Management of hyperkalaemia

UK renal association recommends that hyperkalaemia should be regarded as a medical emergency due to its potential for life threatening consequences (1).

All patients with severe hyperkalaemia (K+ ≥ 6.5 mmol/L) are referred to secondary care for immediate assessment and treatment (1)

All patients with known or suspected hyperkalaemia should undergo urgent assessment using the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach, an early warning scoring (EWS) system, and an appropriate escalation plan bearing in mind that the first presentation may be an arrhythmia (1).

Management of hyperkalaemia includes the following:

• confirm that it is true hyperkalaemia
• establish the severity of hyperkalaemia - mild, moderate, severe
• obtain a ECG and look for changes (2)
  • all patients with a serum potassium value ≥ 6.0 mmol/L should have an urgent 12-lead ECG performed and assessed for changes of hyperkalaemia
  • a minimum of continuous 3-lead ECG monitoring for all patients with a serum potassium value ≥ 6.5 mmol/L, patients with features of hyperkalaemia on 12-lead ECG, and in patients with a serum potassium value between 6.0-6.4 mmol/L who are clinically unwell or in whom a rapid rise in serum potassium is anticipated
    
• key treatments for hyperkalaemia include:
  • cardiac protection
    • IV calcium salts
  • shift potassium into cells
    • insulin-glucose infusion
    • salbutamol
  • remove potassium from body
    • cation-exchange resins
    • patiromer
      • NICE suggests that (4):
        • patiromer is recommended as an option for treating hyperkalaemia in adults in emergency care for acute life-threatening hyperkalaemia alongside standard care
        • noted that patiromer would not replace intravenous insulin and glucose, but it might replace calcium resonium
  • blood monitoring
    • serum potassium
      • serum K + is monitored closely in all patients with hyperkalaemia to assess efficacy of treatment and look for rebound hyperkalaemia after the initial response to treatment wanes
      • should be assessed at least 1, 2, 4, 6 and 24 hours after identification and treatment of hyperkalaemia
    • blood glucose
      • blood glucose concentration should be monitored at regular intervals (0, 15, 30, 60, 90, 120, 180, 240, 300, 360 minutes) for a minimum of 6 hours after administration of insulin-glucose infusion in all patients with hyperkalaemia
  • primary and secondary prevention of hyperkalaemia (1)
• a comprehensive medical and drug history and clinical examination to determine the cause of hyperkalaemia (once the patient is stable) (1)

Treatment is determined according to severity of hyperkalaemia.

• indications for prompt intervention are
  • symptoms of hyperkalaemia
  • changes on ECG
  • severe hyperkalemia (greater than 6.5 mmol/L)
  • rapid-onset hyperkalaemia
  • underlying heart disease, cirrhosis, or kidney disease (3)

Patients in the community with suspected pseudohyperkalaemia should be referred to hospital for verification of hyperkalaemia and appropriate treatment if necessary (1)

Reference:

(1) UK Kidney Association. Clinical Practice Guidelines - Management of Hyperkalaemia in Adults. October 2023.

(2) Lott C et. al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation. 2021 Apr;161:152-219. doi: 10.1016/j.resuscitation.2021.02.011.

(3) Kim MJ, Valerio C, Knobloch GK. Potassium Disorders: Hypokalemia and Hyperkalemia. Am Fam Physician. 2023 Jan;107(1):59-70.

(4) NICE (February 2020). Patiromer for treating hyperkalaemia