediate Questions
D. What does the ECG show? The ECG
is the most important test, (besides
the potassium level). It provides more
of a "bioassay" than the serum
potassium. Changes seen with
potassium increase include peaked T
waves, flat P waves, prolonged PR
interval and a widened QRS complex,
progressing to a sine wave and arrest.
 Immediate Questions
E. Is the patient taking any medication that
could raise the potassium level? Is the
patient receiving potassium in an
intravenous solution? If the patient is
receiving spironolactone, triamterene,
indomethacin and other NSAIDs; ACE-
inhibitors, trimethoprim / sulfamethoxazole,
pentamidine, succinylcholine; stop these
medications immediately.
 Differential Diagnosis
A. Redistribution
1. Acidosis drives potassium out of
the cells and can cause
hyperkalemia
2. Cellular breakdown
a. Rhabdomyolysis
b. Hemolysis
c. Tumor lysis syndrome
 Differential Diagnosis
B. Increased total body potassium
1. Inadequate excretion
a. Renal caused (acute or chronic
renal failure)
b. Mineralocorticoid deficiency or
Addison's disease
c. Drug-induced (potassium sparing
diuretics [e.g., spironolactone]
and ACE-inhibitors)
2. Excessive intake
 Differential Diagnosis
C. Pseudohyperkalemia
1. Hemolysis of the specimen
2. Prolonged period of tourniquets
occlusion prior to blood draw
3. Thrombocytosis/leukocytosis
 Plan
The severity of hyperkalemia (as
judged by the serum level and the
ECG) dictates treatment.

A. Repeat any abnormal value, taking

care to avoid hemolysis, while assessing
for increased WBC or platelets.

B. Prevention of further hyperkalemia;

discontinue any potassium administration
and any contributing drugs.
 Plan
C. Calcium administration. Calcium
counteracts membrane effects andprotects
the heart. Calcium antagonizes the
membrane effects of hyperkalemia and
restores normal excitability within minutes.
Administer one to two ampules of calcium
gluconate, (10-20 mL of a 10% solution IV
over 3-5 minutes), with the patient on a
cardiac monitor.
 Plan
D. Potassium can be quickly shifted into
cells by the administration of alkali or
glucose plus insulin (one ampule D50 and 10
units regular insulin).Sodium bicarbonate (1
ampoule [44 mmol] of bicarbonate) may be
administered intravenously over several
minutes.
 Plan
E. Remove potassium from body. Kayexolate
may be administered orally or as an enema.
Remember that this will trade potassium for
sodium and result in a sodium load. Normal
saline diuresis can assist removal of
potassium.
 ACUTE THERAPY OF HYPERKALEMIA

Condition: ECG changes of

hyperkalemia

Therapy: Calcium gluconate (10%) 10

ml IV over 3 minutes. Repeat in 5
minutes if needed. Follow with 10 units
regualar insulin IV; the insulin may be
by IV push, but must be followed with 1
ampule D50 IV push; alternatively, 10
unity regular insulin in 500cc D20 may
be infused over 30 to 60 minutes.

Comment: Lasts only 30 to 60 minutes.

No bicarbonate after calcium.
 ACUTE THERAPY OF HYPERKALEMIA

Condition: After acute phase or if

no ECG changes

Therapy: Kayexalate: Oral dose

of 30 to 60 grams in 50 ml
sorbitol (20%). Rectal dose of 50
grams in 200 ml sorbitol(20%) as
retention (30 to 45 minutes)
enema.
Comment: Oral dose preferred
(enemas are only if patient
cannot take po).
 ACUTE THERAPY OF HYPERKALEMIA

Condition: If renal failure

Therapy: Hemnodialysis as soon

as possible. Kayexalate also will
be effective, but not immediately.