A Mnemonic for the Treatment of Hyperkalemia | Potassium | Medical Specialties

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  04/21/2015 1 A Mnemonic for the Treatment of Hyperkalemia Nick Wolters, PGY1 Resident Grandview Medical Center Hyperkalemia ã 30 YOF, ESRD, missed 2 dialysis sessions over the last week ã Potassium level came back at 7 mEq/L ã EKG shows widened QRS ã Urgent dialysis indicated; however, while waiting for nephro to see patient….   ã What are your med options to treat her hyperkalemia? Peaked T Waves Mnemonic C A B I G K L D See (C) A BIG Potassium (K) Level (L) Decrease (D) Calcium  –  Chloride/Gluconate Albuterol Bicarbonate Insulin + Glucose (Dextrose) Kayexalate (Sodium Polystyrene) Loops - Diuretics Dialysis Stabilize Cardiac Membrane Move K Intracellularly Remove K from blood Calcium ã For severe hyperkalemia with EKG changes  – Does NOT LOWER SERUM K!  – “Stabilizes” ventricles against arrhythmia   ã Chloride vs gluconate  – Elemental calcium ã One ampule 10% CaCl 2 = 270mg elemental Ca ã One ampule 10% CaGluconate= 90mg elemental Ca  – Osmolality ã CaCl 2 = 2053 mOsm/L  –  Central line preferred ã CaGluconate= 697 mOsm/L  –  Good for peripheral ã Dosing: 1000-3000 mg IV over 3-5 min  – Can be repeated in 5 min if EKG changes still  – Effect in minutes, lasts 30-60 min Calcium ã Never with bicarbonate as can precipitate CaCO 3 ! ã Give even if Ca levels are normal or elevated ã Case reports of sudden death in patients given IV calcium while receiving digoxin  04/21/2015 2 Albuterol ã B 2  agonist  – Drives K into cells via Na/K ATPase ã Dosing is 4-8x normal albuterol dosing  – 10-20 mg via med neb over 10 minutes    – Drops K by 0.5-1.0 mEq/L  – Modest K lowering (0.4mEq) can be seen with an albuterol MDI ã Mild tachycardia can be seen ã Not effective for patients on non-selective Beta Blockers ã Should never be used for single treatment of hyperkalemia   Bicarbonate ã Increases pH, H ions leave cells as part of buffer system; only use if acidotic  – K moves into cells to balance loss of H  – Enhance insulin-mediated K uptake?? ã Short-term infusions of bicarb (up to 4 hours) have little effect on serum K levels  – Probably works best via prolonged infusion rather than IV push 50 mEq ã 150mmol/L IV at variable rate ã Bicarb complexes with calcium  – Counterproductive when calcium is antagonizing membrane effects of hyperkalemia Insulin/Glucose ã Drives K into cells via Na-K-ATPase pump in skeletal muscle  – Give glucose to prevent drop in blood sugar, don’t give glucose if blood sugar > 250 mg/dL ã 10 units of short-acting insulin IV (we use Humalog)  – With 50 ml of 50% dextrose IV (if necessary) ã Giving glucose in hyperglycemia could worsen hyperkalemia ã Effect within 10-20 min , peaks at 30-60 min, lasts 4-6 hrs  – Check sugar within an hour ã K+ should drop 0.6 mEq/L ã Utilized in emergency treatment of hyperkalemia Kayexalate ã Sodium polystyrene sulfonate (SPS)  – Cation exchange resin ã Exchanges Na for excreted potassium in the gut ã Most exchange takes place in the colon ã Each gram can bind 0.65mEq of K  –  though this is unpredictable ã Can give orally (preferred) or by retention enema  – Oral dose 15-30 grams, repeat every 4-6 hours  – Enema: 50 grams with 150 ml tap water ã Can cause constipation  –  given with a laxative (20% sorbitol)  – Very little effects of SPS over sorbitol alone Kayexalate ã Two Main Concerns  – Slow Effect ã Onset is at least 2 hours, may take 6 hours for max effect ã SPS enema is more rapid, but less of a K removing enema  – Case reports of necrotic bowel lesions ã Recs to not use in postop, SBO, ileus patients ã Can remove K from body, but poor choice for urgent hyperkalemia Loop Diuretic ã Spills K into urine  – Makes sense ONLY IF pt hypervolemic, normovolemic   ã Furosemide 40-80mg IV; Bumetanide 1-2mg IV  – Furosemide 40 mg = bumetanide 1 mg  – Onset 15min, duration of 2-3 hours  04/21/2015 3 Dialysis ã Most effective option for K removal  – 1mEq/L drop in first 60min  – 2mEq/L drop after 3 hours ã K rebound after dialysis  – Rebound K amount is proportional to K removed during HD ã Precipitates ventricular arrhythmias?? ã Patients should have continuous EKG monitoring Wuzzle Remember… References ã Weisberg, LS. Management of Severe Hyperkalemia. Crit Care Med 2008 Vol 36, No 12. Pgs. 3246-3251 ã Marino’s ICU Book. 4 th  Edition. 2014. Wolters Klewer Health. Philadelphia, PA ã Lexi-Comp ONLINE® [database on the Internet]. Hudson (OH): Lexi-Comp Inc. 2015[cited 4/17/15]. Available from: http://crlonline.com/crlsql/servlet/crlonline
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