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  • Hyperkalaemia

Hyperkalaemia

Table of Contents
  • Overview/Classification
  • Triage
  • Causes
  • Clinical features 
  • Investigations
  • Management 
  • Management - Mild hyperkalaemia (5.5 - 6.0 mmol/L) (1,2,7)
  • Management - Moderate hyperkalaemia (6.1 - 7.0mmol/L) (1,2)
  • Management - Severe hyperkalaemia (>7.0 mmol/L + ECG changes) (1,2)
  • References

Overview/Classification #

Potassium level (mmol/L) 
Normal Range (1)3.5 – 5.0 mmol/L
Mild hyperkalemia 5.5 – 6.0 mmol/L
Moderate hyperkalemia 6.1 – 7.0 mmol/L
Severe hyperkalemia >7.0 mmol/L + ECG changes
  • Key points:
    • The most common cause of an elevated potassium level is due to haemolysis of the blood cells/sampling error (always make sure you repeat the level!)
    • $Cardiac disturbances can be a serious complication of hyperkalaemia – always make sure you get an ECG!$

Triage #

Triage category depends on the severity of the serum K+ levels 

  • Mild to moderate – within hours 
  • Severe – emergency requiring immediate attention

Causes #

  • Spurious (2)
    • $Haemolysis – due to rupture of blood cells in the sample during/shortly after the blood draw releasing K+ (this is the most common cause; always repeat the sample first to confirm that it is a true hyperkalaemia)$
    • Prolonged tourniquet time 
  • Increased intake
    • IV/oral supplementation 
    • Blood transfusions 
  • Reduced output (3)
    • Acute/chronic renal disease
    • Kidney failure requiring dialysis (should discuss with nephrology as a matter of urgency) 
  • Cellular shift (3)
    • Acidosis 
    • Insulin deficiency 
    • Tissue destruction 
  • $Medications$ (2,4)
    • Spironolactone 
    • Amiloride 
    • ACE inhibitors (-pril) 
    • ARBS (-sartan) 
    • NSAIDs (aspirin, ibuprofen) 
    • Beta blockers (-olol) 
    • Other – e.g. digoxin (in toxicity), heparin, trimethoprim, movicol

Clinical features  #

 Signs and symptoms can often be very vague and non-specific (5)

Symptoms Signs 
Muscle weakness Fatigued SOB Muscular paralysis Palpitations Chest painBradycardia (secondary to heart block) Tachypnoea (from respiratory muscle weakness) Muscle weakness and flaccid paralysis Depressed/absent tendon reflexes

Investigations #

Initial investigations

InvestigationSignificance
VBGRepeat sampleMonitor for acidosis
UEC Serum K+ 
ECGLook for cardiac disturbances that may result from high levels of K+ (in order of severity). For examples of ECG changes refer to: https://litfl.com/hyperkalaemia-ecg-library/ {hyperlink to website} (6)Tall tented T wavesP wave widening/flattening
PR prolongation, disappearance of P wavesbradyarrhythmias Widening of QRSSine waveVF      

Management  #

Initial steps: REPEAT/confirm the measurement (on a gas) +/- a formal UEC + CMP if nil recent ECG Consider causes and contributing medications or supplements

Management – Mild hyperkalaemia (5.5 – 6.0 mmol/L) (1,2,7) #

  • Initial steps (above) plus:
Resonium 15 – 30g POorResonium 30 – 50g PR daily if not tolerating PO/NBM
  • Recheck K+ within 4-6 hrs, cease resonium when possible

Management – Moderate hyperkalaemia (6.1 – 7.0mmol/L) (1,2) #

  • Initial steps (above) plus:
  • Notify senior clinician
10 units actrapid + 50 ml of 50% glucose over 5 mins (Get nursing staff to check BSLs at 15 mins, 30 mins then hourly for 6 hrs)
  • Recheck K+ within 1-2 hrs

Management – Severe hyperkalaemia (>7.0 mmol/L + ECG changes) (1,2) #

  • Initial steps (above) plus:
  • Notify senior clinician – will likely need cardiac monitoring running with management 
If evidence of arrhythmia on ECG or QRS widening, consider giving: #10 ml calcium gluconate 10% IV over 2-3 minsCan repeat to max 50 mls until ECG stabilises {{Note: Calcium works to antagonise the cardiac effects of hyperkalaemia, however it does not lower the K+ level (see below)}} {{Beware: avoid using calcium in patients on digoxin (may precipitate ventricular arrhythmias)}} (8)
To reduce the serum K+ level: 10 units actrapid + 50 ml of 50% dextrose over 5 minsGet nursing staff to check BSLs at 15 mins, 30 mins then hrly for 6 hrs plus Nebulised salbutamol 10mg over 30 mins for synergistic effectUse only 5mg if patient has a history of ischaemic heart disease
Other options: loop diuretics (e.g. furosemide) (9), #sodium bicarbonate (10), newer therapies (e.g. #patiromer oral suspension (11) 

 {{Note, newer therapies including patiromer may not yet be supplied by hospitals in Australia}}

References #

​​1.     Clinical Guideline: Management of Hyperkalaemia in Inpatients and the Emergency Department Austin Health 2018

2.     Marshall S, Ruedy J. On Call: Principles and Protocols (3rd Edition). In: Brown AF, Cadogan M, Celenza A, editors. On Call: Principles and Protocols. Pennsylvania W.B. Saunders & Company

3.     Mount DB. Causes and evaluation of hyperkalemia in adults. Table: Major causes of hyperkalemia; UpToDate 2021 [Available from: https://www.uptodate.com/contents/causes-and-evaluation-of-hyperkalemia-in-adults

4.     Ben Salem C, Badreddine A, Fathallah N, Slim R, Hmouda H. Drug-induced hyperkalemia. Drug Saf. 2014 Sep;37(9):677-92. doi: 10.1007/s40264-014-0196-1. PMID: 25047526.

5.     Jones C, Border D, Jones A, Turnock D, Lloyd F. Guidelines for dealing with adult patients with hyperkalaemia in the community NHS; 2021 [Available from: https://www.yorkhospitals.nhs.uk/seecmsfile/?id=3483&inline=1.

6.     Buttner R, Burns E. Hyperkalaemia Life in the Fast Lane 2021 [Available from: https://litfl.com/hyperkalaemia-ecg-library/.

7.     2008. Hyperkalaemia – Management of Acute Hyperkalaemia in Adults. Clinical Procedure. Canberra: Canberra Hospital and Health Services.

8.     Bower JO, Mengle HAK. The additive effect of calcium and digitalis: a warning, with a report of two deaths. JAMA 1936;106: 1511–53. doi:10.1001/jama.1936.02770140013004

9.     Rastergar A, Soleimani M. Hypokalaemia and hyperkalaemia. Postgrad Med J. 2001;77:759–64.

10.  Dépret, F., Peacock, W.F., Liu, K.D. et al. Management of hyperkalemia in the acutely ill patient. Ann. Intensive Care 9, 32 (2019). https://doi.org/10.1186/s13613-019-0509-8

11.  Blair HA. Patiromer: A Review in Hyperkalaemia. Clin Drug Investig. 2018 Aug;38(8):785-794. doi: 10.1007/s40261-018-0675-8. PMID: 30030701.

  • Contributors

  • Reviewing Consultant/Senior Registrar

Dr Michelle Truong

Dr Adam Steinberg

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Updated on April 12, 2023
Table of Contents
  • Overview/Classification
  • Triage
  • Causes
  • Clinical features 
  • Investigations
  • Management 
  • Management - Mild hyperkalaemia (5.5 - 6.0 mmol/L) (1,2,7)
  • Management - Moderate hyperkalaemia (6.1 - 7.0mmol/L) (1,2)
  • Management - Severe hyperkalaemia (>7.0 mmol/L + ECG changes) (1,2)
  • References

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