Hypekalemia EUSEM 2012

KONSTANTINOS FAKIRIS, MD

ANAESTHESIOLOGIST

MANCHESTER, UK

ROOM Istanbul I STATE OF THE ART A42

METABOLIC EMERGENCIES

Disclosures

Dr Fakiris , anesthetist consultant employed by

Penine Acute Hospital NHS Trust, has no commercial

relationships that might impact this presentation

A.V.M. Alfonzo et al.

Resuscitation (2006) 70, 10—25

Has the danger of hyperkalemia

been exaggerated?

Hyperkalemia in the ED

Hyperkalemia has changed with

the advent of the RALES study

Pilot study

dose-related risk of

hyperkalemia

Estimated incidence : ~10%

Nephrol Dial Transplant (2004) 19: 2163–2166

Any other risk factors?

Other risk factors

Impaired kidney function :

33-83%

Medications :

35-75%

Medications that induce

Hyperkalemia

ACEIs

ARBs

Beta blockers

Potassium sparing diuretics

Antibiotics (Trimethoprim, Penicilllin G

potassium)

NSAIDs

Succinylcholine

Digoxin

Evans and Greenberg, Journal of Intensive Care Medicine 20(5); 2005

A.V.M. Alfonzo et al., Resuscitation (2006) 70, 10—25

Established Knowledge :

ECG based diagnosis

A.V.M. Alfonzo et al., Resuscitation (2006) 70, 10—25

“ The ability of physicians to predict hyperkalemia

from the ECG ”

Wrenn et al.

Sensitivity of 35-43%

Specificity of 85%

Using the EKG alone resulted in missing over

half the cases of hyperkalemia

15% of patients identified as having

hyperkalemia by EKG, had normal potassium

Wrenn et al. The ability of physicians to predict hyperkalemia from the ECG. Annals of

Emergency Medicine (1991) vol. 20 (11) pp. 1229-1232

ECG is not a sensitive method of detecting

hyperkalemia even in high risk patients

If empiric treatment is based on ECG

mistreatment of at least 15% of patients

Annals of Emergency Medicine (1991) vol. 20 (11) pp. 1229-1232

“ The ability of physicians to predict hyperkalemia

from the ECG ”

Wrenn et al.

Montague B T et al. CJASN 2008;3:324-330

©2008 by American Society of Nephrology

Potassium quintiles by presence of strict criteria

for electrocardiogram (ECG) changes.

―Retrospective review of the frequency of ECG

changes in Hyperkalemia” Brian Montague et al

There is no support for ECG use in guiding

treatment of stable patients

Management of hyperkalemia should be guided by

the clinical scenario and serial potassium

measurements

Clin J Am Soc Nephrol. 2008 Mar;3(2):324-30

Is this an emergency?

Medical History

Renal failure

Comorbidities ( CHF, Adrenal insufficiency)

Drugs

Did the K+ increase quikly?

If yes, treat as an emergency

How high is the K+ level?

If serum K+ > 7.0 mEq/L, treat as an emergency

Any EKG changes of cardiac instability?

If yes, treat as an emergency

Guidelines and Audit Implementation Network, December 2008

Therapy - Antagonizing the Cellular

Effects of Hyperkalemia

Calcium

Regardless of the blood calcium level

Without alteration of serum potassium levels

Rapid onset of action (< 3 minutes)

Duration of action : 30 – 60 mins

Calcium

Calcium chloride :

10 ml ( 10%) contain 13.5 mEq ( 272 mg) Ca

Greater bioavailability

It can be given rapidly

Calcium gluconate :

10 ml ( 10%) contain 4.65 mEq ( 93 mg) Ca

Less toxic to local tissue

May not be effective in low-flow states

Calcium

What kind?

Calcium chloride if central access, unstable

patient

Otherwise, calcium gluconate

Contraindications to Calcium

Should not be given in bicarbonate-containing

solutions

Digoxin toxicity

“Do not use calcium [to treat hyperkalemia

associated with digoxin toxicity]; it may worsen

ventricular arrhythmias.” Poisoning & Drug

Overdose” (Olson KR ed) Lange 2007 Fifth

Edition

Digoxin toxicity and Calcium

May precipitate life-

threatening arrhythmias

Irreversible contraction

Stone Heart Theory

Lown B, Black H, Moore FD.

Digitalis, electrolytes, and the surgical patient

Am J Cardiol 1960;6:309-37


Animal models failed to demonstrate any adverse

effects

5 case reports (last one in 1997)

Hack JB, et al.

The effect of calcium chloride in treating hyperkalemia due to acute

digoxin toxicity in a porcine model.

Clin Toxicol 2004;42:337– 42

Bower JO, Mengle HAK.

The additive effect of calcium and digitalis : a warning, with a report of two deaths

JAMA 1936; 106: 1511-53


… On post-operative day 2, she received several doses of

Digalen for a heart rate of 100 beats/min and a blood pressure

of 90/50 mm Hg. By the sixth postoperative day, she had received

approximately 15 cc…

More than 24h after the last dose of Digalen, she received 10cc

of 10% calcium gluconate through a peripheral intravenous line

of rate control.

2 min later she had a generalized convulsion with only slight

muscular fibrillations. She was pronounced dead shortly

thereafter…

Bower JO, Mengle HAK. The additive effect of calcium and

digitalis : a warning, with a report of two deaths.

JAMA 1936; 106: 1511-53


Only hyperkalemia was associated with

increased mortality, after multivariate analysis

―… We question the ‗stone heart‘ theory, and suggest

that intravenous calcium may not be harmful in

digoxin-intoxicated patients‖

Levine M et al. J Emerg Med 2011, Jan;40:41-6.

Insulin and dextrose

Beta agonists

Bicarbonate

Therapy - Agents That Promote Cellular

Uptake of Potassium

Insulin and dextrose

Na+/K+-ATPase pump stimulation

Unaffected by kidney failure or b- blockade

Start : 10 minutes

Peak effect : 30 minutes

Maximal decrease : 0.5 – 1.2 mEq/l

Duration : 4-6 hours

10 units are recommended

Emergency interventions for hyperkalaemia

Copyright © 2009 The Cochrane Collaboration.

Beta-agonists

Paradoxical elevation of K,

returned to baseline : 3 min

Main side effect : tachycardia

Unpredictable in impaired

renal function

Dose-response relationship

20 mg of nebulized

salbutamol are recommended

Emergency interventions for hyperkalaemia (Review)


Combination of agents

Synergistic effect of

salbutamol and insulin

Allon M, Copkney C. Albuterol and insulin

for the treatment of hyperkalemia in

hemodialysis patients. Kidney Int.

1990;38:869-872.

Sodium Bicarbonate

Inverse relationship

between serum K+

and blood pH

Treatment over a

period of several days,

in most of the studies



Sodium Bicarbonate

Allon M, Shanklin N. Effects of bicarbonate administration on plasma potassium in dialysis

patients: interactions with insulin and albuterol. Am J Kidney Dis. 1996;28(4):508-514.

Loop diuretics and saline

Cation Exchange Resins

Dialysis

Therapy - Removing Potassium

From the Body


Exchanges sodium for

potassium, in the

colon

Each gram binds 0.65-

1.0 mmol of potassium

Usual dose : 30-60 g

mixed with 100 ml

20% sorbitol orally

Initial study ( Scherr et

al., 1961)

Not well designed

Flinn et al, NEJM, 1961

SPS + Sorbitol vs

Sorbitol alone

Sorbitol alone as

effective


Potential fatal complications

Intestinal necrosis

Bleeding

Ischemic colitis

Perforation

Aspiration pneumonia

“…Concomitant administration of sorbitol is not recommended.”

FDA, September 2009

Sterns et al. Ion-Exchange Resins for the Treatment of Hyperkalemia: Are They

Safe and Effective? J Am Soc Nephrol 21: 733–735, 2010

“…It would be wise to exhaust

other alternatives for managing

hyperkalemia before turning to

these largely unproven and

potentially harmful therapies.”

Renal Replacement Therapy

The most effective method

Conventional hemodialysis more rapid

Decrease by 1.3 mmol/L of potassium within first hour

Increasing blood flow

Blood/dialysate [K+] gradient

Less [K+] in dialysate

Other treatments Blumberg et al. Amer J Med; 1988: 85, 507-512

Allon et al. American Journal of Kidney Diseases

1995;26(4):607–13.

Renal Replacement Therapy

Early consideration when :

Established renal failure

Oliguric acute kidney injury

Marked tissue breakdown

Resistancy to medical treatment

European Resuscitation Council Guidelines,

Resuscitation.2010.08.015, pp : 1400 - 1433

Disposition

A low post-treatment value does not mean that the

hyperkalemic episode is over

No clear admission criteria

Potassium > 8.0 mEq/L

Acute worsening of renal function

Comorbid medical conditions

Outpatient dialysis for stable patients with ESRD

Conclusions

Always stop medicines/food and fluids that exacerbate

hyperkalemia

Careful cardiac monitoring and repeated blood testing

including glucose is mandatory

A negative ECG does not negate the need for treatment

in severe cases

Digoxin toxicity can increase serum potassium.

Calcium MUST be administered slowly over 20

minutes


Conclusions

Beta-2 agonists are not recommended as a single

agent

Calcium /insulin/beta-2 agonists are not definitive

therapies – they simply buy time for definitive

therapy.


Hypekalemia EUSEM 2012

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