Hyperkalemia management in the emergency department: An expert panel consensus

Abstract

Hyperkalemia is a common electrolyte abnormality identified in the emergency department (ED) and potentially fatal. However, there is no consensus over the potassium threshold that warrants intervention or its treatment algorithm. Commonly used medications are at best temporizing measures, and the roles of binders are unclear in the emergent setting. As the prevalence of comorbid conditions altering potassium homeostasis rises, hyperkalemia becomes more common, and hence there is a need to standardize management. A panel was assembled to synthesize the available evidence and identify gaps in knowledge in hyperkalemia treatment in the ED. The panel was composed of 7 medical practitioners, including 5 physicians, a nurse, and a clinical pharmacist with collective expertise in the areas of emergency medicine, nephrology, and hospital medicine. This panel was sponsored by the American College of Emergency Physicians with a goal to create a consensus document for managing acute hyperkalemia. The panel evaluated the evidence on calcium for myocyte stabilization and potassium shifting and excretion. This article summarizes information on available therapies for hyperkalemia and proposes a hyperkalemia treatment algorithm for the ED practitioner based on the currently available literature and highlights diagnostic pitfalls and evidence gaps.

Treatment of hyperkalemic emergencies

“…No consistent thresholds for potassium levels warranting treatment have been proposed. [3] First, higher serum potassium is associated with higher mortality. A retrospective multicenter study revealed that higher serum potassium levels, severe underlying diseases, and developing acute kidney injury (AKI) from normal baseline renal function were associated with higher mortality.…”

“…[6] Second, electrocardiogram (ECG) changes indicate higher risk of mortality in hyperkalemia. [3,7] Elevated serum potassium in cardiac myocytes results in cardiac instability inducing ventricular fibrillation and cardiac arrest. [8] Higher mortality occurs in patients with serum potassium ≥6.0 mmol/L possessing new ECG changes than those without ECG changes.…”

“…[8] Higher mortality occurs in patients with serum potassium ≥6.0 mmol/L possessing new ECG changes than those without ECG changes. [3,9] Based on present studies and guidelines, we recommend treatment should be initiated under the following circumstances: (1) serum potassium ≥6.0 mmol/L with or without ECG changes; (2) presence of more than two ECG changes, clinical manifestations of hyperkalemia, and risk factors for hyperkalemia (Table 1), with serum potassium 5.5-5.9 mmol/L; [9] (3) a clinical course likely to progress to hyperkalemia, such No World J Emerg Med, Vol 13, No 3, 2022 as in anuresis patients complicated by rhabdomyolysis or tumor lysis syndrome, even if the serum potassium is <6.0 mmol/L. [7] Nonetheless, more evidence-based studies are necessitated concerning thresholds for HE treatment.…”

“…[8] If calcium salts and insulin-glucose fail to control HEs, nebulized beta-2 agonists (albuterol 10-20 mg) should be given as an adjuvant treatment but should not be given as monotherapy due to some hyperkalemia patients being unresponsive to beta-2 agonists. [3,9] Beta-2 agonists induce a mild hyperglycemic state, so simultaneous administration of beta-2 agonists with IV insulinglucose can achieve better effi cacy and lower the risk of hypoglycemia. [7] However, high doses of beta-2 agonists may cause side effects such as palpitations, tremors, headaches, and angina, particularly in patients with coronary heart disease.…”

“…[1] Hyperkalemic emergencies (HEs) are commonly encountered (2%-3%) in the emergency department (ED). [2,3] In-hospital mortality rate for hospitalized hyperkalemic patients is about 14.1% and 4.5 times higher than that of those with normal potassium. [4] Quick recognition and treatment are critical for decreasing morbidity and mortality.…”