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      Anonymous
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      Management of Hyperkalemia

      The most serious manifestations of hyperkalemia are muscle weakness or paralysis, cardiac conduction abnormalities, and cardiac arrhythmias, including sinus bradycardia, sinus arrest, slow idioventricular rhythms, ventricular tachycardia, ventricular fibrillation, and asystole. These manifestations usually occur when the serum potassium concentration is ?7.0 meq/L with chronic hyperkalemia or possibly at lower levels with an acute rise in serum potassium. Patient would often require admission to hospital for treatment.

      Treatment prior to admission:

      A patient with known hyperkalemia or a patient with renal failure with suspected hyperkalemia should have intravenous access established and should be placed on a cardiac monitor
      In the presence of hypotension or marked QRS widening, intravenous bicarbonate, calcium, and insulin given together with 50% dextrose may be appropriate

      Avoid calcium if digoxin toxicity is suspected; magnesium sulfate (2 g over 5 min) may be used alternatively in the face of digoxin-toxic cardiac arrhythmias

      Treatment in Hospital:

      Once the patient reaches the emergency department, assessment and treatment include the following:
      Continuous ECG monitoring with frequent vital sign checks
      Assessment of the ABCs and prompt evaluation of the patient’s cardiac status with an electrocardiogram
      Discontinuation of any potassium-sparing drugs or dietary potassium
      If the hyperkalemia is severe (potassium >7.0 mEq/L) or if the patient is symptomatic, begin treatment before diagnostic investigation of the underlying cause. Individualize treatment based upon the patient’s presentation, potassium level, and ECG.
      Dialysis is the definitive therapy in patients with renal failure or in whom pharmacologic therapy is not sufficient. Any patient with significantly elevated potassium levels should undergo dialysis, as pharmacologic therapy alone is not likely to adequately bring down the potassium levels in a timely fashion.

      Medications

      1. Treat promptly after the diagnosis is confirmed by the blood test. If levels are mildly elevated patient may just need restriction of potassium supplements (which is the most important cause of hyperkalemia) and fruits rich in potassium such as banana.
      2. Admit all patients who have life threatening hyperkalemia to the Intensive Care Unit. Cardiac monitoring is vital.
      3. Promptly administer intravenous calcium. This shields the heart from potentially life threatening abnormal heart rhythms induced by the potassium.
      4. Give Insulin intravenously along with concentrated dextrose solution (50%). Insulin is known to move the potassium present in the blood inside the cells. This however is only a temporary measure because in few hours the potassium will move back to the blood. However, this technique helps to buy time until the excess potassium is excreted through kidneys. Dextrose is only given to prevent insulin from causing hypoglycemia (low glucose levels)
      5. Give intravenous Sodium Bicarbonate to buffer the blood. This also helps to shift potassium from the blood in to the body cells and promotes excretion of potassium through the kidneys.
      6. Give Abuterol by nebulization or by intravenous infusion. This will also shift excessive potassium into the cells.
      7. Give diuretics such as Furosemide or HCTZ. This will allow kidneys to excrete excess potassium in urine.
      8. Give cation exchange resin such as Sodium Polystyrene Sulfonate (SPS, Kayexalate) either orally or as a retention enema. This resin takes up potassium in the gut and stops it from getting absorbed in to the blood.
      9. Perform hemodialysis if the conservative measures listed above are ineffective or if the hyperkalemia is very severe, or if the patient has marked tissue breakdown and is releasing large amounts of potassium from the injured cells.

      Badri.

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