Episode 74- An Expert Talks: Intricacies of Hyperkalemia Management


Episode Summary:

Not your average hyperkalemia episode! Jimmy Pruitt, host of the Pharm-So-Hard podcast, shares some pearls on hyperkalemia management

Show Notes:

Key Points:

“‘An Expert Talks: Intricacies of Hyperkalemia Management”:
– HyperK can cause muscle weakness, paralysis, cardiac conduction abnormalities/ arrhythmias (bradycardia, cardiac arrest, ventricular tachycardia/fibrillation), peaked T waves/ loss of P waves, and widening of the QRS interval. Remember that a normal EKG does not exclude significant hyperK and that EKG changes can happen at lower K levels (<5.5 mEq/L)
Calcium works by “stabilizing” the cardiac membrane by (in a nutshell) making the resting potential more negative and by increasing the threshold potential. We should see EKG normalization within minutes, but effects may only last 30-60 minutes, so re-dosing may be necessary. 1 g IV Ca chloride contains 3x more calcium than 1 g IV Ca gluconate (13.6 vs 4.6 mEq) and is preferred in emergent situations (EKG changes, peri-arrest)
Insulin works by driving K into cells by enhancing the activity of the Na-K-ATPase in skeletal muscle. It is given as 5-10 units (or 0.1 units/kg) IV regular insulin, with the 5 unit dose being optimal — do not give it subcutaneously. It can lower the K by ~1 mEq/ L and should start to work within 10-20 mins, peak at 30-60 mins, and last 4-6 hours (can repeat every 2-6 hours)
Glucose/dextrose (25-50 g IV) is mainly given with IV regular insulin to prevent hypoglycemia and can be held if BG is > ~200; it should not be used alone without IV regular insulin as a shifting agent
Albuterol works by shifting K into cells by enhancing the activity of the Na-K-ATPase. It is given as 10-20 mg nebulized over 10 minutes. It can lower the K by 0.5-1.5 mEq/L
Resins/ cation exchangers like patiromer, sodium zirconium cyclosilicate (SZC; Lokelma), and SPS (Kayexelate) bind K in the GI tract. These agents are typically used as a bridge to dialysis in patients without severe hyperK. They have minimal effect on K levels, lowering K by 0.37 mEq/L at four hours. SPS has been associated with intestinal necrosis and contains 1500 mg sodium for every 15 g dose
Sodium bicarbonate theoretically works by binding H+, causing the H/K pump to pull in K in exchange for an H– with minimal/no effects on the K level. Consider giving it as 150 meq/ L (isotonic) over 2-4 hours in patients with metabolic acidosis and use the 50 mEq amp of bicarb (hypertonic) if you have EKG changes
Loop diuretics increase K excretion in the urine. It is given as 40 mg IV furosemide BID or a continuous infusion. It will not be very effective for patients that do not make urine (use resins instead)
Hemodialysis– mostly indicated in patients who are already on HD or have CKD, in consultation with nephrology. It is preferred to the resins if the procedure can be performed ASAP
ER-Rx Episode 74

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