Clinical Practice Guidelines Treatment of Acute ...

1 Clinical Practice Guidelines Treatment of Acute Hyperkalaemia in Adults Final version: June 2020. Review date: June 2025. Authors: Dr Annette Alfonzo Consultant Nephrologist & Clinical Director, Faculty member of European Resuscitation Council, Victoria Hospital Kirkcaldy, Fife Dr Alexander Harrison Consultant in Nephrology and Intensive Care, Brighton and Sussex University Hospitals nhs trust Dr Richard Baines Consultant Nephrologist and Head of Renal and Transplant Service, University Hospitals of Leicester nhs trust Dr Ann Chu Academic Clinical Fellow Renal Medicine and Medical Education, Imperial college London Mr Simon Mann Renal Pharmacist.

2 Lancashire Teaching Hospitals nhs foundation trust Mr Murdoch MacRury Patient representative Endorsements The National Institute for Health and Care Excellence (NICE) has accredited the process used by the Renal Association to produce its Clinical Practice Guidelines . Accreditation is valid for 5 years from January 2017. More information on accreditation can be viewed at Method used to arrive at a recommendation The recommendations for the first draft of this guideline resulted from a collective decision reached by informal discussion by the authors and, whenever necessary, with input from the Chair of the Clinical Practice Guidelines Committee.

3 If no agreement had been reached on the appropriate grading of a recommendation, a vote would have been held and the majority opinion carried. However this was not necessary for this guideline. Conflicts of Interest Statement All authors made declarations of interest in line with the policy in the Renal Association Clinical Practice Guidelines Development Manual. Further details can be obtained on request from the Renal Association. Acknowledgements The authors wish to thank Dr Charlie Tomson, retired Consultant Nephrologist and former Chair of the UK.

4 Renal Association (2010-2012), Professor Ketan Dhatariya, Chair of the Joint British Diabetes Society for In- Patient Care (JBDS-IP), Dr Clare Crowley, Consultant Pharmacist (Medicines Saftety) at Oxford University Hospitals and Mr Murdoch MacRury for his insight into the Treatment of hyperkalaemia from a patient's perspective. We also wish to acknowledge the contributions of the original writing group whose collaborative efforts produced the 2014 Hyperkalaemia guideline. Renal Association Clinical Practice Guidelines Treatment of Acute Hyperkalaemia in Adults July 2020 2.

5 Contents Executive Summary of changes since 2014 Hyperkalaemia Guideline ..5. Guideline development ..7. Introduction ..8. Summary of Clinical Practice Guidelines for Hyperkalaemia .. 10. 17. Figures .. 18. Summary of Audit Measures .. 19. Hyperkalaemia in the Community ( Guidelines ).. 22. Introduction .. 22. Patient monitoring ( Guidelines ) .. 26. Management of patients receiving RAASi drugs ( Guidelines ).. 30. Threshold for Treatment of hyperkalaemia (Guideline ) .. 33. Indications for hospital assessment ( Guidelines - ).

6 35. Treatment : Dietary interventions (Guideline ) .. 37. Treatment : Sodium bicarbonate (Guideline ) .. 39. Treatment : Diuretics (Guideline ) .. 41. Treatment : Calcium resonium (Guideline ) .. 42. Treatment : Patiromer ( Guidelines ) .. 44. Treatment : Sodium zirconium cyclosilicate ( Guidelines ) .. 49. Prevention ( Guidelines ) .. 53. Treatment Algorithm: Community (Guideline ) .. 57. Hyperkalaemia in 59. Introduction .. 59. Clinical assessment ( Guidelines ) .. 61. ECG and cardiac monitoring ( Guidelines ) .. 63. Laboratory analysis ( Guidelines ).

7 68. Treatment ( Guidelines ) .. 73. Blood monitoring ( Guidelines ) .. 101. Treatment of hyperkalaemia in haemodialysis patients ( Guidelines ) .. 105. Referral to specialist services and escalation of care ( Guidelines ) .. 110. Minimum standards for patient transfer ( Guidelines ) .. 112. Prevention ( Guidelines ).. 114. Renal Association Clinical Practice Guidelines Treatment of Acute Hyperkalaemia in Adults July 2020 3. Treatment Algorithm: Hospital ( Guidelines ) .. 118. Hyperkalaemia in Resuscitation .. 120. Introduction .. 120.

8 References .. 121. Hyperkalaemic cardiac arrest Special circumstance ( Guidelines ) .. 121. Audit Measure .. 121. Rationale ( Guidelines ) .. 121. References .. 122. Resuscitation strategy in dialysis patients ( Guidelines ) .. 123. Treatment : Calcium chloride ( Guidelines ) .. 128. Treatment : Insulin-glucose ( Guidelines ).. 129. Treatment : Sodium bicarbonate ( Guidelines ) .. 132. Treatment : Initiation of dialysis during cardiac arrest ( Guidelines ) .. 133. Prevention ( Guidelines ).. 140. Lay 143. Appendices .. 144. Appendix 1: Oral potassium lowering drugs.

9 145. Appendix 2: Summary of Clinical trials of oral potassium lowering drugs .. 146. Appendix 3A: Drug administration and safety - IV calcium preparations .. 147. Appendix 3B: Drug administration and safety Insulin-glucose 149. Appendix 3C: Drug administration and safety - Salbutamol .. 151. Appendix 3D: Drug administration and safety Patiromer .. 152. Appendix 3E: Drug administration and safety Sodium zirconium 153. Appendix 3F: Drug administration and safety Calcium resonium .. 154. Appendix 4 Sine wave ECG .. 155. Appendix 5 Hyperkalaemia Algorithm - Community.

10 156. Appendix 6 Hyperkalaemia Algorithm 157. Appendix 7 Hyperkalaemia Algorithm Resuscitation .. 158. 159. Renal Association Clinical Practice Guidelines Treatment of Acute Hyperkalaemia in Adults July 2020 4. Executive Summary of changes since 2014 Hyperkalaemia Guideline Format of the Guideline The 2020 Hyperkalaemia guideline has been divided into 3 sections to allow easy navigation: Section I: Management of Hyperkalaemia in the Community Section II: Management of Hyperkalaemia in Hospital Section III: Management of Hyperkalaemia in Resuscitation New therapies for treating hyperkalaemia Sodium zirconium cyclosilicate (SZC).