Ahmed Shakam, Eman Ezzat El-Gohary, Ahmed Adam · Ahmed Shakam, Eman Ezzat El-Gohary, Ahmed Adam...
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The American Heart Association (AHA) provided 2005 Cardio Pulmonary Resuscitation (CPR) guidelines that defined hyperkalemia as a serum potassium (K + ) concentration higher than 5 mmol/ L. It was classified according to serum K + level as a mild elevations (5-6 mmol/ L), a moderate elevations (6-7 mmol/ L) and a severe elevations (>7 mmol/ L with toxic Electro Cardio Graphic (ECG) changes. The reported incidence of hyperkalemia in hospitalized patients is between 1 and 10%. Although hyperkalemia is less frequent than hypokalemia but is more likely to cause serious complications in critically ill patients. The vast majority of cases are related to patients prescribed angiotensin converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) in conjunction with spironolactone with pre-existing or new renal failure. Ahmed Shakam, Eman Ezzat El-Gohary, Ahmed Adam Faculty of Medicine, University of Alexandria, EGYPT Assess the response of serum K + levels after initial lines of management of hyperkalemic patients with renal impairment in the first twelve hours of patient presentation at the Emergency Department. The study included 50 hyperkalemic patients with renal impairment, who were presented to the emergency department or critical units. Inclusion criteria were; serum K + level (6-7mmol/L) and serum creatinine level (2-5 mg/dl). Exclusion criteria were: a normal kidney function, renal replacement therapy, pH > 7.1 and ECG changes due to hyperkalemia. Selected patients were given different initial lines of management for the first twelve hours or till serum K+ level declined to < 6mmol/L as follow; The first group (G1); 10 patients were managed by intravenous (IV) infusion of 10 units of Insulin Act Rapid (AR) over 2 hours, provided in 25 gm glucose in the form of 100 ml of glucose 25% in non-diabetic patients or in diabetic patients with glucose level below 250 mg/dl. This infusion was repeated every 2 hours unless serum K+ level declined to < 6mmol/L. The second group (G2); 10 patients were managed by 10 mg nebulized salbutamol over 2 hours,(2) where the nebulization settings were given divided in to 4 doses of 2,5 mg (2,5 ml) per setting each half an hour, that was more safe to avoid any un-tolerated tachycardia. These four nebulization settings were repeated every 2 hours unless serum K+ level declined to < 6mmol/L. The third group (G3); 10 patients were managed by sodium bicarbonate (NaHCO 3 ) 50mmol IV over 5-15 minutes, for 2 hours after ensuring that each 2 hours the arterial blood gases (ABGs) were revealing that pH was >7.5 and bicarbonate (HCO 3 ) was> 28mmol/L. This dose was repeated every 2 hours unless serum K+ level declined to < 6mmol/L. The fourth group (G4); 10 patients were managed by a cocktail of all previous lines. This cocktail was repeated every 2 hours unless serum K+ level declined to < 6mmol/L. The fifth group (G5); 10 patients were managed by giving IV furosemide(Lasix) 10 mg/ 2 hours, provided that Blood Pressure (BP) was not below 110/70mmhg.This dose was repeated every two hours unless serum K+ level declined to < 6mmol/L. Follow up of serum K+ level was done each 2 hours till the end of the twelve hours management or till serum K+ level declined to < 6mmol/L. 50 patients were randomly distributed into 5 groups and given different initial lines of management as: • G1: 10 units of IV insulin (AR) over 2 hours, G2: 10 mg nebulized salbutamol over 2 hours, G3: NaHCO 3 (50mmol) IV/ 2 hours, G4: a triple cocktail of all previous lines and G5: IV furosemide (Lasix) 10mg/ 2 hours. Each line of treatment was repeated every two hours unless serum K + level declined to <6 mmol/L. Comparison between the five studied groups according to initial serum K + levels, serum K + levels after 2 hours and serum K + changes IV insulin, nebulized salbutamol and the triple cocktail were equally effective lines of treatment for moderate, non-cardiac and non-alkalotic hyperkalemic patients in the first 2 and 4 hours of therapy However, the nebulized salbutamol was not effective line of treatment after 12 hours. Repeating the dose of nebulized salbutamol could be recommended within the first twelve hours guided with serum K + level. However, insulin alone is a more safe line of choice in decompensated cardiac or pre-arrhythmic hyperkalemic patients and may get better results at the end of the first twelve hours. Nebulized salbutamol could be favorable to be the first treatment to be given or to be added when hypoglycemia is liable to occur. NaHCO 3 is minimally effective alone and its effect is mainly in controlling and preventing metabolic acidosis rather than in lowering serum K + level. Although furosemide is increasing urinary potassium excretion in normal kidney, but it has no significant therapeutic effect within the first twelve hours of acute presentation of moderate hyperkalemic patients of our study. To the best of our knowledge, no research done to assess the long standing effect of any of the therapeutic options of treatment of hyperkalemia after 12 hours. This is important to assess the efficacy of therapy. Whatever the recommended line of therapy, not enough to give a bolus of treatment once without assessing the response within two hours and follow up of the serum K + levels within twelve hours. Repeating the dose of hypokalemic therapy should be considered every six hours all over the non- dialysis period of such unstable moderate hyperkalemic patients. Mild or severe hyperkalemic patients may need different options of therapy. Moreover hyperkalemic patients with normal kidney functions may also need other options of therapy. It is recommended to study the average duration consumed with hyperkalemic renal patients before taking the decision of hemodialysis. Comparison between the five studied groups according to ending and continuing treatment after 2 hours G1 G2 G3 G4 G5 Patients reaching the end point of treatment after 2 hours 5 3 0 6 0 Patients continuing with the same treatment after 2 hours (the remaining sample) 5 7 10 4 10 Comparison between the five remaining after 2 hours studied groups according to initial serum K+ levels, serum K + levels after 4 hours and serum K + changes. Comparison between the five studied groups according to ending and continuing treatment after 4 hours G1 G2 G3 G4 G5 Patients reaching the end point of treatment after 4 hours 9 9 1 10 0 Patients continuing with the same treatment after 4 hours (the remaining sample) 1 1 9 0 9 Comparison between the five remaining after 2 hours studied groups according to initial serum K+ levels, serum K + levels after 4 hours and serum K + changes. However, after 12 hours, only G1 (IV insulin) had statistical significant decline in serum K+ level in comparison to G3 (NaHCO 3 ) and G5 (furosemide). While G4 (the triple cocktail) had only statistical significant decline in serum K + level in comparison to G3 (NaHCO 3 ).
Transcript of Ahmed Shakam, Eman Ezzat El-Gohary, Ahmed Adam · Ahmed Shakam, Eman Ezzat El-Gohary, Ahmed Adam...
The American Heart Association (AHA) provided 2005 Cardio Pulmonary Resuscitation (CPR)guidelines that defined hyperkalemia as a serum potassium (K+) concentration higher than 5 mmol/ L.It was classified according to serum K+ level as a mild elevations (5-6 mmol/ L), a moderate elevations(6-7 mmol/ L) and a severe elevations (>7 mmol/ L with toxic Electro Cardio Graphic (ECG) changes.
The reported incidence of hyperkalemia in hospitalized patients is between 1 and 10%. Althoughhyperkalemia is less frequent than hypokalemia but is more likely to cause serious complications incritically ill patients. The vast majority of cases are related to patients prescribed angiotensinconverting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) in conjunction withspironolactone with pre-existing or new renal failure.
Ahmed Shakam, Eman Ezzat El-Gohary, Ahmed AdamFaculty of Medicine, University of Alexandria, EGYPT
Assess the response of serum K+ levels after initial lines of management of hyperkalemic patients withrenal impairment in the first twelve hours of patient presentation at the Emergency Department.
The study included 50 hyperkalemic patients with renal impairment, who were presented to theemergency department or critical units. Inclusion criteria were; serum K+ level (6-7mmol/L) and serumcreatinine level (2-5 mg/dl). Exclusion criteria were: a normal kidney function, renal replacement therapy,pH > 7.1 and ECG changes due to hyperkalemia.
Selected patients were given different initial lines of management for the first twelve hours or till serumK+ level declined to < 6mmol/L as follow; The first group (G1); 10 patients were managed by intravenous(IV) infusion of 10 units of Insulin Act Rapid (AR) over 2 hours, provided in 25 gm glucose in the form of100 ml of glucose 25% in non-diabetic patients or in diabetic patients with glucose level below 250 mg/dl.This infusion was repeated every 2 hours unless serum K+ level declined to < 6mmol/L. The second group(G2); 10 patients were managed by 10 mg nebulized salbutamol over 2 hours,(2) where the nebulizationsettings were given divided in to 4 doses of 2,5 mg (2,5 ml) per setting each half an hour, that was moresafe to avoid any un-tolerated tachycardia. These four nebulization settings were repeated every 2 hoursunless serum K+ level declined to < 6mmol/L. The third group (G3); 10 patients were managed bysodium bicarbonate (NaHCO3) 50mmol IV over 5-15 minutes, for 2 hours after ensuring that each 2 hoursthe arterial blood gases (ABGs) were revealing that pH was >7.5 and bicarbonate (HCO3) was> 28mmol/L.This dose was repeated every 2 hours unless serum K+ level declined to < 6mmol/L. The fourth group(G4); 10 patients were managed by a cocktail of all previous lines. This cocktail was repeated every 2hours unless serum K+ level declined to < 6mmol/L. The fifth group (G5); 10 patients were managed bygiving IV furosemide(Lasix) 10 mg/ 2 hours, provided that Blood Pressure (BP) was not below110/70mmhg.This dose was repeated every two hours unless serum K+ level declined to < 6mmol/L.Follow up of serum K+ level was done each 2 hours till the end of the twelve hours management or tillserum K+ level declined to < 6mmol/L.
50 patients were randomly distributed into 5 groups and given different initial lines of management as:• G1: 10 units of IV insulin (AR) over 2 hours, G2: 10 mg nebulized salbutamol over 2 hours, G3: NaHCO3
(50mmol) IV/ 2 hours, G4: a triple cocktail of all previous lines and G5: IV furosemide (Lasix) 10mg/ 2hours.
Each line of treatment was repeated every two hours unless serum K+ level declined to <6 mmol/L.
Comparison between the five studied groups according to initial serum K+ levels, serum K+
levels after 2 hours and serum K+ changes
IV insulin, nebulized salbutamol and the triple cocktail were equally effective lines of treatmentfor moderate, non-cardiac and non-alkalotic hyperkalemic patients in the first 2 and 4 hours oftherapy
However, the nebulized salbutamol was not effective line of treatment after 12 hours.
Repeating the dose of nebulized salbutamol could be recommended within the first twelve hoursguided with serum K+ level.
However, insulin alone is a more safe line of choice in decompensated cardiac or pre-arrhythmichyperkalemic patients and may get better results at the end of the first twelve hours.
Nebulized salbutamol could be favorable to be the first treatment to be given or to be added whenhypoglycemia is liable to occur.
NaHCO3 is minimally effective alone and its effect is mainly in controlling and preventingmetabolic acidosis rather than in lowering serum K+ level.
Although furosemide is increasing urinary potassium excretion in normal kidney, but it has nosignificant therapeutic effect within the first twelve hours of acute presentation of moderatehyperkalemic patients of our study.
To the best of our knowledge, no research done to assess the long standing effect of any of thetherapeutic options of treatment of hyperkalemia after 12 hours. This is important to assess theefficacy of therapy.
Whatever the recommended line of therapy, not enough to give a bolus of treatment once withoutassessing the response within two hours and follow up of the serum K+ levels within twelve hours.Repeating the dose of hypokalemic therapy should be considered every six hours all over the non-dialysis period of such unstable moderate hyperkalemic patients.
Mild or severe hyperkalemic patients may need different options of therapy.
Moreover hyperkalemic patients with normal kidney functions may also need other options oftherapy.
It is recommended to study the average duration consumed with hyperkalemic renal patientsbefore taking the decision of hemodialysis.
Comparison between the five studied groups according to ending and continuing
treatment after 2 hours
G1 G2 G3 G4 G5
Patients reaching the
end point of treatment
after 2 hours
5 3 0 6 0
Patients continuing
with the same
treatment after 2 hours
(the remaining
sample)
5 7 10 4 10
Comparison between the five remaining after 2 hours studied groups according to initial serum K+ levels, serum K+ levels after 4
hours and serum K+ changes.
Comparison between the five studied groups according to ending and continuing
treatment after 4 hours
G1 G2 G3 G4 G5
Patients reaching the
end point of treatment
after 4 hours
9 9 1 10 0
Patients continuing
with the same
treatment after 4 hours
(the remaining
sample)
1 1 9 0 9
Comparison between the five remaining after 2 hours studied groups according to initial serum K+ levels, serum K+ levels after 4
hours and serum K+ changes.
However, after 12 hours, only G1 (IV insulin) had statistical significant decline in serum K+ level incomparison to G3 (NaHCO3) and G5 (furosemide). While G4 (the triple cocktail) had only statisticalsignificant decline in serum K+ level in comparison to G3 (NaHCO3).
