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Hyperkalaemia in Adults
Hyperkalaemia in Adults
Explicit definition of patient group to which it applies Applies to: All adult inpatients and outpatients
(e.g. inclusion and exclusion criteria, diagnosis) referred with incidental hyperkalaemia from their GP,
NEMS or the Outpatient Department.
Excludes: Diabetic ketoacidosis (DKA), Paediatrics
Approval
DTC
INPATIENTS:
For all inpatients K+ > 6.0 mmol/L (K+ >6.5 mmol/L in renal dialysis patients) request
an ECG and repeat potassium sample.
Renal dialysis patients with K+ >6.5 mmol/L should be referred directly to the renal
team.
OUTPATIENTS:
For all outpatients with K+ > 6.0 mmol/L (K+ >6.5 mmol/L in renal dialysis patients)
arrange for the patient to attend NEMS for an ECG and repeat potassium sample.
Renal dialysis patients with K+ >6.5 mmol/L should be referred directly to the renal
team.
Where patients are known to be under the care of a specific medical speciality (e.g.
renal, oncology, cardiology etc) their GP should refer them directly to the speciality.
Send blood sample for repeat serum potassium urgently. For patients with “fragile” red
cells, chronic lymphocytic leukaemia, thrombocytosis, and vasculitis request ‘Whole
Blood Potassium’ (in a Lithium-Heparin tube).
Repeat K+ < 6.0 mmol/L and renal function stable - no urgent action required. Arrange
dietary modification and medication review; for outpatients admission to hospital is not
required.
Repeat K+ = 6.0 - 6.5 mmol/L follow the guideline and consider discharge if appropriate.
Patients seen by NEMS with ECG changes will be referred to ED resus for treatment.
Patients with no ECG changes will be referred to AMRU for assessment and
management.
Repeat K+ > 6.5 mmol/L follow the guideline. Patients seen by NEMS will be referred to
ED resus for treatment.
Check potassium and renal Step 3 Reduce Total Contact Renal Registrar
function again after 4-6 hours Body Potassium. on-call urgently.
and then daily. See page 4+9.
Exclude pseudohyperkalaemia.
Stop all potassium-containing/sparing drugs.
Low potassium diet.
Ensure adequate hydration and monitor urine output.
Treat hypotension.
Monitor renal function.
See page 6 for clinical assessment and investigations
3d) DIALYSIS
If patient does not respond to above measures, contact Renal
Registrar on-call urgently to discuss further management.
Repeat K+ < 6.0 mmol/L and renal function stable - no urgent action required.
Arrange dietary modification and medication review; admission to hospital is not
required.
Repeat K+ = 6.0 - 6.5 mmol/L follow the guideline and consider discharge if
appropriate.
Definition
Hyperkalaemia is classified as a raised serum potassium level:
Mild: K+ = 5.5 - 5.9mmol/L
Moderate: K+ = 6.0 - 6.4mmol/L
Severe: K+ ≥ 6.5mmol/L or if ECG changes or symptoms present
Causes of Hyperkalaemia
Pseudohyperkalaemia
Test tube haemolysis - NEVER refrigerate samples and ensure samples
arrive at the laboratory within 5 hours
EDTA contamination (from FBC sample tube)
Prolonged tourniquet time
Marked leucocytosis and thrombocytosis (measure Lithium Heparin whole
blood potassium not serum concentration in these disease states)
Sample taken from drip arm
Acute kidney injury
Chronic kidney disease
Drugs (potassium supplements, potassium-sparing diuretics such as amiloride,
aldosterone antagonists such as spironolactone, ACE inhibitors, angiotensin II
antagonists, NSAIDs, heparin, -blockers, digoxin poisoning)
Acidosis, including diabetic ketoacidosis (NB this guideline does not apply to the
management of hyperkalaemia in DKA: see below and separate DKA Guideline).
Mineralocorticoid deficiency (e.g. Addison’s)
Endogenous (tumour-lysis syndrome, rhabdomyolysis, trauma, burns)
Please note that this list is not comprehensive and that other causes may need to be
considered.
Clinical Assessment
Urine output – very important. If oliguric, medical treatment much less likely to work.
Review potassium intake e.g. IV fluids, potassium supplements, diet.
Review drugs (ACE inhibitors, Angiotensin II Antagonists and potassium sparing
diuretics).
Review history for possible causes of renal disease or major tissue destruction.
Review recent biochemistry results, in particular renal function and recent potassium
levels.
Fluid status – signs of dehydration or fluid overload.
Potassium levels may be assessed on an arterial or venous blood sample using a point
of care blood gas analyser in emergencies. This must be followed up with a formal
laboratory measurement.
Investigations
12-lead ECG
U&Es, venous bicarbonate, glucose, FBC
If unwell consider arterial blood gases
Treatment of Hyperkalaemia
Exclude pseudohyperkalaemia.
Stop all potassium supplements (IV and oral).
Review patient’s medication for possible contributors to hyperkalaemia and or
acute renal failure.
Reduce dietary K+ intake.
Ensure adequate hydration and urine output.
If potassium > 6.5mmol/l or ECG changes monitor patients cardiac rhythm
until it is stable and potassium level is in range.
After any of the above steps: Recheck potassium 2 hours after treatment.
If K+ remains > 6.5mmol/L or ECG changes persist contact on call Renal
Registrar urgently.
If potassium has improved but the patient is oligo/anuric or developing renal
failure contact the Renal Registrar on-call urgently as the potassium will
almost certainly rebound.
3d) DIALYSIS
If the patient does not respond to the above measures dialysis will be required.
DIALYSIS IS LIKELY TO BE NEEDED IF POTASSIUM VERY HIGH (>7.5
mmol/L), PATIENT IS OLIGO/ANURIC, PATIENT IS ALREADY ON
LONGTERM DIALYSIS OR HAS ADVANCED CKD. In these situations contact
the Renal Registrar on-call urgently to discuss management.
References:
1. Ahee P, Crowe AV. The management of hyperkalaemia in the emergency
department. J Accid Emerg Med 2000; 17: 188-191
2. Guidelines and audit implementation network, Northern Ireland. GAIN- Guidelines
for the treatment of hyperkalaemia in adults: August 2014. Accessed 22/1/2016.
http://www.gain-
ni.org/images/Uploads/Guidelines/GAIN_Guidelines_Treatment_of_Hyperkalaemia_i
n_Adults_GAIN_02_12_2014.pdf
3. Weisberg LS. Management of severe hyperkalemia. Crit Care Med 2008; 36:12;
3246-3251
4. Burgess C. Clinical Management Guideline for Patients with Hyperkalaemia, Kings
College Hospital NHS Foundation Trust. Version 1 September 2008
5. Alfonzo A. et al. Treatment of Acute Hyperkalaemia in Adults. The Renal
Association. March 2014.
6. Calcium Resonium 99.934% w/w Powder for Oral/Rectal Suspension - Sanofi.
Summary of product characteristics [last update 16/01/2015] on Electronic Medicines
Compendium: (accessed on [27.05.15]) via www.medicines.org.uk/
To prepare and administer the enema using Calcium Resonium® oral powder:
For every inpatient diagnosed with acute kidney injury (AKI) that requires a low potassium
diet, please ensure that you:
1. Liaise with the hospital kitchen (via Carillion) and arrange a low potassium/renal diet
by ringing:
City Campus: extension 59099
QMC Campus: extension 63221
2. Refer the patient to your ward dietitian using Nervecentre or contacting the
department of Dietetic and Nutrition:
City Campus: extension 57139
QMC Campus: extension 62040
3. Inform patient and/or relative about suitable options (see next page)
A dietitian will assess each patient individually and will provide appropriate dietetic advice
based on the patients current potassium intake and clinical conditions.
Dietitians are trained to advise on a low potassium diet as well as ensuring that the patients
diet is well balanced. Many inpatients with AKI may require a low potassium diet only
temporarily. Following a low potassium diet if not needed will inevitably lead to water
soluble vitamin and micronutrient deficiency.
This appendix should only be used during weekends or bank holidays. Inpatients should
still be referred to the department of Dietetics and Nutrition as the dietitians will provide
appropriate dietetic advice and follow up.
Why do you need to follow a low potassium diet while you are in hospital?
Potassium is a mineral which is needed in the body for your muscles and heart to work
properly. The amount of potassium in the blood is normally controlled by your kidneys.
When your kidneys are not working properly or if you are taking certain medications the
potassium level in the blood can rise. High levels of potassium in the blood can be
dangerous as it can have an effect on your heart. In order to keep the level of potassium in
your blood safe you need to reduce the amount of potassium in your diet. You should only
follow a low potassium diet if you have been advised by your health care
professional to do so.
This leaflet gives you some initial advice to help you reduce the amount of potassium in
your diet while you are in hospital. If you need to follow low potassium diet you should be
referred to a registered dietitian who will give you personalised dietary advice and ensure
that your diet remains well balanced.
Food to avoid at this time Food you can eat at this time
FRUIT - Bananas, oranges, kiwi fruit, Apples, pears, clementines, up to 10
avocados, peaches, strawberries, all grapes, tinned fruit.
dried fruit
STARCHY FOODS - Jacket/baked Boiled potatoes, potatoes that have
potatoes, oven/microwave/retail chips, been par-boiled then roasted/fried.
manufactured potato products. Pasta, rice, noodles, breads.
SWEET SNACKS - Chocolate, Sponge cake, Madeira cake, plain
chocolate biscuits, liquorice, fruit cake, scones, cream cakes, jelly,
chocolate cake, muesli bars, biscuits marshmallows, chewy sweets, mints,
and cakes containing lots of nuts/dried biscuits and cakes not containing
fruit/chocolate. dried fruit/nuts/chocolate.
SAVORY SNACKS - Potato Corn or maize based snacks,
crisps/snacks, chips, nuts, tomato popcorn, rice cakes, bread sticks and
soup, mushroom soup. sandwiches.
DRINKS - Coffee, malted milk drinks Tea, herbal tea, squash/cordial, barley
(e.g. Ovaltine / Horlicks), drinking water, mineral water, flavoured water,
chocolate, fruit juices, smoothies. fizzy drinks (i.e. lemonade).
SALT SUBSTITUTES (to avoid) - e.g. Other seasonings e.g. pepper, herbs,
Lo-Salt, So-Lo, reduced sodium salt. spices.
Please discuss with your dietitian if you have diabetes and/or if you have been advised to
follow this long term.
(The information above has been adapted from the “First Line Potassium Lowering Dietary Advice” diet sheet
th
developed by the Renal Nutrition Group of the British Dietetic Association 2012 accessed on the 6 July 2015
via www.bda.org.uk )
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