Severity & Risk Stratification
The first step of treatment requires determining whether hyperkalemia is life-threatening . No evidence-based definition for severe hyperkalemia exists. Clinical judgement is needed, with attention to the following factors:
- Potassium level: above 6.5-7 mM is more worrisome.
- Chronic hyperkalemia is better tolerated .
- Acute hyperkalemia is more dangerous.
Below is a consensus definition of severe hyperkalemia from a KDIGO conference. The European Resuscitation Council has similarly defined severe hyperkalemia as > 6.5 mM.
Association Between Hyperkalemia And Outcomes
The potassium ion is the most abundant cation in the body. There is an estimated total reserve of 30004000 mmol in adults, of which only 60 mmol are extracellular . Hyperkalemia is associated with poor outcomes in many different settings: in the general population , in patients with cardiac and renal disease and in critically ill patients . In a retrospective study of hospitalized patients, Khanagavi et al. found that acute kidney injury and prolonged hyperkalemia are independent predictors of in-hospital mortality. In acute myocardial infarction, a serum potassium above 4.5 mmol/L is associated with a higher mortality . More recently, Legrand et al. identified that a serum potassium> 4.5 mmol/L in heart failure patients admitted to the emergency department is associated with an increased risk of death.
The net effect is a U-shaped mortality curve associated with potassium abnormalities . Several observational studies have identified hypokalemia as an independent risk factor for poor outcome . This association raises concern regarding the potential for overcorrection, as may occur with some fast-acting potassium-lowering agents. However, these associations do not mean causality and thresholds for treating hyperkalemia remain debated.
Strategies For Avoiding Hypoglycemia
Preventing hypoglycemia is important. Some clinicians use up to 20 units of IV regular insulin as the hypokalemic effect is dose-dependent.8 Here is a suggested strategy for administering enough dextrose to counter the initial insulin bolus of 10 or 20 units. It is loosely based on the Rush University protocol.4 Other strategies include q30 minute glucose checks for the first 3 hours with as needed supplemental glucose orders or lower insulin doses.
|50 gm of D50* OR25 gm of D50 + D10 infusion 250 mL/hr for first hour
|25 gm of D50 if blood glucose < 70 mg/dL
|q 30 minutes for first hour, then hourly up to 3 hours
|D50 = dextrose 50% D10 = dextrose 10%
* There are drawbacks to administering 100 mL of D50. Adam Spaulding, PharmD discusses D50 vs. D10 for severe hypoglycemia in the ED. 50 mL of D50 + infusion of D10 might prevent rebound hypoglycemia and hypertonicity issues with an initial 100 mL dose of D50.
** A supplemental D10 infusion may be needed beyond one hour depending on blood glucose concentrations.
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Cardiac Manifestations Of Hyperkalaemia
Although patients with hyperkalemia can present rarely with weakness progressing to flaccid paralysis, paresthesias, or depressed deep tendon reflexes, the clinical presentation of hyperkalemia is usually benign until cardiac rhythm or conduction disorders occur. Elevation of extracellular potassium has several effects on myocardial electrophysiology that contribute to intracardiac conduction disturbances. The intracellular to extracellular potassium gradient lessens when extracellular potassium increases, thus decreasing the resting membrane potential. Elevated extracellular potassium also increases membrane permeability for potassium, lowers membrane resistance, increases repolarizing currents, and shortens transmembrane action potential duration.
While rising serum potassium initially increases conduction velocity, it decreases it at higher levels . Classic hyperkalemia electrocardiographic findings include signs of hyperexcitability such as peaked T-waves . Further, altered conduction may manifest as PR prolongation, loss of P-waves, QRS widening, bradycardia, and ultimately a sine wave rhythm due to action potential shortening and prolongation of diastolic depolarization.
Causes Of Hyperkalemia In Acutely Ill Patients
Factors associated with the development of hyperkalemia can be classified into three categories, and include altered renal clearance of potassium , release from the intracellular space and altered transfer to the intracellular space . Hyperkalemia in the patient with normal renal function is unusual and should prompt evaluation for pseudo-hyperkalemia if no ECG abnormalities consistent with hyperkalemia are identified . While concomitant medications are often a contributor to hyperkalemia, in our experience they are rarely the only cause in acute settings.
Table 1 Mechanisms contributing to the development of hyperkalemia
A special warning should be made with regards to the use of succinylcholine, classically used to induce paralysis in acutely ill patients for rapid sequence intubation. Succinylcholine induces skeletal muscle cell depolarization with an efflux of intracellular potassium by nicotinic receptor activation. In a population of critically ill patients, succinylcholine increased serum potassium on average 0.4 mmol/L . It should be avoided in patients with hyperkalemia and in patients with up-regulation of nicotinic receptors, as they are at risk of greater potassium elevation. This includes those with anatomical denervation, prolonged administration of neuromuscular blocking drugs, burn injury, and prolonged immobilization . Alternative to succinylcholine are available in patients at risk of hyperkalemia .
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Accordingly How Do You Give Insulin Iv
Mix 250 units of regular human insulin in 250 mL of normal saline . Flush approximately 30 mL through the line prior to administration. Do not use a filter or filtered set with insulin. Piggyback the insulin drip into intravenous fluid using an intravenous infusion pump with a capability of 0.1 mL/hr.
Treatment And Prevention Of Hyperkalemia In Adults
INTRODUCTION Hyperkalemia is a common clinical problem that is most often a result of impaired urinary potassium excretion due to acute or chronic kidney disease and/or disorders or drugs that inhibit the renin-angiotensin-aldosterone system . Therapy for hyperkalemia due to potassium retention is ultimately aimed at inducing potassium loss . In some cases, the primary problem is movement of potassium out of the cells, even though the total body potassium may be reduced. Redistributive hyperkalemia most commonly occurs in uncontrolled hyperglycemia . In these disorders, hyperosmolality and insulin deficiency are primarily responsible for the transcellular shift of potassium from the cells into the extracellular fluid, which can be reversed by the administration of fluids and insulin. Many of these patients have a significant deficit in whole body potassium and must be monitored carefully for the development of hypokalemia during therapy. The treatment and prevention of hyperkalemia will be reviewed here. The causes, diagnosis, and clinical manifestations of hyperkalemia are discussed separately. DETERMINING THE URGENCY OF THERAPY The urgency of treatment of hyperkalemia varies with the presence or absence of the symptoms and signs associated with hyperkalemia, the severity of the potassium elevation, and the cause of hyperkalemia. Our approach to therapeutic urgency is as follows :Continue reading > >
Insulin Mechanism Of Action In Hyperkalemia1415
Insulin causes an intracellular shift of potassium by stimulating Na+-H+antiporters, promoting sodium influx. Increased intracellular sodium concentrations trigger the activation of the Na+-K+ATPase transporter, which exchanges intracellular sodium for extracellular potassium. A dose of 10 units IV insulin regular has been estimated to lower serum potassium levels by 0.6 to 1.2 mEq/L in 1hour.16
Why Do You Give Insulin And D50 For Hyperkalemia
Hyperkalemia is a life-threatening condition that requires prompt management in the ED. One of the most common treatment options is the administration of insulin and glucose to help shift potassium into the cell temporarily. Usually this is ordered as 10 units of regular insulin IV and 1 ampule of D50.
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Examples Of Recent Errors
Several recent insulin errors during hyperkalemia treatment have been reported to ISMP or have appeared in the literature. For example, just this month, we learned about an error in which a nurse correctly calculated the volume needed for a 10 unit dose of insulin lispro, but accidentally measured out 20 units of insulin using a 10 mL non-insulin syringe. A physician prescribed treatment that included calcium gluconate 1 g IV, insulin lispro 10 units IV, and dextrose 50% IV. The nurse calculated that she would need 0.1 mL of the insulin for the 10 unit dose, and a nurse manager verified the calculation. Using a 10 mL syringe, she drew the insulin lispro into the syringe up to the first gradation mark, believing this represented 0.1 mL. But the first syringe marking was actually 0.2 mL. The nurse manager did not verify the dose in the syringe prior to administration. The error was quickly discovered when a clinical nurse specialist asked the nurse, who had just completed orientation, to demonstrate how she had measured the insulin dose in a 10 mL syringe. The patients blood glucose was monitored, and she experienced no adverse effects.
What Medications Are Used To Treat Hyperkalemia
Drugs used in the treatment of hyperkalemia include the following:
- Calcium : Reduces the risk of ventricular fibrillation caused by hyperkalemia.
- Insulin administered with glucose: Facilitates the uptake of glucose into the cell, which results in an intracellular shift of potassium.
Furthermore, how do you treat hyperkalemia?
Similarly one may ask, what are the drugs that reduce potassium?
- Diuretics. Diuretics like furosemide, bumetanide, hydrochlorothiazide, and chlorthalidone are the main medication-related cause of low potassium levels.
- Risperdal and Seroquel.
What potassium level necessitates urgent treatment for hyperkalemia?
A Hyperkalemia Emergency, which we define as a serum potassium> 6.0 meq/L or a sudden increase in serum potassium 1.0 meq/L above 4.5 meq/L within 24 hours associated with cardiopulmonary arrest, evolving critical illness, AMI, or signs and symptoms of neuromuscular weakness, should be treated with agents that
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Data Sources And Independent Variables
We used electronic medical records to determine patient demographics and specific comorbidities relevant to hypoglycemia risk . CKD status was determined using the CKD-EPI eGFR based on IDMS-calibrated serum creatinine using a strategy recommended by Siew et al. We considered an eGFR< 60 ml/min/1.73 m2 as consistent with significant CKD as an eGFR of 60 to 90 ml/min/1.73 m2 in older adults is of unclear significance. Excessive alcohol intake was defined as a chronic ingestion of4 standard drinks daily.
We collected data on weight and height and calculated the body mass index in kg/m2. We used the Malnutrition Universal Screening Tool score as a surrogate for malnutrition . The presence of sepsis was determined using SEPSIS-3 guidelines and AKI was determined using KDIGO guidelines. We examined the use of specific medications within the previous 24 h which may affect the glycemic response .
Risk Factors For Developing Hypoglycemia
The study by Apel et al identified 3 factors associated with a higher risk of developing hypoglycemia:
Renal dysfunction, in and of itself, may also be a risk factor for developing hypoglycemia. Some evidence suggests that insulin is metabolized by the kidneys to some extent. Furthermore, patients with acute kidney injury have clinically relevant changes in insulin metabolism, as evidenced by increased hypoglycemic events and lower insulin requirements upon developing AKI.6
A higher insulin dose caused more hypoglycemia .7
The 2018 study by Scott et al, identified that lower glucose prior to insulin , higher doses of insulin , and lower doses of D50 were independently associated with hypoglycemia in the multivariate analysis.5 Age, history of diabetes, and history of renal failure were not independently associated.
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When Do You Recheck Potassium After Hyperkalemia Treatment
After initial interventions, potassium should be rechecked within one to two hours, to ensure effectiveness of the intervention, following which the frequency of monitoring could be reduced. Subsequent monitoring depends on the potassium level and the potential reversibility of the underlying cause.
Insulin For The Treatment Of Hyperkalemia: A Double
Potassium plays a critical role in cellular metabolism and normal neuromuscular function. Tightly regulated homeostatic mechanisms have developed in the process of evolution to provide primary defense against the threats of hyper- and hypokalemia. The kidney plays a primary role in potassium balance, by increasing or decreasing the rate of potassium excretion. Distribution of potassium between the intracellular and the extracellular fluid compartments is regulated by physiologic factors such as insulin and catecholamines which stimulate the activity of the Na+-K+ ATPase. Only about 10% of the ingested potassium is excreted via the gut under normal physiologic conditions .
The definition of hypoglycemia has been a topic of debate. The workgroup of the American Diabetes Association and the Endocrine Society defines iatrogenic hypoglycemia in patients with diabetes mellitus as all episodes of an abnormally low plasma glucose concentration that expose the individual to potential harm. A plasma glucose concentration of 70 mg/dL is recommended as the alert value even though symptoms of hypoglycemia usually develop at a level below this threshold . This value allows time for close monitoring of the patient to prevent symptomatic hypoglycemia and has been used to define hypoglycemia in numerous clinical trials.
Disclosures. None declared.
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High Serum Potassium Levels
High serum potassium levels can be life-threatening and requires immediate therapy. There are several conditions which can significantly affect serum potassium levels and cause them to rise.
The amount of potassium in the blood determines the excitability of nerve and muscle cells, including the heart muscle or myocardium. When potassium levels in the blood rise, this reduces the electrical potential and can lead to potentially fatal abnormal heart rhythms.
Study Design And Setting
We conducted a retrospective, multi-site cohort study at the acute hospitals within the Monash Health hospital network . Monash Health is the largest public health network located in the south-east region of the state of Victoria in Australia, servicing around one-quarter of the population of the city of Melbourne. The study population included all patients treated with IDT irrespective of admission type or location , from Jan 1, 2019 to March 1, 2020.
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Insulin Dosing Evaluation In Hyperkalemia
Several studies have compared insulin dosing strategies in hyperkalemia.8-10,13,18 These studies compared patients receiving 10 units to lower doses, such as 5 units or 0.1 unit/kg, and assessed for potassium-lowering ability and incidence of hypoglycemia.8-10,13,18 Hypoglycemia was generally defined as blood glucose less than 70 mg/dL however, there were varying definitions of severe hypoglycemia and duration of monitoring for hypoglycemia after insulin administration.8-10,13,18
Medication Errors During Insulin Administration For Patients With Hyperkalemia
Hyperkalemia is a serious, potentially lethal electrolyte disturbance that requires medical treatment without delay if it is severe enough to cause disturbances in cardiac conduction. Although hyperkalemia treatment guidelines in the literature vary,1 many organizations begin treatment with the administration of one or more intravenous bolus doses of 50% dextrose and an IV bolus dose of 10 units of insulin. Some organizations use a rapid-acting insulin rather than short-acting insulin because it may decrease the incidence of hypoglycemia, given its shorter half-life.1
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Study Selection And Outcomes
We considered articles to be eligible for inclusion if they reported on using insulin in the management of hyperkalemia. We included all study designs that used a standardized protocol except for case reports. We also excluded articles from further review if they fulfilled one or more of the following criteria: patients less than 18 years of age hyperkalemia that occurred in an operative setting and articles in which there were co-interventions for the management hyperkalemia .
Our primary outcome was the mean change in serum K+ concentration at 60 minutes after starting the administration of insulin.
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Hyperkalemia Management: Preventing Hypoglycemia From Insulin
Insulin remains one of the cornerstones of early severe hyperkalemia management. Insulin works via a complex process to temporarily shift potassium intracellularly. Though insulin certainly lowers plasma potassium concentrations, we often underestimate the hypoglycemic potential of a 10 unit IV insulin dose in this setting. The purpose of this post is to highlight the need for proper supplemental glucose and blood glucose monitoring when treating hyperkalemia with insulin.
This is such an important medication safety issue, the Institute for Safe Medication Practices highlighted it in a .
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Can Lactulose Be Used For Hyperkalemia
Diarrhea may occur if the dose of lactulose is too high. Problems associated with diarrhea are fluid and potassium loss in the diarrheal stool leading to dehydration and low blood levels of potassium .
Also Know, does calcium bind to potassium? Calcium is given intravenously to protect the heart, but calcium does not lower the potassium level. Then insulin and glucose are given, which move potassium from blood into cells, thus lowering the potassium level in blood. Albuterol may be given to help lower the potassium level.
Moreover, how does albuterol work in hyperkalemia?
Albuterol is an adrenergic agonist that has an additive effect with insulin and glucose, which may in turn help shift potassium into the intracellular space. This agent lowers the serum potassium level by 0.5-1.5 mEq/L. It can be very beneficial in patients with renal failure when fluid overload is concern.
What is the emergency treatment for hyperkalemia?
Drugs used in the treatment of hyperkalemia include the following: Calcium : Reduces the risk of ventricular fibrillation caused by hyperkalemia. Insulin administered with glucose: Facilitates the uptake of glucose into the cell, which results in an intracellular shift of potassium.