Cardiac unit of the birmingham hospital diet
(1A) Audit Measures The frequency of ECG changes in patients treated with intravenous calcium salts. We suggest that cation-exchange resins are not used in the emergency treatment of severe hyperkalaemia, but may be considered in patients with mild to moderate hyperkalaemia. Outcome of hyperkalaemic cardiac arrest with dialysis during CPR. Ionisation and haemodynamic effects of calcium chloride and calcium gluconate in the absence of hepatic function. (1A). Pseudo-hyperkalaemia can be excluded by performing simultaneous measurements of plasma potassium in a lithium heparin anti-coagulated specimen and in a clotted sampled. We recommend that hyperkalaemia is regarded as a medical emergency given its potential for life-threatening consequences. Other causes of pseudo-hyperkalaemia include a high platelet count, haemolysis, erythrocytosis, difficult venepuncture, prolonged storage time of clotted samples, or cold storage conditions. Deakin CD, Nolan JP, Soar J, et al. 26-27. To find the care you need, use the A-Z menu to see a comprehensive list of health care services. The hyperkalaemia module comprises of a series of guideline statements accompanied by supporting evidence and audit measures. Figure 2: Progressive changes in ECG with increasing severity of hyperkalaemia. In a study of hospital patients, the most common causes were renal failure (77%), drugs (63%) and hyperglycaemia (49%). There is no evidence-based guideline for the timing of dialysis initiation, but early nephrology or intensive care referral is ideal. The Renal Association encourages non-renal specialties to record audit measures for all patients diagnosed with hyperkalaemia irrespective of whether or not they are referred to renal services. avoiding wide fluctuations in temperature) for specimens from primary care are important strategies. This in turn can cause electrocardiographic (ECG) changes. (2C). (2B). Atropine 7 may be ineffective in the presence of hyperkalaemia. The effect of induced hyperkalaemia on the normal and abnormal electrocardiogram. Areas for future research include: The incidence of hyperkalaemia in patients with AKI. (2C). In patients receiving haemodialysis, it is useful to establish duration since last dialysis, type of dialysis access (e. Wider consultation has also been sought via the Renal Association and Resuscitation Council (UK) website. Comparison of aminophylline and insulin infusions in treatment of hyperkalaemia in patients with end-stage renal disease. Purpose This guideline has been developed to improve the treatment of acute hyperkalaemia and reduce the risk of complications associated with hyperkalaemia and its treatment. We recommend that a precipitating cause be considered for all patients presenting with hyperkalaemia. Some of the typical arrhythmias are shown in Figure 3. (1B). Hospital laboratories should be capable of providing data to help audit compliance with these guidelines. The teaching of a structured tool improves the clarity and content of interprofessional clinical communication. Fourthly, the ECG appearance may be atypical in patients with hyperkalaemia associated with diabetic ketoacidosis. 1,2 Another common cause of contamination is sampling from the arm into which potassium-containing fluids are being infused. Potassium disorders - clinical spectrum and emergency management. The choice of calcium salt, chloride or gluconate, has largely been guided by practicalities such as availability, local practice and the clinical condition of the patient. Treatment of hyperglycaemia by altering the transcellular gradient in patients with renal failure: effect of various therapeutic approaches. eGFR The severity of illness at presentation of hyperkalaemia as represented by EWS. 6,7. The mortality caused by hyperkalaemia in the general population is unknown, but in patients with ESRD, it accounts for 1. narrowing of the QRS complex). Studies investigating efficacy of nebulised salbutamol in hyperkalaemia. The management of hyperkalaemia in the emergency department. External pacing methods may be useful whilst treatment for hyperkalaemia is underway. We suggest that dialysis is considered for hyperkalaemic cardiac arrest if hyperkalaemia is resistant to medical therapy. Near fatal arrhythmia caused by hyperkalaemia. g beta-blockers). It is applicable to clinicians in all specialties. Figure 4: There are five key steps in the treatment of hyperkalaemia ( never walk away without completing all of these steps ). Davey M, Caldicott D. Each contributor was nominated by their organisation to represent their specialist area. Adverse events as a result of treatment with intravenous calcium salts. There is conflicting evidence on the bioavailability of ionised calcium in the two preparations. Ensure that your institution has an education programme that is focused on the prevention of patient deterioration for ward staff and responding clinical personnel. 9999. In clinical practice, early identification has the potential benefits of ensuring appropriate triage, safe patient transfer and appropriate ward placement. g. The Royal College of Physicians (London) has developed a National Early Warning Scoring System (NEWS) for use in the UK. (2B). The ACB endorses the guidelines submitted for our consideration as they stand but would appreciate that the following comments are taken into account on the first review date. EDTA sample contamination is common and often undetected, putting patients at unnecessary risk of harm. IV calcium may not be deemed necessary in patients in whom emergency dialysis is planned or being initiated for severe hyperkalaemia. Suppression of sinoatrial function results in sinus bradycardia or standstill, and escape beats or rhythms may maintain some output in these circumstances. 6,7. Electrocardiography is unreliable in detecting potentially lethal hyperkalaemia in haemodialysis patients. central venous catheter or AV fistula), recent problems on dialysis (e. We recommend that salbutamol is not used as monotherapy in the treatment of severe hyperkalaemia. Evaluation of the presenting illness usually helps to determine the cause of hyperkalaemia. We recommend that a precipitating cause be considered for all patients presenting with hyperkalaemia. Albuterol and insulin for treatment of hyperkalaemia in haemodialysis patients. Loss of atrial capture during DDD pacing: what is the mechanism. Near-patient testing of potassium values using arterial blood gas analysers: can we trust these results. The incidence of pseudo-hyperkalaemia in the community compared with hospital patients. Guideline development This guideline is a collaboration between the Renal Association and Resuscitation Council (UK). (1B). This guideline has been reviewed by the Renal Association Clinical Practice Guideline Committee and the Resuscitation Council (UK) Executive Committee. Interestingly, a survey of 60 doctors, including 24 consultants, showed that 51. We recommend that patients with hyperkalaemia are managed in an area appropriate to their level of clinical need (Level of care 1, 2 or 3). 8. Although bradycardia is documented to be a potential adverse effect of intravenous calcium salts, calcium can increase the heart rate in patients with hyperkalaemia-induced bradycardia. Each guideline statement begins with a recommendation (Grade 1 evidence) or a suggestion (Grade 2 evidence). 14 Surrogate markers of efficacy have generally been reported. 8816 or 205. 11-13 These reports illustrate a temporal association, but lack evidence of a cause-and-effect relationship. The incidence of hyperkalaemia in patients with ESRD (i. 1 It is important to elicit any background of kidney disease. ED haemodialysis for treatment of renal failure emergencies. Sacchetti A, Stuccio N, Panebianco P, et al. Bradycardia associated with severe hyperkalaemia may be resistant to conventional treatment and is enhanced in patients taking negatively chronotropic drugs (e. Sodium bicarbonate is often used in clinical practice, but there is little evidence to support its use. This effect is independent of its hypoglycaemic action. 16. The disturbance associated with the most immediately life-threatening consequences is hyperkalaemia. Feb 2010. Given that interventions are attempted for other potentially reversible problems in cardiac arrest, e. Electrolytes assessed by point of care testing-Are the values comparable with results obtained from the central laboratory. Guideline 8. It is a potentially life-threatening emergency that can be corrected with treatment. A further contribution regarding the influence of the different constituents of the blood on the contraction of the heart. We recommend that all patients with known or suspected hyperkalaemia undergo urgent assessment by nursing and medical staff to assess clinical status using the ABCDE approach, an early warning scoring system, and an appropriate escalation plan bearing in mind that the first presentation may be an arrhythmia. The frequency of dialysis initiation for hyperkalaemic cardiac arrest. Mahoney BA, Smith WA, Lo DS, Tsoi K, Tonelli M, Clase CM. (1C). Standardising the assessment of acute-illness severity in the NHS. Some patients are particularly at risk of hyperkalaemia and there should be a high index of suspicion of hyperkalaemia if these patients become unwell. A response may be seen with a narrowing of the QRS complex (Figure 5), reduction in T wave amplitude (Figure 5), increase in heart rate in bradycardic patients or reversal of arrhythmia. When escape rhythms do not maintain output in these settings, asystolic cardiac arrest ensues. 4. In summary, IV calcium has been widely recommended for the treatment and prophylaxis of arrhythmias in patients with hyperkalaemia. Drugs, including over-the-counter medications, are an important cause of hyperkalaemia. This allows you to manage your health and stay connected with your UAB health care providers. We suggest that renal function is assessed before commencing treatment with drugs that can cause hyperkalaemia and thereafter, renal function and serum potassium be monitored in the community after initiation, after dose adjustments and during acute illness. 1 - Hyperkalaemia: Transfer to renal services. Your thoughts are important and allow us to reward great performance and identify areas for improvement. The multidisciplinary writing group consists of nephrologists, intensivists, resuscitation experts, a clinical biochemist, renal nurses and a renal pharmacist. (1B). (2B). The importance of emergency treatment for hyperkalaemia and other electrolyte disorders has been acknowledged in the European Resuscitation Council (ERC) Guidelines. Ahuja T, Freeman D Jr, Mahnken JD, et al. For this reason, many guidelines have recommended the use of calcium gluconate, which is regarded as less toxic on peripheral veins. Therefore, we recommend an equivalent dosage of calcium chloride or gluconate (6. Although much of the evidence to support its use arises from case reports and anecdotal experience, 4 there remains little doubt of the importance of IV calcium in emergency treatment of hyperkalaemia even when the serum calcium is normal. Suppression of atrioventricular (AV) conduction will give rise to varying degrees of AV block and in the event of complete AV block, a ventricular escape rhythm may maintain some output. chest drain for tension pneumothorax, cardiopulmonary bypass for hypothermia, pericardiocentesis for cardiac tamponade, it seems reasonable to consider dialysis treatment during CPR for patients with hyperkalaemic cardiac arrest. We recommend that measures are taken to prevent hyperkalaemia in patients at risk. Hyperkalaemia. Smith GB, Prytherch DR, Schmidt PE, et al. 2,3 There is controversy about the drug treatment of hyperkalaemia. (1A). 8mmol), is given to patients with hyperkalaemia in the presence of ECG evidence of hyperkalaemia. (2C). Luzza F, Careri S, Oreto G. (2B). It is effective within 3 minutes as shown by an improvement in the ECG appearance (e. The management of hyperkalaemia in the emergency department. The P wave amplitude is diminished in the early stages as T wave amplitude increases. National Confidential Enquiry into Patient Outcome and Death. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. In contrast, there are reports in the literature showing no adverse effects in patients given IV calcium in the presence of unrecognised digoxin toxicity. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Potassium disorders - clinical spectrum and emergency management. 14 Potassium-exchange resins are often used but their place in acute treatment is limited. Point of care testing systems and processes, used for the measurement of potassium, should follow best practice as identified by the MHRA (Medicines and Healthcare Regulatory Agency, 2010). Temporal profile of serum potassium concentration in nondiabetic and diabetic outpatients on chronic dialysis. Progressive changes in ECG with increasing severity of hyperkalaemia. In clinical practice, there may be a combination of factors contributing to hyperkalaemia. 3. muscle weakness, paraesthesiae, palpitations) may suggest severe hyperkalaemia. We recommend that lithium heparin anti-coagulated specimens are the sample type of choice when rapid turnaround of urea and electrolytes results is required. Sharratt CL, Gilbert CJ, Cornes MC, et al. Nebulised albuterol for acute hyperkalaemia in patients on haemodialysis. NICE clinical guideline 50: Acutely ill patients in hospital: recognition of and response to acute illness in adults in hospital (2007). 4. Treatment is not complete until the cause is identified and steps taken to prevent recurrence. (1C). This also raises some doubt about the efficacy of the gluconate salt in patients with acute kidney injury, which is often associated with haemodynamic compromise. 6. In this setting there are reports showing ECG changes suggestive of myocardial ischaemia or pseudoinfarction. Adverse events, including hypoglycaemia, are not consistently reported. (1C). 8mmol), is given to patients with hyperkalaemia in the presence of ECG evidence of hyperkalaemia. Comparison of the point-of-care blood gas analyzer versus the laboratory auto-analyzer for the measurement of electrolytes. The frequency of recurrence of hyperkalaemia beyond 48 hours after an acute episode. e. Other potential adverse effects are peripheral vasodilation, hypotension, bradycardia, syncope and arrhythmias. The clinical course is unpredictable and sudden death can occur in the absence of premonitory ECG changes. The group met in November 2010 in Fife, Scotland to agree the scope for the guideline and critically assess the available evidence for the treatment of acute hyperkalaemia. The proportion of patients requiring inter-hospital transfer for treatment of hyperkalaemia. 5. Calcium content of IV calcium salts used in treatment of hyperkalaemia. 2-4 The EWS uses a combination of several vital signs and mental status abnormalities to help detect acutely ill patients who are seriously ill and likely to deteriorate. 1,2. Hyperkalaemia may occur in the context of pre-existing chronic kidney disease (CKD) or acute kidney injury (AKI). We recommend that intravenous calcium chloride or calcium gluconate, at an equivalent dose (6. The correlation between potassium measurements using a blood gas analyser versus the laboratory. 14 There are several limitations in the evidence available on the treatment of hyperkalaemia. (1A). Serum potassium is unreliable as an estimate of in vivo plasma potassium measurement. g. Predictors of the development of hyperkalemia in patients using angiotensin-converting enzyme inhibitors. This highlights the need for guidance on the application of BGA machines in the management of hyperkalaemia. (2C). We recommend that urea and electrolytes are measured using paired lithium heparin and clotted serum samples from a large vein using gentle traction, and with prompt laboratory analysis if pseudo-hyperkalaemia is suspected. Causes of death in patients with end-stage renal disease treated by dialysis in a center in Israel. We recommend a standardised approach to the management of patients with hyperkalaemia using the aid of a treatment algorithm (Appendix 4). 2,3. (1B). References: Chacko B, Peter JV, Patole S, et al. 1 Therefore the first step in assessing the hyperkalaemic patient is assessing this risk and taking immediate action. Hyperkalaemia induced complete atrioventricular block with a narrow QRS complex. Hyperkalaemia in hospitalized patients: causes, adequacy of treatment, and results of an attempt to improve physician compliance with published therapy guidelines. We recommend that hospitals adopt standard regimens for drug administration and monitoring in the treatment of hyperkalaemia to reduce adverse events. There are no RCTs on the use of calcium salts for the treatment of hyperkalaemia. Hyperkalaemia. Given that the ECG is the best tool for assessing cardiac toxicity, the effect of IV calcium is assessed by an improvement in ECG appearance, and IV calcium is not without risk, then IV calcium should be reserved for patients with ECG changes of hyperkalaemia. Rationale The incidence of hyperkalaemia in hospital patients is between 1. The typical ECG features of hyperkalaemia are shown in Figure 1. Tomcsanyi JJ. Morduchowicz G, Winkler J, Drazne E, et al. The presence of arrhythmias, muscular weakness or paraesthesiae in a patient at risk should raise the clinical suspicion of hyperkalaemia. Incidence and outcomes of patients with hyperkalaemia diagnosed. This study concluded that BGA machines can be used to guide treatment. They both concluded that there is sufficient agreement between the results to use the BGA analyser to guide clinical decisions. Non-compliance with diet or dialysis regimen is an important and preventable cause of hyperkalaemia. e. g. (1B). Both preparations can be given safely if venous access is adequate. 1% and 10%. Patients with hyperkalaemia are at increased risk of arrhythmias. e. IV calcium was shown to be effective in treatment and prophylaxis in patients with acute kidney injury during the Korean War. Nyirenda MJ, Tang JI, Padfield PL, et al. The duration of action is only 30-60 minutes, so further doses may be necessary if hyperkalaemia remains uncontrolled. In emergencies where hyperkalaemia is suspected, specimens collected in a lithium heparin tube can be analysed more rapidly as there is no requirement to wait for the sample to clot before centrifugation. We suggest that inter- or intra-hospital patient transfer be coordinated by senior clinicians and follows national guidelines. You can access these convenient and secure tools from anywhere you can connect to the internet. References Soar J, Perkins GD, Abbas G et al. We recommend that medical students and junior doctors are educated in the recognition, treatment, potential hazards and prevention of hyperkalaemia. 14 Adverse events associated with treatment have been poorly documented. The use of intravenous (IV) calcium in the treatment of hyperkalaemia is well established in clinical practice, but is based on sparse evidence. The most significant consequences of hyperkalaemia are arrhythmias and cardiac arrest, therefore early recognition, cardiac monitoring and prompt treatment are essential. There are some important differences between the two available solutions. We suggest that non-steroidal anti-inflammatory drugs or trimethoprim, particularly in combination with renin-angiotensin blockade, are avoided in the patients with CKD 4 and 5, and care should also be taken in the elderly. In general terms, the greater the severity of hyperkalaemia, the higher the incidence of ECG abnormalities and risk of arrhythmias. The dose should be repeated if there is no effect within 5-10 minutes. 1 This process begins with an assessment of the risk of arrhythmias, followed by action to reduce the serum potassium concentration by shifting potassium back into cells and removing it from the body. It is acute rises in potassium that are associated with cardiac mortality, and the guidelines from the Renal Association (certainly the flow diagrams anyhow) do not seem to make this distinction. tachycardia, arrhythmia). hypernatraemia, hypercalcaemia, and alkalaemia) or exacerbate (e. The main risk of insulin-glucose therapy is hypoglycaemia. Drugs are an important cause of hyperkalaemia, especially following the widespread use of renin-angiotensin-aldosterone blocking drugs in the treatment of heart failure and for renal protection. Interestingly, in the historical case series by Chamberlain in 1964, up to 60ml 10% calcium gluconate and 90ml 10% calcium chloride were used with no serious adverse events documented. Planning, Initiating and Withdrawal of Renal Replacement Therapy.
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2 - Hyperkalaemia: Minimum standards for safe patient transfer. Should glucose be administered before, with, or after insulin, in the management of hyperkalaemia. It has relevance to all clinicians and is encountered in a variety of clinical settings. Thirdly, ECG changes may be minimal even in patients (i. Figure 4: There are five key steps in the treatment of hyperkalaemia. Hyperkalaemia causes a rapid reduction in resting membrane potential leading to increased cardiac depolarization, and muscle excitability. The perception that long-term haemodialysis patients develop some tolerance to hyperkalaemia is debatable. (2C). We suggest a standardised approach to the management of patients with hyperkalaemic cardiac arrest using the aid of a treatment algorithm (Appendix 6). Blood gas analysers (BGA) are increasingly available at the point of care with analytical repertoires that include electrolyte measurements. haemodialysis patients) most at risk of hyperkalaemia. 822. Table 2: Factors associated with an increased risk of hyperkalaemia. The relatively short duration of action of IV calcium (30-60 minutes) may not be considered in patients with prolonged hyperkalaemia. (1B). Hyperkalemia in hospitalized patients: causes, adequacy of treatment, and results of an attempt to improve physician compliance with published therapy guidelines. There are numerous unanswered questions about the treatment of patients with hyperkalaemia. Request an Appointment Online or call: 800. The main adverse effect of IV calcium is tissue necrosis if extravasation occurs. Physician interpretation of the ECG results in the diagnosis of hyperkalaemia with a sensitivity of just 0. We recommend escalation of care in patients with hyperkalaemia requiring renal replacement therapy in addition to other organ support (e. The frequency of bowel complications with the use of cation-exchange resins. Acker CG, Johnson JP, Palevsky PM, et al. Rationale for Clinical Practice Guideline for Acute Hyperkalaemia. g. Given the uncertainty, the chloride salt has been recommended in the setting of haemodynamic instability, including cardiac arrest. It is also widely accepted that emergency treatment should be initiated for hyperkalaemia if suspected on clinical grounds or ECG features. Limitations Most studies assessing the efficacy of treatment for hyperkalaemia are of patients with end-stage renal disease, are small and have variable designs. We suggest that transfer to renal services be considered in clinically stable patients in whom hyperkalaemia cannot be controlled (i. EWS or calling criteria help to identify the need for more frequent monitoring, when to call for expert help and the need for escalation of care. Hospitals should ensure that the system used is validated for their specific patient population to identify those at increased risk of serious clinical deterioration or death on admission and during hospital stay. Secondly, the ECG may be normal even in the presence of severe hyperkalaemia. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Adverse events in relation to treatment of hyperkalaemia. 4. We recommend that intravenous calcium chloride or calcium gluconate, at an equivalent dose (6. Guideline 8. A life-threatening complication of extreme hyperkalaemia in a patient on maintenance haemodialysis. (1C). (1A). 3 References: Smith GB. We recommend that measures are taken to prevent recurrence of hyperkalaemia after acute treatment and appropriate follow-up should be arranged. The proportion of patients with documented hypoglycaemia (blood glucose The proportion of acute hospital admissions referred to Renal Services for treatment of hyperkalaemia in a single centre annually. Acker CG, Johnson JP, Palevsky PM, et al. Table 1: The ABCDE approach to assess and treat the deteriorating patient. hyponatraemia, hypocalcaemia or acidosis) the effects of hyperkalaemia. 5. Local laboratory medicine specialists should ensure that the all methods used for measurement of potassium are fit for purpose and that the methods are appropriately quality controlled and quality assessed. 6,7. The effects of intravenous calcium in patients with digoxin toxicity. Therefore knowledge of current medication and any recent changes to medication is very useful. The administration of hypertonic glucose alone is not recommended for the treatment of hyperkalaemia as endogenous insulin production is unlikely to be sufficient for a therapeutic effect and there is a risk of exacerbating the hyperkalaemia by inducing hypertonicity. Potassium measurement can be undertaken in the laboratory or at the point of care using a variety of techniques. We recommend that all patients with known or suspected hyperkalaemia undergo urgent assessment by nursing and medical staff to assess clinical status using the ABCDE approach, an early warning scoring system, and an appropriate escalation plan bearing in mind that the first presentation may be an arrhythmia. Among haemodialysis patients, hyperkalaemia is the reason for emergency dialysis in 24% of cases 11 and is responsible for 3-5% of deaths. The frequency of hyperkalaemia and its significance in chronic kidney disease. We suggest that serum potassium be assessed at least 1, 2, 4, 6 and 24 hours after identification and treatment of hyperkalaemia. Laboratories may differ in their requirements for other tests and different reference intervals may also apply. This guideline does not comprehensively cover the treatment of hyperkalaemia in out-patient or primary care settings. g. Incidence and outcomes of patients with hyperkalaemia diagnosed: in the community in the out-patient clinic after hospital admission 2. g. We suggest that the decision to initiate RRT for patients with hyperkalaemia in the ICU and the chosen modality take into account local practice and dialysis facilities. (1B). A summary of this approach including clinical indicators relevant to hyperkalaemia is given below. 8 mmol) for initial therapy. Hyperkalaemia is associated with depression of conduction between adjacent cardiac myocytes, manifesting in prolongation of the PR interval and QRS duration. The intravenous calcium salt used (gluconate or chloride) and indications for use are inconsistent and there are no clinical trials on which to base a recommendation. Walter RB, Bachli EB. Thank you for choosing UAB Medicine for your care. We recommend that the blood glucose concentration is 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. DB2010(02). (2C). Pseudohyperkalemia in Serum: A New Insight into an Old Phenomenon. Cardiac arrest in special circumstances: Electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Calcium content of intravenous calcium salts used in treatment of hyperkalaemia. 2. Also as you are well aware, delayed separation and processing cause pseudohyperkalaemia and this common scenario is absent as a possible explanation from the flow diagram. 1 Laboratories have developed standard protocols to reduce the risks of pseudo-hyperkalaemia and pseudo- normo kalaemia. Although the ECG is useful in assessing patients with hyperkalaemia, there are some shortfalls. This guideline has been endorsed in full by: This guideline has been endorsed with the following stipulation by. (1A). We recommend that stable patients with severe hyperkalaemia be admitted to an area with facilities for cardiac monitoring, ideally in a renal unit, coronary care unit, HDU or ICU depending on local facilities or practice. Recognition of hyperkalaemia depends on laboratory tests and the ECG appearances. A single dose of 10ml 10% calcium gluconate is often administered irrespective of the response which is often inadequate. 14-15 In reality, the digoxin level is usually unknown at presentation. This issue is compounded by the variability in ECG interpretation. 6% would wait for laboratory confirmation and 48. (1B). To date, there have been five case reports of death in this context. Device Bulletin, Management and Use of IVD point of Care Test Devices. Outcome of cardiac arrest in patients receiving haemodialysis (HD) in an out-patient dialysis facility versus all in-hospital cardiac arrests. 4 This will provide two values with the lower being in the heparinised specimen. The atrial myocardium is more sensitive than the ventricular myocardium to the effects of hyperkalaemia and the specialised tissue (sinoatrial node and bundle of His) is the least sensitive. Review of Evidence The literature was reviewed using a multiple database search - The Cochrane Library (1995-2013), Ovid MEDLINE (1946-2013), EMBASE (1974-2013), PubMed (1960-2013), Up-to-Date (2011), Web of Knowledge (2001-2013) for all human studies published in english pertaining to the treatment of hyperkalaemia in adults. 4 Hyperkalaemia usually occurs in patients with renal impairment which can be acute or chronic. 1. ventilation or circulation). (2C). Caution with administration of IV calcium has historically been advised in patients with known or suspected digoxin toxicity. A systematic approach taking into account clinical priorities may reduce this variability, enhance patient outcome and reduce adverse events related to hyperkalaemia and its treatment (Figure 4). Comparison of aminophylline and and insulin-dextrose infusions in acute therapy of hyperkalaemia in end-stage renal disease patients. UAB Medicine offers a wide range of medical, surgical, and support services. 8-10. An unusual hyperkalaemia induced block. Electrolyte disorders and arrhythmogenesis. 10,24-25. g. This guideline focuses on the recognition and emergency treatment of acute hyperkalaemia in adults in secondary care settings. We recommend that hyperkalaemia is regarded as a medical emergency given its potential for life-threatening consequences. 34-0. The 12-lead ECG is frequently not repeated after administration to assess response. g. Prolonged asystolic hyperkalaemic cardiac arrest with no neurological sequelae. This guideline has been developed by a multidisciplinary group to critically assess the literature, address the controversies in treatment and to provide a standardised approach to the treatment of acute hyperkalaemia in adults. Uraemia is known to attenuate the hypoglycaemic response to insulin although this does not affect its hypokalaemic action. All cardiac arrest rhythms have been documented and success has been reported with dialysis during cardiopulmonary resuscitation (CPR). In reality, many patients have rapid changes in their ECG. Furthermore, a recent study has shown no increased risk of arrhythmias or mortality in patients treated with IV calcium in the presence of digoxin intoxication. Effects of presentation and electrocardiogram on time to treatment of hyperkalaemia. 43. References Alfonzo A, Isles C, Geddes C, et al. 934. Although in some clinical scenarios diuretics or intravenous fluids are used in the treatment of hyperkalaemia associated with acute kidney injury, there is no evidence to support this practice. Martin TJ, Kang Y, Robertson KM, et al. We recommend that the treatment of hyperkalaemia follows a logical 5-step approach. This provides an advantage over whole blood measurements from blood gas analysers because haemolysis can be identified by visual inspection after centrifugation or by spectrophotometric analysis of the specimen for the presence of haemoglobin. Firstly, the value of the ECG is dependent on the skill of the interpreter. Most studies do not assess the incidence of arrhythmias in clinically significant hyperkalaemia and the evidence for the use of intravenous calcium salts in preventing and treating arrhythmias is limited to case reports and anecdotal evidence. We recommend that the treatment of hyperkalaemia follows a logical 5-step approach. The ECG is used to assess cardiac toxicity and risk of arrhythmias, and should be recorded promptly during the assessment of patients with known or suspected hyperkalaemia. 5. Telmisartan, ramipril, or both in patients at high risk for vascular events. The management of hyperkalaemia in the emergency department. 16 In clinical practice, there are several pitfalls in the administration of IV calcium. Drug-induced hyperkalemia: old culprits and new 3 offenders. 4% would base clinical decisions on results obtained from the BGA. Adverse events as a result of treatment with intravenous calcium salts. e. The ECG changes associated with hyperkalaemia are attributable to the physiological effect of a raised serum potassium on myocardial cells. Fatality from calcium chloride in a chronic digoxin toxic patient. g. We recommend that patients are referred to the ICU team by a senior member of the referring team if escalation of care is required from the outset or if the patient fails to respond to initial treatment. In hyperglycaemic patients, e. 2. In patients presenting to an Emergency Department, the median time to treatment was 117 minutes (IQR 59-196 minutes). Co-existing metabolic disturbances can ameliorate (e. This risk is associated with the dose of glucose administered, but studies show conflicting results with the incidence of hypoglycaemia ranging from 11-75% when 25g glucose is administered (Table 4). Effect of bicarbonate administration on plasma potassium in dialysis patients: interactions with insulin and albuterol. References: Nyirenda MJ,Tang JI, Padfield PL, et al. Early identification of hyperkalaemia, with or without adverse clinical signs, enables specific interventions, specialist referral (if required) and appropriate escalation of care. (1C). Other authors highlight the insensitivity of the ECG in assessing the severity of hyperkalaemia. serum K. Calcium salts in management of hyperkalaemia. The frequency of prescribed drugs potentially contributing to hyperkalaemia. 1 The published electrolyte values used to define hyperkalaemia and its severity vary. The ECG changes of hyperkalaemia usually follow a progressive pattern (Figure 2). The risk increases with the length of the inter-dialytic interval, recirculation on dialysis and with dietary non-adherence. It provides online diagnosis and treatment for many routine minor conditions, such as colds, allergies, bladder infections, pink eye, and more. 7 Local risk assessments of the relative value and safety of point of care verus laboratory delivery of potassium measurements should form part of the development process. 3. If dialysis patients present with hyperkalaemia to the emergency department or a non-renal ward, the local renal team should be informed urgently as medical interventions will only temporarily control hyperkalaemia. A full blood count should also be performed to exclude a haematological disorder. Most nephrologists have little experience in initiating dialysis during cardiac arrest, but it is technically feasible and all modalities have been used. Both preparations, calcium chloride and calcium gluconate, are available in the form of 10ml of 10% solution (Table 3). poor blood flow via dialysis access, recent access interventions), medication, and any recent dietary indiscretions. Hyperkalaemic cardiac arrest is uncommon, but potentially reversible even after prolonged resuscitation efforts. Patients with renal failure may experience delayed hypoglycaemia, up to 6 hours after infusion, 16 therefore close monitoring is required for several hours. Table 2: Factors associated with an increased risk of hyperkalaemia. In many instances, the ECG is available before serum biochemistry and may show complete heart block. When is a high potassium not a high potassium. El-Sherif N and Turitto G. It is recommended that the following audit measures be recorded for patients with hyperkalaemia. Table 1: The ABCDE approach to assess and treat the deteriorating patient. (1A) Audit measure: Outcome measures in patients diagnosed with hyperkalaemia. This may account for the observed variability in the treatment of patients with hyperkalaemia, even within the same hospital. Treatment of hyperkalaemia in a patient with unrecognized digitalis toxicity. 9% of mortality. Potassium disorders - clinical spectrum and emergency management. The incidence and outcome of hyperkalaemic cardiac arrest. We suggest that intravenous sodium bicarbonate infusion is not used routinely for the acute treatment of hyperkalaemia. Routine samples for measurement of urea and electrolytes are usually requested in a clotted serum sample. The ECG changes with hyperkalaemia do not consistently follow a stepwise, dose-dependent pattern. When 10% calcium gluconate is used, sequential doses of 10ml solution are often required whereas a single dose of calcium chloride is more likely to be effective. 12,13. 1 Uniform guidance on the treatment of hyperkalaemia based on the best available evidence is therefore needed. diabetic ketoacidosis, insulin should be given without dextrose as the cause of hyperkalaemia is likely to be the hyperglycaemia itself. Study designs vary with few randomised controlled trials (RCTs), small study size and variable statistical analysis. Continuous ECG monitoring will enable early recognition and prompt treatment to prevent life-threatening arrhythmias. We recommend that nurses working in renal, cardiac or acute care settings are educated in the recognition, treatment, potential hazards and prevention of hyperkalaemia. Click a link below to jump to a UAB Medicine department or use the search utilities to the left for a specific Condition or Treatment. We suggest that patients in the community with suspected pseudohyperkalaemia are referred to hospital for verification of hyperkalaemia and appropriate treatment if necessary. 15. Consider fluid bolus (with care), vasopressors, inotropes treatment of arrhythmia, correct electrolyte abnormalities. We recommend that lithium heparin anti-coagulated specimens are the sample type of choice when rapid turnaround of urea and electrolytes results is required. (1B). The ability of physicians to predict hyperkalaemia from the ECG. 7. Get started by clicking the letter that corresponds to your condition to learn more. Wrenn KD, Slovis CM, Slovis BS. Hundal HS, Marette A, Mitsumoto Y, et al. Most hospitals in the UK use EWS systems to assess and detection and monitoring of acutely ill patients. Extremely wide QRS complex with VVI pacing. (1C). We value your feedback about your experience with UAB Medicine. As hypercalcaemia may potentiate digoxin toxicity, a slower rate of administration, over 30 minutes, has been recommended in these patients. (1B). The proportion of acute hospitals in the UK implementing the hyperkalaemia treatment algorithms. A careful medical history may reveal the cause of hyperkalaemia. Detection, Monitoring and Care of Patients with CKD. 4. Labelling the time of collection on specimens, reducing transit times, and optimising storage conditions (i. Consensus conference on the afferent limb: identifying hospitalised patients in crisis. In practice, a baseline assessment and serial monitoring of vital signs are useful in assessing the response to treatment. Electrolyte abnormalities are a recognised cause of cardiac arrhythmias, cardiac arrest and sudden death. Rationale Hyperkalaemia is unpredictable and arrhythmias and cardiac arrest can occur at any time. The proportion of patients who develop adverse effects of salbutamol (e. g. Despite this, there is limited evidence to guide treatment. European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. When using evacuated tubes for blood collection, if the order of draw is wrong, the sample can be contaminated with potassium EDTA (for full blood count). The frequency of ECG changes in patients treated with intravenous calcium salts. Hyperkalemia and digoxin toxicity in a patient with kidney failure. Hyperkalaemic cardiac arrest is the worst complication, but the evidence for recommendations is limited to case reports, small case series and clinical experience. (1B). The choice of specimen sent to the laboratory will depend on the tests requested and the urgency. These measures may in turn reduce out-of-hours calls to deputising services and admissions to acute medicine units for the investigation of hyperkalaemia. We recommend that all patients presenting with hyperkalaemia undergo a comprehensive medical and drug history and clinical examination to determine the cause of hyperkalaemia. Seniority of ICU personnel from whom advice was sought. We recommend that all patients presenting with hyperkalaemia undergo a comprehensive medical and drug history and clinical examination to determine the cause of hyperkalaemia. 1-3. We recommend that urea and electrolytes are measured using paired lithium heparin and clotted serum samples from a large vein using gentle traction with prompt laboratory analysis if pseudo-hyperkalaemia is suspected. The clinical presentation may be over-shadowed by the primary illness, but some symptoms (e. It has been suggested that calcium gluconate has limited bioavailability because of chelation and the reliance on hepatic metabolism, 6 but in contrast, no difference in availability of ionised calcium was shown in the anhepatic stage of liver transplantation.
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