Management of Hyperkalemia
Dr. Jordyn Johnson
Editor: Omar Lopez MS3
Definition of Hyperkalemia?
Causes?
Lab errors: Hemolysis (not reported at LCM), Sampling, handling/transport
Pseudohyperkalemia (high platelets, WBC’s or RBC’S)
Thrombocytosis, Blood transfusion
Lupus
Medications: heparin, lithium, paralytics, penG, antifungals
EKG Changes
Nontraditional ECG changes:
T wave inversions and pseudonormalizations
bundle branch, bifascicular, sinoatrial exit, and atypic bundle branch blocks
ST depressions and elevations
HyperK mimics:
left ventricular hypertrophy
early benign repolarization
acute coronary ischemia
Why is Hyperkalemia dangerous?
K above 5.1 in MI is an independently significant risk factor for mortality.
Repeated episodes of hyperkalemia also significantly increased mortality in admitted patients
Temporary vs Definitive Tx
Temporizing:
Stabilization of cardiac membrane (Calcium gluconate)
Redistribution of potassium (insulin and albuterol)
Elimination of potassium (diuretics)
Long term:
Address underlying causes
Diet - least emphasized but an important factor
Adverse Effects
Calcium infusion:
Heart block in patients with digoxin-induced hyperkalemia
Acute dermal calcifications.
Theoretic risk of metastatic vascular calcifications.
Albuterol: Hypoglycemia and tachycardia
Diuretics:
dysnatremias, hypomagnesemia
nephrolithiasis
Sodium Bicarbonate:
Acute pulmonary edema
May precipitate acute hyperosmolarity including case reports of central pontine myelinolysis.
Worsening of AKI and mortality in patients undergoing cardiac surgery
Newer potassium exchange resins can induce hypomagnesemia, hypercalciuria, and even edema at high doses
Changes of Practice
Sodium Bicarbonate: It has been found that isotonic really only works for patients with metabolic acidosis and is inappropriate if the patient is also fluid overloaded. Hypertonic sodium bicarbonate or “amp of bicarb” has been proven not to work.
Kayexalate: Cochrane review found there to be no significant studies supporting its use. Given its risk profile including GI disturbances, significant electrolyte abnormalities and, when given alone or with cathartics, bowel necrosis its use has been decreased.
EMCrit: “Neither kayexalate nor patiromer has been proven to lower potassium acutely. Neither one currently has a role for emergent therapy of hyperkalemia.”
Citations
Farkas, J. (2022, June 11). Hyperkalemia. EMCrit Project. Retrieved September 22, 2022, from https://emcrit.org/ibcc/hyperkalemia/
Hollander-Rodriguez, J. C., & James F. Calvert, J. (2006, January 15). Hyperkalemia. American Family Physician. Retrieved September 22, 2022, from https://www.aafp.org/pubs/afp/issues/2006/0115/p283.html#:~:text=Patients%20with%20hyperkalemia%20and%20characteristic,be%20given%20intravenous%20calcium%20gluconate.&text=Acutely%20lower%20potassium%20by%20giving,agonist%20by%20nebulizer%2C%20or%20both.&text=Total%20body%20potassium%20should%20usually,sodium%20polystyrene%20sulfonate%20(Kayexalate).
Malone, D. J. (2015, November). Taking a second look at Kayexalate. Hospital pharmacy. Retrieved September 22, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4750843/
sbord1. (2021, August 2). Elevated potassium: Let's rethink kayexalate and other potassium binding agent. website. Retrieved September 22, 2022, from https://www.nextlevelemergencymedicine.com/single-post/elevated-potassium-let-s-rethink-kayexalate-and-other-potassium-binding-agent
Sodium bicarbonate for hyperkalemia in the emergency department. Pharmacy Friday Pearls. (2022, February 11). Retrieved September 22, 2022, from https://www.pharmacy-pearls.org/sodium-bicarbonate-for-hyperkalemia-in-the-emergency-department/