How should we manage hyperkalaemia?

How do you manage the patient with hyperkalaemia? Guidelines are based on literature that is not robust.

In this review we look at the guidelines and then at some of the more recent lierature that challenges the proposed algorithms.

European Resuscitation Guidelines for Hyperkalaemia (1)

The goals are listed as:

1. Protecting the heart: this usually involves administration of Calcium
2. Shifting the potassium into the cells; usually involving glucose and insulin and salbutamol in severe cases
3. Removing the potassium from the body: involves either dialysis or a binding agent, the later, which may not really have an effect in the emergency department.
4. Monitoring the potassium and glucose levels.

Let’s look at two groups of patients:, those in cardiac arrest from severe hyperkalaemia and those not arrested, with varying degrees of hyperkalaemia.

References

1. Lott C et al. European resuscitation Council Guidelines 2021: Cardiac Arrest in Special Circumstances. Resuscitation 2021;161: 152-219
2. Jessen K.K et al. Pharmacological interventions for the acute treatment of hyperkalaemia: A systematic review and meta-analysis.Resuscitation 208 (2015) 110489.
3. Freeman K, et al. Effects of presentation and electrocardiogram on time to treatment of hyperkalemia. Acad Emerg Med. 2008;15:239–49.
4. Alfonzo A, Soar J, MacTier R, et al. Clinical practice guidelines: treatment of acute hyperkalaemia in adults. UK Renal Assoc. 2014;147:59–77.
5. Truhlář A, Deakin CD, Soar J, et al. European resuscitation council guidelines for resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation. 2015;95:148–201.
6. Durfey N, Lehnhof B, Bergeson A, et al. Severe hyperkalemia: can the electrocardio- gram risk stratify for short-term adverse events? West J Emerg Med. 2017;18: 963–71.
7. Mahoney BA, et al. Emergency interventions for hyperkalaemia. Cochrane Database Syst Rev. 2005(2):6–38 Art. No.: CD003235.
8. Wu Y-H, Chou J-W, Lai H-C, Su G-S, Cheng K-S, Chen T-W. Adverse gastrointestinal effects with kayexalate or kalimate: a comprehensive review. Clin Exp Gastroenterol. 2021;14:1–18.