Death by Bananas

The Management of Hyperkalaemia

Dr. Kiaran Flanagan, Clinical Lead Acute Medicine UHCW

June 2012

Case 1

• Patient comes into ED referred by GP for high potassium of 6.7

• You see the notes in the SIFT tray

• What do you do? ...

How to manage

• Pick up notes and PUT STICKER ON THE LIST

• ABCDE

• What are you likely to find?

• What urgent investigation do you need to make a treatment decision?

• What action would you take if – 1. Normal

– 2. Abnormal

What next?

• History...

• Examination...

• Further tests

• What are you looking for?

What next...

• Senior review?

• Actions you should recommend...– Drugs

– Monitoring

– Admit/ Discharge

– Further checks

– Anticipated future actions

– How will you make this happen?

Case 2

• Patient on the ward

• ATSP – unwell, vomiting

• Day 2 of admission – post op R hemicolectomy

• What do you do?

What do you do?

• ABCDE

• Investigations?

• Monitoring...

Patient hyperkalaemic

• What else do you look for?

• What test needs to have been done?

• What treatment do you need to give?

Recheck K at 3 hours

• Still high...

• What next?– Treatment

– Advice

– Monitoring

Recheck K at 6 hours

• Still high...

• What do you do?– Treatment

– Monitoring

– Ask for help

• Who

• What will you tell them and how?

• What for

Case 3

• Patient – Medical ALERT to Resus

• Drowsy

• High glucose

• What do you do????

What do you do?

• ABCDE

• Urgent tests

• What is the diagnosis?

• How do you manage?

Case 4

• Cardiac Arrest Call

• PEA

• What do you think about?

Hyperkalaemia in cardiac arrest

• What do you give?

Case 5

• Called to ward 1, pt unwell

• Low BP, low glucose, high potassium

• What do you do?– Assessment

– Further tests?

– Working diagnosis

– Treatment?

Causes of Hyperkalaemia• Decreased or impaired potassium excretion – renal

failure, potassium-sparing diuretics, urinary obstruction, sickle cell disease, Addison disease, and systemic lupus erythematosus (SLE)

• Additions of potassium into extracellular space - potassium supplements (eg, PO/IV potassium, salt substitutes), rhabdomyolysis, and hemolysis (eg, blood transfusions, burns, tumor lysis)

• Transmembrane shifts (ie, shifting potassium from the intracellular to extracellular space) - acidosis and medication effects (eg, acute digitalis toxicity, beta-blockers, succinylcholine)

• Factitious or pseudohyperkalemia - improper blood collection (eg, ischemic blood draw from venipuncture technique), laboratory error, leukocytosis, and thrombocytosis

Causes

• Ineffective elimination– Kidneys

– Drugs

– Endocrine

• Excessive release from cells– Injury

– Metabolic

• Excessive intake– Lethal Injection

• Pseudo

ECG Changes

How does it affect the heart?

• Hyperkalemia results in:

• Inhibition of atrial myocardial depolarization.

• Slowing of heart rate.

• Prolonging QRS duration; complexes may become bizarre.

• Also known as atrial standstill.

• Rhythm called sinoventricular rhythm.

• The ECG is a poor substitute for serum potassium levels to determine

the degree of abnormality

ECG Changes

• From reduction of P wave amplitude and prolongation of PR

interval to absence of P waves altogether.

• Increase of QRS duration.

• Increase of QT duration.

• Slowing of heart rate.

• T waves become tall and spiked.

• Decreased R wave amplitude

ECG Changes

3 Principles of Treatment

• Stabilise myocardium

• Move it into cells

• Increase elimination

Dextrose - Insulin

• How does it work?

• How long for?

• How do you give it?

• What is the dose?

• Other considerations...

Calcium Gluconate

• How does it work?

• How long for?

• How do you give it?

• What is the dose?

• Other considerations...

Sodium Bicarbonate

• How does it work?

• How long for?

• How do you give it?

• What is the dose?

• Other considerations...

Calcium Resonium

• Hmmm....

More controversial

• Salbutamol

• Furosemide

Protocols

• If K > 6 mmol– Calcium Resonium

– Unless – Rising fast/ patient septic then treat as below

• If K > 6.5 – normal ECG– Dextrose Insulin

– Calcium Resonium

Protocols

• If K > 6.5 – abnormal ECG or

• If K > 7

– Calcium Gluconate

– Dex Insulin

– Salbutamol

– Sodium Bicarbonate

– RRT

Important Bits...

• POTENTIAL LIFE THREATENING EMERGENCY

• TREAT IF INDICATED

• TRUST BUT VERIFY

• RECHECK

• CARDIAC MONITORING

• EXPERT HELP

• PREVENTION