Hyperkalemia

-- SX: weakness, paresthesias,N/V, constipation, palpitations/dysrhythmias
-- Hx: CKD/ESRD, dialysis, extreme excersise, truma,DM, Malignancy
-- PE: Cardiac, Neuro: weakness, decreased reflexes, AMS
-- DATA: BMP,CBC, EKG (peaked T waves, prolonged PR interval-prolonged QRS, loss of P wave, ST elevation,)
-- MEDS:ACE/ARB, MRctrumAs,Bactrum, NSAIDs, beta-blockers
-- DDX: Cellular Shifts (( Acidemia- K shift out of cells, Rhabdomyolysis, Tumor Lysis Syndrome, Beta-blockers, Aldosterone deficient states: (T4 RTA, primary adrenal insufficiency). Decreased clearance: (AKI, CKD, ESRD) Medication-related: (ACEi, ARB, MRA, NSAIDs, TMP/SMX, digoxin, heparin) Excessive intake (bananas, oranges, potatoes, tomatoes, and coconut water)
-- will treat if ...

  • potassium ≥ 6.5 mEq/L, even if the ECG is “normal.”

  • Any ECG changes at K ≥ 5.5

  • Rapidly rising potassium (e.g., tumor lysis, crush injury, massive hemolysis), even before it reaches 6.5

  • Hyperkalemia with significant acidosis

  • markedly decreased renal function (AKI or advanced CKD

  • Hyperkalemia in a hemodialysis patient

Plan

  • repeat BMP/VBG ( r/o Pseudo-Hyperkalemia: hemolysis, severe leukocytosis)

  • Calcium gluconate 1–2 g IV over 5–10 min if EKG changes or K>6.5 , Recheck EKG after ~5–10 minutes If EKG changes persist → repeat dose (can give every hour it lasts 30-60 mins)

  • Shift K+ (temporizing measures) (Lasts for 4-6hrs)

    • Insulin 10 units IV with 50cc (25mg) D50 if BG < 250 (Lasts for 4-6hrs)

    • Albuterol nebulizer (SABA) 10-20 mg can be added, but not used as monotherapy

  • Eliminate

    • Furosemide 40mg IV

    • Sodium zirconium cyclosilicate (Lokelma) 10g TID along with laxative

    • Dialysis if emergency and unable to lower potassium by other means

  • Consider a bicarb amp (50 mEq) if pH is less than 7.2, if acedemia persist 150 mEq in 1 L D5W Run at 100–200 mL/**hr

  • Trend K q 2-4h

  • Repeat above if K still ≥6.0–6.5, EKG changes persist or recur

  • STOP repeating and escalate after second rounds of elimination or Severe AKI / ESRD -> consult nephrology and Start dialysis

  • Continuous telemetry

  • Check glucose q1hr first 4-6 hrs

  • hypoglycemic protocol ordered

  • Discontinue any likely causative medications

  • Consider sending CK, hemolysis labs (retic count, LDH, haptoglobin, smear), TLS labs (UA, phos, calcium), or cortisol/renin/aldo in the correct clinical context

  • If c/f Adrenal Insufficiency - hydrocortisone 15-25mg split 2-3 doses + fludrocort 0.05-0.2 daily