Severe HYPERKALEMIA Management Algorithm

1 Severe HYPERKALEMIA Management Algorithm Does patient have Severe HYPERKALEMIA ? 1) K> mEq/L, 2) risk factors for, 3) clinical Do not apply symptoms/signs* of, AND 4) ECG changes* consistent with HYPERKALEMIA NO. this Algorithm YES *see back page for symptoms, signs and ECG findings Place patient on cardiopulmonary monitor; obtain ECG (if not already done) Definitions: Place patient on ZOLL defibrillator; CPR board immediately available Normal K+ levels are mEq/L. Manage airway as clinically indicated Mild HYPERKALEMIA : mEq/L. Obtain IV/IO access or access central line (CVC, port, PICC) if present Moderate HYPERKALEMIA : mEq/L. Obtain blood1: I-stat, renal, Ca, Phos, Mg, CK, and cortisol; urine for UA Severe HYPERKALEMIA : > mEq/L. Search for & treat underlying cause, if known. Remove any K+ going to the patient (TPN or IVF). 1st: Methods to decrease myocardial excitability IV calcium - to stabilize the myocardium and prevent arrhythmia Peripheral access: Calcium gluconate 50 mg/kg IV over 5 minutes via pump o not a one-step med, MD orders in EPIC.

2 Central access or arrest state2: Calcium chloride 20 mg/kg IV over 5 minutes via pump o Onset 1-3 minutes, lasts 30-60 minutes. Goal is normalization of ECG, so can repeat dosing in 10 minutes if no changes 2nd: Methods to decrease serum potassium levels Temporarily shift K+ from serum into cells (no effect on total body K+). Give all three unless contraindications are present IV sodium bicarbonate NaHCO3 1 mEq/kg IV over 5 minutes via pump Onset 15-60 minutes, lasts 12-24 hours. May repeat in 10 minutes Use only when patient has known or suspected acidosis (pH< ). 1. Pseudohyperkalemia occurs when IV insulin and dextrose a traumatic blood draw results in Dextrose gm/kg (max 25 grams) as D25W (or D10W in neonates) COMBINED WITH cellular hemolysis and a falsely Regular insulin 1 unit for every 4-5 grams of Dextrose (max 5 units insulin ) In One Bag. elevated K+ level Infuse over 60 120 minutes.

3 2. o Use HYPERKALEMIA order set (not an ED order set yet) For patients in arrest or peri- o Order STAT from pharmacy arrest state, remember pneumonic Onset 15 30 minutes, lasts 12 24 hours CBIG for Calcium Chloride, Bicarb, Nebulized albuterol (beta agonist) insulin and Dextrose, in that order Albuterol 10 mg nebulized over 10-15 minutes Onset 30 minutes, lasts 2-4 hours. 3rd: Methods of potassium elimination from the body Consider rechecking serum K+. IV furosemide - decreases total body stores by increasing urinary excretion of K+ level every 15-30 minutes not indicated in patients without functioning kidneys Continue to resuscitate the Furosemide 1 mg/kg (max 20 mg) IV - not to exceed mg/kg/min or 4 mg/min patient as indicated Hemodialysis is not an ED STS therapy; if indicated, consult nephrology immediately, as there Continue to search for, and are considerable time delays as a 1st-line therapy and requires large central venous access treat, the underlying cause Consult Nephrology Consult Critical Care and admit to PICU.

4 Please remember to utilize the HYPERKALEMIA order set which is in EPIC (not an ED order set). Causes of HYPERKALEMIA : Kidney/adrenal dysfunction Shift of potassium out of cells into bloodstream ( , acidosis, rhabdomyolysis, trauma, burns, hemolysis, tumor lysis). Medications ( , potassium supplements, ACE Inhibitors, NSAIDs, potassium-sparing diuretics). Symptoms of HYPERKALEMIA : nausea, fatigue, muscle weakness, myalgia, palpitations, paresthesia Signs of HYPERKALEMIA : bradycardia, hypotension, weakened pulse, arrhythmia, cardiac arrest Definitions: ECG findings during HYPERKALEMIA : Mild HYPERKALEMIA : mEq/L. Mild (limited cardiac effects) to Moderate HYPERKALEMIA (ECG changes likely): Moderate HYPERKALEMIA : mEq/L. o Prolonged PR, peaked T waves Severe HYPERKALEMIA : > mEq/L. Severe (possible suppression of cardiac electrical activity and cardiac arrest): o Widening of QRS, ECG tracing with sinusoidal shape, tenting of T waves, flattening of P waves Potassium Pearls: The most important clinical effect of HYPERKALEMIA is related to electrical rhythm of the heart Normal potassium blood levels are critical for maintaining normal cardiac electrical rhythm, muscle function (smooth and skeletal), and nerve function Both hypokalemia and HYPERKALEMIA can lead to arrhythmias A slowly rising potassium level ( , as seen in chronic kidney failure) is better tolerated than an abrupt rise Management .

5 Medications in BLUE are in ED, those in ORANGE must be obtained from pharmacy Principal Treatment Dose Onset Duration Reversible Calcium 50 mg/kg (max 2000 mg/dose) IV over 5 1-3 minutes 30-60 minutes Depolarization Gluconate (10%) minutes; may repeat in 10 minutes Calcium Chloride 20 mg/kg (max 1000 mg/dose) IV over 5 1-3 minutes 30-60 minutes (10%) min; central venous access only; preferred in cardiac arrest; may repeat in 10 minutes Shift K+ into NaHCO3 ( ) 1 mEq/kg (max 50 mEq/dose) IV over 5 15-60 12-24 hours cells minutes; may repeat in 10 minutes minutes insulin and Use HYPERKALEMIA order set choose 15-30 12-24 hours Dextrose dextrose/ insulin infusion. Dose is minutes prepared in pharmacy. Albuterol 10 mg ( mL) nebulized 30 minutes 2-4 hours [1 x mL and 3 x ]. Remove K+ Kayexelate 1 gm/kg/dose (max 50 grams) PO or PR 1-2 hours 4-6 hours from body Furosemide 1 mg/kg (max 20 mg) IV; not to exceed Start of End of diuresis mg/kg/min or 4 mg/min diuresis Hemodialysis Rapid Duration of dialysis This Algorithm has been developed by the Medical Resuscitation Committee Last revised: September 2017.

6 "The contents of this publication, including text, graphics and other materials ("Contents") is a recitation of general scientific principles, intended for broad and general physician understanding and knowledge and is offered solely for educational and informational purposes as an academic service of Cincinnati Children's Hospital Medical Center (CCHMC). The information should in no way be considered as an establishment of any type of standard of care, nor is it offering medical advice for a particular patient or as constituting medical consultation services, either formal or informal. While the Content may be consulted for guidance, it is not intended for use as a substitute for independent professional medical judgment, advice, diagnosis, or treatment.