ACEP ID:

HyperK

Left Arrow Right Arrow Down Arrow Up Arrow Left Arrow Right Arrow Down Arrow Up Arrow
 

Recognition and Treatment of Hyperkalemia in the ED

Section IconHistory and Physical
Presentation/Chief Complaint
Fatigue/Malaise/Weakness/Paralysis
Nausea/Vomiting/Decreased oral intake
Palpitations/Rapid Heart Rate
Chronic Kidney Disease
Missed Dialysis/Volume overload/Extremity edema
Crush injury/Burns/Trauma
Medication overdose
Chest pain
Review history of presentation
Recent medications and changes
Medication compliance
Duration of new symptoms
Oral intake
Review past medical history
Recent medications and changes
Hypertension/Congestive heart failure
Diabetes
Cancer
Chronic kidney disease/Dialysis
Hypoaldosteronism Syndromes (acquired or congenital)
Systemic lupus erythematosus
Social History
  • Transportation issues
  • Med Compliance issues
Review medications
Amino acids
Antibiotics
  • Trimethoprim
  • Penicillin G
Anti-Fungals
  • Azoles
ARBs and ACE inhibitors
Beta-Blockers
Calcium Chanel Blockers
  • Verapamil
Digoxin/Digitalis
Diuretics, potassium sparing
  • Spironolactone
  • Triamterene
  • Amiloride
Heparin
Herbal Supplements (milkweed, lily of the valley, Siberian ginseng, Hawthorn berries, or preparations from dried toad skin or venom [Bufo, Chan Su, Senso])
Immunotherapy/Immunosuppression
  • Cyclosporine
  • Tacrolimus
Lithium
Non-Steroidal Anti-inflammatories
Paralytics
  • Succinylcholine
  • Suxamethonium
Potassium supplements
Statins (somatostatin)
Herbal Therapies
Birth control (Yazmin 28)
Review Physical Exam & Vital Signs
Dry mucous membranes
Jugular venous pressure
Rhythm and rate of pulses
Presence of edema
If fistula present: assess for thrill and pulses distally
HD line or peritoneal access in place
References
  1. Ben Salem C, Badreddine A, Fathallah N, Slim R, Hmouda H. Drug-induced hyperkalemia. Drug Saf. 2014;37(9):677-692. doi:10.1007/s40264-014-0196-1
  2. Hollander-Rodriguez JC, Calvert JF Jr. Hyperkalemia. Am Fam Physician. 2006;73(2):283-290.
  3. Acker CG, Johnson JP, Palevsky PM, Greenberg A. Hyperkalemia in hospitalized patients: causes, adequacy of treatment, and results of an attempt to improve physician compliance with published therapy guidelines. Arch Intern Med 1998;158:917–24.
  4. Mount DB, Causes and evaluation of hyperkalemia in adults. UpToDate. Updated: May 26, 2020
Section IconYour Tests to Order
Studies
Basic metabolic profile panel with calculation of anion gap (Confirm potassium level if factitious hyperkalemia is suspected).
Complete blood count
Electrocardiogram
In select cases
Digoxin level
Arterial Blood Gas
Lactate dehydrogenase with suspected hemolysis.
Creatinine phosphokinase and urine myoglobin for suspected rhabdomyolysis.
Uric acid and phosphorus if patient has known or suspected cancer for tumor lysis syndrome
New presentation in-patient work up can be assisted by obtaining Cortisol and aldosterone levels to assess for mineral corticoid deficiency.
Magnesium
Calcium
Urinalysis
References
  1. Shingarev R, Allon M. A Physiologic-Based Approach to the Treatment of Acute Hyperkalemia. Am J Kidney Dis. 2010;56(3):578-584
  2. Arnold R, Pianta TJ, Pussell BA, Endre Z, Kiernan MC, Krishnan AV. Potassium control in chronic kidney disease: implications for neuromuscular function. Intern Med J. 2019 Jul; 49 (7):817-825
  3. Fitch, K., Woolley, J. M., Engel, T., & Blumen, H. (2017). The Clinical and Economic Burden of Hyperkalemia on Medicare and Commercial Payers. American health & drug benefits, 10(4), 202–210.
  4. Simon LV, Hashmi M, Farrell MW. Hyperkalemia. [Updated 2020 Jun 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan. Learn More
Section IconEvaluation and Causes
Consider etiology
Spurious/factitious, can occur through number of mechanisms:
  • Hemolysis of blood sample
  • Sampling, handling/transport
Pseudohyperkalemia (high platelets, WBC’s or RBC’S)
Dietary potassium.
Starvation
Thrombocytosis
Blood transfusion
Renal dysfunction
  • AKI (acute kidney injury)
  • CKD (chronic kidney disease)
Cirrhosis
Congestive Heart Failure
Medications
  • Potassium supplements
    Drug side effects
    Amino acids
    Antibiotics
    • Trimethoprim
    • Penicillin G
    Anti-Fungals
    • Azoles
    ARBs and ACE inhibitors
    Beta-Blockers
    Calcium Chanel Blockers
    • Verapamil
    Digoxin/Digitalis
    Diuretics, potassium sparing
    • Spironolactone
    • Triamterene
    • Amiloride
    Heparin
    Herbal Supplements (milkweed, lily of the valley, Siberian ginseng, Hawthorn berries, or preparations from dried toad skin or venom [Bufo, Chan Su, Senso])
    Immunotherapy/Immunosuppression
    • Cyclosporine
    • Tacrolimus
    Lithium
    Non-Steroidal Anti-inflammatories
    Paralytics
    • Succinylcholine
    • Suxamethonium
    Potassium supplements
    Statins (somatostatin)
    Herbal Therapies
    Birth control (Yazmin 28)
    Hypoaldosteronism
    Primary (Addison's disease) or secondary
    Hyporeninemic hypoaldosteronism
    Congenital adrenal hyperplasia
    Cellular Shifting
    Acidosis (Diabetic Ketoacidosis, lactic acidosis, metabolic acidosis)
    Insulin deficiency or hyperglycemia
    Hypertonicity.
    Other Causes
    Strenuous Exercise
    Hyperkalemic periodic paralysis
    Lead
    • Systemic lupus erythematosus
    • Pseudo-hypoaldosteronism
    Cell breakdown /injury
    • Crush and burn injuries/Rhabdomyolysis
    • Severe intravascular hemolysis
    • Tumor lysis syndrome
    Ingestions with unknown mechanism
    • alfalfa, dandelion, Noni juice, toad consumption
    References
    1. Davis KR, Crook MA. Seasonal factitious increase in serum potassium: Still a problem and should be recognised. Clin Biochem 47(2014) 283-286.
    2. Hultman E, Bergstrom J. Plasma potassium determination. Scand J Clin Lab Invest 1962;14:87–93.
    3. Stankovic AK, Smith S. Elevated serum potassium values: the role of preanalytic variables. Am J Clin Pathol 2004;121: S105–S12.
    4. Labadi A, Nagy A, Szpmor A, Miseta A, Kovacs L. Factitious Hyperkalemia in Hematologic Disorders. Scandinavian Journal of Clinical and Laboratory Investigation, 77:1, 66-72
    5. Sevastos N, Theodossiades G, Archimandritis AJ. Pseudohyperkalemia in serum: a new insight into an old phenomenon. Clin Med Res 2008;6:30–2.
    6. Hartmann RC, Auditore JV, Jackson DP. Studies on thrombocytosis. I. Hyperkalemia due to release of potassium from platelets during coagulation. J Clin Invest 1958;37:699–707.
    7. Ong YL, Deore R, El-Agnaf M. Pseudohyperkalaemia is a common finding in myeloproliferative disorders that may lead to inappropriate management of patients. Int J Lab Hematol 2010;32:151–7.
    8. Sevastos N, Theodossiades G, Savvas SP, Tsilidis K, Efstathiou S, Archimandritis AJ. Pseudohyperkalemia in patients with increased cellular components of blood. Am J Med Sci 2006;331: 17–21.
    9. Ralston SH, Lough M, Sturrock RD. Rheumatoid arthritis: an unrecognised cause of pseudohyperkalaemia. BMJ 1988;297: 523–4.
    10. Alani FSS, Dyer T, Hindle E, Newsome DA, Ormerod LP, Mahoney MP. Pseudohyperkalaemia associated with hereditary spherocytosis in four members of a family. Postgrad Med J (1994) 70, 749-51. Clin Pathol 1966;19:496–7.
    11. Sevastos N, Theodossiades G, Efstathiou S, Papatheodoridis GV, Manesis E, Archimandritis AJ. Pseudohyperkalemia in serum: the phenomenon and its clinical magnitude. J Lab Clin Med 2006;147:139–44.
    12. Thurlow V, Ozevlat H, Jones SA, Bailey IR. Establishing a practical blood platelet threshold to avoid reporting spurious potassium results due to thrombocytosis. Ann Clin Biochem 2005;42:196–9.
    13. Nijsten MW, de Smet BJ, Dofferhoff AS. Pseudohyperkalemia and platelet counts. N Engl J Med 1991;325:1107. 2.
    14. Colussi G. Pseudohyperkalemia in leukemias. Am J Kidney Dis 2006;47:372–3.
    15. Guiheneuf R, Vuillaume I, Mangalaboyi J, Launay D, Berthon C, Maury JC, Maboudou P, Rousseaux J. Pneumatic transport is critical for leukaemic patients with major leukocytosis: what precautions to measure lactate dehydrogenase, potassium and aspartate aminotransferase?. Ann Clin Biochem 2010;47:94–6.
    16. Mansoor S, Holtzman NG, Emadi A. Reverse pseudohyperkalemia: an important clinical entity in chronic lymphocytic leukemia. Case Rep Hematol 2015;2015:1–3.
    17. Abraham B, Fakhar I, Tikaria A, Hocutt L, Marshall J, Swaminathan S, Bornhorst JA. Reverse pseudohyperkalemia in a leukemic patient. Clin Chem 2008;54:449–51.
    18. Lee HK, Brough TJ, Curtis MB, Polito FA, Yeo KTJ. Pseudohyperkalemia-is serum or whole blood a better specimen type than plasma? Clin Chim Acta 2008;396:95–6.
    19. Kellerman PS, Thornbery JM. Pseudohyperkalemia due to pneumatic tube transport in a leukemic patient. Am J Kidney Dis 2005;46:746–8.
    20. Garwicz D, Karlman M. Early recognition of reverse pseudohyperkalemia in heparin plasma samples during leukemic hyperleukocytosis can prevent iatrogenic hypokalemia. Clin Biochem 2012;45:1700–2.
    21. Ku ASW, Chen RHS, Law RLK. Pseudohyperkalaemia with acute leukaemia: association with pneumatic tube transport of blood specimens. Hong Kong Med J 2014;20:158–60.
    22. Chawla NR, Shapiro J, Sham RL. Pneumatic tube “pseudo tumor lysis syndrome” in chronic lymphocytic leukemia. Am J Hematol 2009;84:613–4.
    23. Meng QH, Krahn J. Reverse pseudohyperkalemia in heparin plasma samples from a patient with chronic lymphocytic leukemia. Clin Biochem 2011;44:728–30.
    24. Katkish L, Rector T, Ishani A, Gupta P. Incidence and severity of pseudohyperkalemia in chronic lymphocytic leukemia: a longitudinal analysis. Leuk Lymphoma 2016;8194:1–4.
    25. Ettinger PO, Regan TJ, Oldewurtel HA. Hyperkalemia, cardiac conduction, and the electrocardiogram: a review. Am Heart J 1974;88:360–71.
    26. Kim A, Biteman B, Malik UF, Siddique S, Martin MR, Ali SA, Maboud N, Raja S, Zachry A, Mahmoud A. A case of pseudohyperkalemia in a patient presenting with leucocytosis and high potassium level: a case report. Cases J 2010;3:73.
    27. Freeman K, Feldman JA, Mitchell P, Donovan J, Dyer KS, Eliseo L, White LF, Temin ES. Effects of presentation and electrocardiogram on time to treatment of hyperkalemia. Acad Emerg Med 2008;15:239–49.
    28. Acker CG, Johnson JP, Palevsky PM, Greenberg A. Hyperkalemia in hospitalized patients: causes, adequacy of treatment, and results of an attempt to improve physician compliance with published therapy guidelines. Arch Intern Med 1998;158:917–24.
    29. Montague BT, Ouellette JR, Buller GK. Retrospective review of the frequency of ECG changes in hyperkalemia. Clin J Am Soc Nephrol 2008;3:324–30.
    30. Dreifus LS, Pick A. A clinical correlative study of the electrocardiogram in electrolyte imbalance. Circulation 1956;14:815–25.
    31. Khodorkovsky B, Cambria B, Lesser M, Hahn B. Do hemolyzed potassium specimens need to be repeated? J Emerg Med 2014;47:313–7.
    32. Mount DB, Causes and evaluation of hyperkalemia in adults. UpToDate. Updated: May 26, 2020
    33. Shingarev R, Allon M. A Physiologic-Based Approach to the Treatment of Acute Hyperkalemia. Am J Kidney Dis. 2010;56(3):578-584
    34. Ben Salem C, Badreddine A, Fathallah N, Slim R, Hmouda H. Drug-induced hyperkalemia. Drug Saf. 2014;37(9):677-692. doi:10.1007/s40264-014-0196-1
    35. Hollander-Rodriguez JC, Calvert JF Jr. Hyperkalemia. Am Fam Physician. 2006;73(2):283-290.
    Section IconRx Treatment
    Goals
    Stabilization of cardiac membrane
    Redistribution of potassium
    Elimination of potassium
    Selected therapies should be individualized to the patient presentation and risk factors based on clinical assessment of acuity.
    Stabilization of cardiac membrane
    Calcium & Dose
    • Calcium gluconate 1gm IV (for the 10% solution do not exceed an infusion rate of 200 mg/minute in adults);
    • Calcium chloride 500 – 1000 mg IV (for the 10% solution do not exceed an infusion rate of 100 mg/minute in adults preferably through a central line, but don’t delay care)
    • Repeat dose if no effect within 5-10 mins
    Counteracts hyperkalemia induced cardiac membrane excitability and protects the heart against arrhythmias 1, 2
    Reverses or improves hyperkalemia related electrocardiogram changes within minutes
    Side effects are vasodilation, hypotension, bradycardia and arrhythmias. Calcium may cause tissue necrosis if it extravasates, risk highest with calcium chloride. 3
    Use with caution in digoxin toxicity as hypercalcemia may worsen the cardiotoxic effects of digitalis 4
    Should not be given in bicarbonate-containing solutions due to risk of precipitation of calcium carbonate
    Redistribution of potassium
    Albuterol
    • Dose: Albuterol 10mg nebulized over 30mins
    • Works on Na-K ATPase to move potassium into the cell in exchange of sodium 5, 6
    • Onset of action is 30mins; lasts up to 2hrs (7, 8)
    • Side effects: tremor, palpitation, anxiety and headache (89)
    • Non-selective beta-blockers may limit the hypokalemic response (10)
    Insulin/Dextrose
    • Dose: Insulin (regular)/Dextrose: 5 units (insulin naïve or CKD) 10 units (not naïve)/ D50 1 - 2 amps. 2
    • Works on Na-K ATPase to move potassium into the cell in exchange of sodium (11)
    • Side effects: Hypoglycemia occurs in 17% of patients, and up to 6hrs after treatment in chronic kidney disease patients 12, 13
    Sodium bicarbonate
    • No evidence to support its use to treat hyperkalemia 14, 15
    • Maybe beneficial in patients with concurrent metabolic acidosis 16
    • May cause sodium and fluid overload (1)
    Elimination of potassium
    Hemodialysis (HD)
    • Emergency hemodialysis can remove 80-100mEq/L of potassium over 2-4 hours 17
    • A dialysate bath establishes a concentration gradient and potassium diffuses out across a membrane. Can help correct acid-base and other electrolyte derangements
    • Central venous access or fistula is necessary
    • Side effects are headache, nausea, vomiting, cramps, chest pain, back pain, itching, hypotension, disequilibrium syndrome, air embolism and arrhythmia (supraventricular and ventricular) (18, 19)
    Peritoneal Dialysis (PD)
    • Can be utilized if patient has existing peritoneal access (34)
    • Urgent-start peritoneal dialysis (PD) is for patients who require dialysis initiation in 24 hours to 2 weeks
    • Benefits include: choice of long-term PD and avoidance of hemodialysis catheters
    • Patients who require emergent dialysis (usually for hyperkalemia, volume overload, or marked uremia) are not generally good candidates for urgent-start PD 35
    • Side effects are early complications from peritoneal dialysis catheter insertion and include pain, bleeding, perforations, leaks, obstructions, infection, hernia, hydrothorax and genital edema (36)
    Loop diuretics
    • Bumetanide Dose: 1-2 mg IV once
    • Furosemide Dose: 20-80 mg IV once
    • Torsemide Dose: 10-40 mg IV once
    • Inhibits Na-K-2Cl cotransporter and promotes potassium removal via urination
    • Intravenous NaCl may have a complementary effect because of the volume and sodium load
    • Side effects are ototoxicity, hypotension, electrolyte imbalance, hypovolemia
    Binders
    Patiromer
    • Dose: Patiromer 8.4-25.2g PO per 24 hours 20
    • Non-absorbable polymer; non-specific potassium binder in exchange for calcium; binds primarily in colon 21
    • Onset of action: 2 to 7hrs (22, 23)
    • Side effects: gastrointestinal discomfort (<5%), constipation (7.2%) and hypomagnesemia (5.3%); serious side effects: drug-drug interaction – ciprofloxacin, levothyroxine and metformin may be sequestered by patiromer if not taken 3hrs apart 20
    Sodium polystyrene sulfonate (SPS)
    • Dose: Patiromer 8.4-25.2g PO per 24 hours 20
    • Commonly used dose: 30g PO or 60g PR once
    • Non-absorbable polymer; non-specific binder of potassium in exchange for sodium
    • No evidence to support its use in the acute setting; may take up to 24 hours to work 24-26
    • Side effects: nausea, vomiting, diarrhea, abdominal cramps and electrolyte imbalance 27
    • Serious side effects: drug-drug interaction and bowel necrosis 22, 28
    • Black box warning 29, 30
    Sodium Zirconium Cyclosilicate (SZC)
    • Dose: SZC 10-30g PO per 24 hours
    • Inorganic zirconium silicate crystal that selectively binds potassium in the intestines 31
    • Onset of action is 1 hour; may reduce potassium by 0.1 to 0.4 mEq/L within 1 hour 32
    • Side effects are gastrointestinal symptoms, hypokalemia and leg edema; serious side effects include drug-drug interaction with dabigatran, atorvastatin and furosemide and it is recommended to administer SZC 2 hours apart 33
    Review this pharmacology PDF of these therapeutic approaches.
    References
    1. Mahoney, B A, et al. Emergency Interventions for Hyperkalemia. The Cochrane Library. 2009.
    2. Truhlar, A, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. 2015, Vol. 95, pp. 148-201.
    3. Calcium Gluconate Package Insert. Lake Zurich, IL : Fresenius Kabi USA LLC, 2017.
    4. Van Deusen, S K, Birkhahn, R H and Gaeta, T J. Treatment of hyperkalaemia in a patient with unrecognized digitalis toxicity. J Toxicol Clin Toxicol. 2003, Vol. 41, pp. 373-376.
    5. Liou, H H, et al. Hypokaleamic effects of intravenous infusion or nebulization of salbutamol in patients with chronic renal failure: comparative study. Am J Kidney Dis. 1994, Vol. 23, pp.266- 271.
    6. Treatment of hyperkalaemia using intravenous and nebulized salbutamol. McClure, RJ, Prasad, Vinod KI. And
    7. Potassium-Lowering Effect of Albuterol for Hyperkalemia in Renal Failure. Montoliu, Jes s, Xm, Lens and L, Revert. 4, 1987, JAMA Internal Medicine, Vol. 147, pp. 713-717.
    8. Allon, M, Dunlay, R and Copkney, C. Nebulised albuterol for acute hyperkalaemia in patients on haemodialysis. Ann Intern Med. 1989, Vol. 110, pp. 426-429.
    9. Mandelberg, A, et al. Salbutamol metered-dose inhaler with spacer for hyperkalaemia. How fast? How safe? Chest. 1999, Vol. 115, pp. 617-622.
    10. Ahmed, J and Weisberg, L. Hyperkalaemia in dialysis patients. Semin Dial. 2001, Vol. 14, pp. 348-356.
    11. Hundal, H S, et al. Insulin induces translocation of the alpha 2 and beta 1 subunits of the Na+/K(+)-ATPase from intracellular compartments to the plasma membrane in mammalian skeletal muscle. J Biol Chem. 1992, Vol. 267, pp. 5040-5043.
    12. Peacock, F, et al. REal World EVidence for TrEAtment of HyperkaLemia in the Emergency Department (REVEAL–ED): A Multicenter, Prospective, Observational Study. J Emerg Med. 2018, Vol. 55, 6, pp. 741-750.
    13. Pierce, D A, Russell, G and Pirkle, J L. Incidence of Hypoglycemia in Patients With Low eGFR Treated With Insulin and Dextrose for Hyperkalemia. Annals of Pharmacotherapy. 2015, Vol. 49, 12, pp. 1322-1326.
    14. Blumberg, A, et al. Effect of various therapeutic approaches on plasma potassium and major regulating factors in terminal renal failure. Am J Med. 1988, Vol. 85, pp. 507-512.
    15. Gutierrez, R, et al. Effect of hypertonic versus isotonic sodium bicarbonate on plasma potassium concentration in patients with end-stage renal disease. Mineral and Electrolyte Metabolism. 1991, Vol. 17, 5, pp. 297-302.
    16. Sterns, R H, et al. Internal Potassium Balance and the Control of the Plasma Potassium Concentration. Medicine. 1981, Vol. 60, 5, pp. 339-354.
    17. Hyperkalemia across the continuum of kidney disease. Palmer, B F and Clegg, D. CJASN : s.n., 2018, Vol. 13, pp. 155-157.
    18. Bergman, H, Daugirdas, J T and Ing, T S. Complications during hemodialysis. [book auth.] J T Daugirdas and T S Ing. Handbook of Dialysis. New York : Little Brown, 1994.
    19. Tumlin, J, et al. Relationship between dialytic parameters and reviewer confirmed arrhythmias in hemodialysis patients in the monitoring in dialysis study. BMC Nephrology. 2019, Vol. 20, 1 80.
    20. Veltassa (patiromer) Package Insert. Redwood City, CA : Relypsa Inc., 2018.
    21. Mechanism of Action and Pharmacology of Patiromer, a Nonabsorbed Cross-Linked Polymer That Lowers Serum Potassium Concentration in Patients With Hyperkalemia. Li, Lingyun, et al. 5, 2016, Journal of Cardiovascular Pharmacology and Therapeutics, Vol. 21, pp. 456-465.
    22. Patiromer for Treatment of Hyperkalemia in the Emergency Department: A Pilot Study. Rafique, Zubaid, et al. 2019, Academic Emergency Medicine.
    23. Patiromer induces rapid and sustained potassium lowering in patients with chronic kidney disease and hyperkalemia. Bushinsky, David A., et al. 6, 2015, Kidney International, Vol. 88, pp. 1427-1433.
    24. Scherr, L, et al. Management of hyperkalemia with a cation-exchange resin. New England Journal of Medicine. 1961, Vol. 264, 3, pp. 115-119.
    25. Nasir, K and Ahmad, A. Treatment of hyperkalemia in patients with chronic kidney disease: a comparison of calcium polystyrene sulphonate and sodium polystyrene sulphonate. J Ayub Med Coll Abbottabad. 2014, Vol. 26, 4, pp. 455-458.
    26. Lepage, L, et al. Randomized Clinical Trial of Sodium Polystyrene Sulfonate for the Treatment of Mild Hyperkalemia in CKD. Clinical Journal of the American Society of Nephrology. 2015, Vol. 10, 12, pp. 2136-2142.
    27. Kayexalate Package Insert. Bridgewater, NJ : Sanofi-Aventis US LLC, 2010.
    28. Harel, Z, et al. Gastrointestinal adverse events with sodium polystyrene sulfonate (kayexalate) use: a systematic review. The American Journal of Medicine. 2013, Vol. 126, 3.
    29. U.S. Food and Drug Administration. [Updated 2017 Sep 6] FDA Drug Safety Communications. Learn More
    30. U.S. Food and Drug Administration. [Updated 2009] Kayexalate. Learn More
    31. Stavros, F, et al. Characterization of structure and function of ZS-9, a K+ selective ion trap. PLoS One. 2014, Vol. 9, 12.
    32. Ash, S R, et al. A phase 2 study on the treatment of hyperkalemia in patients with chronic kidney disease suggests that the selective potassium trap, ZS-9, is safe and efficient. Kidney Int. 2015, Vol. 88, 2, pp. 404-411.
    33. Lokelma Package Insert. s.l. : AstraZeneca Pharmaceuticals LP, Wilmington, DE, 2018.
    34. Roseman, D. A., Schechter-Perkins, E. M., & Bhatia, J. S. (2015). Treatment of lifethreatening hyperkalemia with peritoneal dialysis in the ED. American Journal of Emergency Medicine, 33(3), 473.e3-5. Learn More
    35. Ghaffari, A., Motwani, S., (2021) Urgent start peritoneal dialysis. Up To Date Retrieved May
    36. 2021 Learn More
    37. Diaz-Buxo JA. Complications of peritoneal dialysis catheters: early and late. Int J Artif Organs. 2006;29(1):50-58. Learn More
    Section IconK+ re-eval and Disposition
    Disposition
    All disposition decisions should account for local standards of care and these recommendations should not supersede the clinical judgement of the treating physician.
    1. Hyperkalemia with unstable vitals:
    • Admit
    2. New Hyperkalemia with stable vitals:
    • Observation/admission for further characterization and treatment
    3. Chronic Hyperkalemia with stable vitals and ECG:
    • K<5.5: DC (discharge) with close outpatient follow-up
    • 5.5<K<6.0: Consider DC with close outpatient follow-up after risk benefits conversation with patient
    • K>6.0: Admit if unable to decrease K with adequate treatment and elimination of K
    4. Hyperkalemia with ESRD, dialysis dependent patient with functioning fistula or temporary HD line:
    • Cause Missed Dialysis with stable vitals and no ECG changes:
      • if able to coordinate outpatient dialysis – discharge to outpatient dialysis center
      • if unable to coordinate outpatient dialysis – consult nephrology for emergent dialysis evaluation, okay to discharge after dialysis and reevaluation with stable vitals
    5. Hyperkalemia with ESRD, dialysis dependent patient with non-functioning fistula or temporary HD line:
    • Obtain vascular access per local protocol.
      Back To Top

    Acknowledgments

    Developed by the ACP Expert Panel on Hyperkalemia
    Reviewed by the ACEP Clinical Resource Review Committee

    CONTRIBUTORS
    James Neuenschwander, MD, FACEP (co-chair) Matthew Weir, MD (co-chair) Terra Armstead DNP, RN, CEN Jason J. Bischof, MD Joanna Hudson, PharmD W. Frank Peacock, MD, FACC, FESC, FACEP Zubaid Rafique, MD, FACEP

     

    ACEP Staff
    Jerry Anderson Riane V. Gay, MPA, CAE Liz Muth, CAE

     

    Downloads
    HyperK Reference List (PDF) Management algorithm for adults with hyperkalemia (PDF) Pharmacology (PDF)

     

    FEEDBACK
    Questions, Contact us today!

     

    Support made possible by AstraZeneca

     

    Publisher’s Notice

    The American College of Emergency Physicians (ACEP) makes every effort to ensure that contributors and editors of its resources are knowledgeable subject matter experts and that they used their best efforts to ensure accuracy of the content. However, it is the responsibility of each user to personally evaluate the content and judge its suitability for use in his or her medical practice in the care of a particular patient. Users are advised that the statements and opinions expressed in this resource are provided as recommendations of the contributors and editors at the time of publication and should not be construed as official College policy. ACEP acknowledges that, as new medical knowledge emerges, best practice recommendations can change faster than published content can be updated. ACEP recognizes the complexity of emergency medicine and makes no representation that this resource serves as an authoritative resource for the prevention, diagnosis, treatment, or intervention for any medical condition, nor should it be used as the basis for the definition of or the standard of care that should be practiced by all health care providers at any particular time or place. To the fullest extent permitted by law, and without limitation, ACEP expressly disclaims all liability for errors or omissions contained within this resource, and for damages of any kind or nature, arising out of use, reference to, reliance on, or performance of such information.

    Copyright 2021, American College of Emergency Physicians, Dallas, Texas. All rights reserved. Produced in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this resource may be reproduced or distributed in any form or by any means or stored in a database or retrieval system without prior written permission of the publisher.

    Requests for permission should be sent here.

    LIVE CHAT
    [ Feedback → ]