B2 agonists: acute management of hyperkalemia

Albuterol and insulin with glucose have an

additive effect on plasma K concentration;
however, ~20% of patients with end-stage renal
dis- ease (ESRD) are resistant to the effect of
2agonists; hence, these drugs should not be
used without insulin
Lactulose 30cc HOLD if BM > 3x/day ODHS
Synthetic sugar, non-absorbable
increases the fecal excretion of K
50 mL D50W + 20 units humolin r Q4
insulin deficiency in DM allows net movement of K
out of cells
+
Insulin lowers plasma K
concentration by
+
shifting K into cells.
Bolus D W without insulin is never appropriate,
50
given the risk of acutely worsening hyperkalemia
due to the osmotic effect of hypertonic glucose.
Hypoglycemia is common with insulin plus
glucose; hence, this should be followed by an
infusion of 10% dextrose at 5075 mL/h, with
close monitoring of plasma glucose concentration.
In
hyperkalemic
patients
with
glucose
concentrations of 200250 mg/dL, insulin should
be administered without glucose, again with close
monitoring of glucose concentrations.
NaHCO3 650 mg/tab TID

Treatment goals:

Immediate antagonism of
hyperkalemia

Rapid reduction in plasma

redistribution into the cells

cardiac
K

effects

of

concentration

by

Diet: 1800 kcal/day 60% CHO 0.8 g/kg/day CHON 60%

HBV <2g Na < 7% sat fats <200mg Cholesterol LSSS
divided into 6EF
No fresh fruits and juices. No potassium in diet. Increase
fiber
Chronic kidney disease and end-stage kidney disease are
very common causes of hyperkalemia, due to the
associated deficit or absence of functioning nephrons.
Hemodialysis is the most effective and reliable method to
reduce plasma K concentration; peritoneal dialysis is
considerably less effective.
The amount of K removed during hemodialysis depends
on the relative distribution of K between ICF and ECF
(potentially affected by prior therapy for hyperkalemia),
the type and surface area of the dialyzer used, dialysate
and blood flow rates, dialysate flow rate, dialysis
duration, and the plasma-to-dialysate K gradient.

CaCO3 tab OD
Intravenous calcium serves to protect the heart,
whereas other measures are taken to correct
hyperkalemia. Calcium raises the action potential
threshold and reduces excitability, without
changing the resting membrane potential. By
restoring the difference between resting and
threshold potentials, calcium reverses the
depolarization blockade due to hyperkalemia.
Calcium Gluconate 10%: 0.5 ml/kg slow IV
injection OR Calcium Chloride 10% : 0.1-0.2 ml/kg
slow IV injection (as above) (Max : 10ml)
Onset of Action: <3 minutes, should see
normalisation of ECG. If not: repeat dose
(twice)
3Duration: ~30 minutes
Salbutamol + ambroxol neb Q4
Onset of Action: 30 minutes, should reduced
intravascular K+ of 0.5-1.5mmol/L
Duration: 2-3 hours

Can shift potassium from the extracellular to

intracellular by increasing blood pH.

no role in the acute treatment of hyperkalemia,

but may slowly attenuate hyperkalemia with
sustained administration over several hours
In patients with metabolic acidosis, a delayed
+
drop in plasma K
concentration can be seen
after 46 h of isotonic bicarbonate infusion
Novomix 20 units/SC TID
Biphasic insulin aspart
Kalimate 1 sachet BID
Calcium polystyrene sulfonate
Prevention and treatment of hyperkalemia
resulting from acute or chronic renal failure
7-9% ca 1g which is exchanged for 53-71 mg of
potassium in vitro
in the GIT (esp colon) and kalimate is
excreted unchanged plystyrene sulfonate
resin in the feces w/o digestion and
absorption
calcium type-resin
used even for aptients with restricted ingestion of
sodium

CBG Monitoring Q4
>281 = 6u
OH c SBT c HMW

80-230 = 2u

ASA 80 mg/tab OD
Atorvastatin 40 mg/tab ODHS
Keltican cap OD
Food supplement(?)
CaCO3 tab OD
Salbutamol + ambroxol neb Q4
Fluimucin neb Q4

231-280

4u

 Mucolytic
acetylcysteine
Omeprazole 40 mg/tab with BF OD
Faktu ointment apply on anal area TID
Clonidine 75 mcg/tab Q8
Lactulose 30cc HOLD if BM > 3x/day ODHS

Levofloxacin 750 mg/IV Q48

Enoxaparin 0.4 ml/SC OD
Tigecycline 50 mg/IV Q12
50 mL D50W + 20 units humolin r Q4
NaHCO3 650 mg/tab TID
Novomiz 20 units/SC TID
Kalimate 1 sachet BID