1 / 22

Hyperkalemia – an emergency?

Hyperkalemia – an emergency?. Shaila Sukthankar Paediatric Nephrology Study Day 22.06.12 RMCH. Hyperkalemia. Overview Clinical cases Emergency Management. Hyperkalemia - causes. Spurious/ pseudohyperkalemia Increased intake Trans-cellular shift Decreased renal tubular excretion

zagiri
Télécharger la présentation

Hyperkalemia – an emergency?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Hyperkalemia – an emergency? Shaila Sukthankar Paediatric Nephrology Study Day 22.06.12 RMCH

  2. Hyperkalemia • Overview • Clinical cases • Emergency Management

  3. Hyperkalemia - causes • Spurious/ pseudohyperkalemia • Increased intake • Trans-cellular shift • Decreased renal tubular excretion • Renal • Endocrine • Drugs

  4. Investigations • Renal • U&Es, acid base balance, urinalysis • TTKG (urine K X P osmol/ plasma K X U osmol) • Endocrine • For another meeting! • Renin, aldosterone, urinary steroids, 17-OHP • Others • FBC, blood film, urate, CK, calcium, phosphate

  5. Case 1 • ER, 15 years old girl • Known to have IDDM for several years • Difficult family circumstances but ER very well engaged and compliant • Recent annual diabetes review 3 months before admission - good glycaemic control • Blood tests unremarkable, urine microalbumin/ creatinine ratio normal • Growth – weight and height 2nd to 9th and postpubertal

  6. Clinical Presentation • Diarrhoeal illness for 1 week – mucus, no blood. Initially polyuric and nocturic, now decreased urine output • Parents noticed her to be pale and tired lately • Examination – pale, BP 130/ 86, hydration and perfusion normal • Urine 3+ glucose, ketones ++

  7. Initial investigations • CBG: pH 7.2, BE –10, Bicarb 15 • Na 128, K 6.5, urea 23 • Hb 9.8, WCC 5.8

  8. Further investigations • Platelet 240 • Glucose 7.8 • Creatinine 210 • Ca 1.9, Pi 2.8 • Blood film – normal RBC and platelet morphology • Urine 2+ protein, 3+ blood with casts

  9. Immediate measures • Stop external sources of K • Stabilise myocardium • IV calcium gluconate • Enhance intracellular shift of K • Nebulised Salbutamol • Sodium Bicarbonate • Glucose Insulin infusion • Increase excretion • Ion exchange resin • Dialysis

  10. Calcium Gluconate • If K >7 mmol/ L or ECG changes • 10% solution • 0.5 ml/ Kg (maximum 20ml) over 10 minutes • With ECG control via large peripheral or central line • Protects myocardium from acute dysrhythmia, no effect on K levels

  11. Salbutamol • First line treatment – nebulised • 2.5mg up to 5 years age, 5mg there after • Can be repeated up to 3 times • Alternatively, if access available, IV salbutamol • 4mcg/ kg • diluted with normal saline or glucose • 50mcg/ml concentration • Over 5 min as slow bolus • Does not lower net K, shifts from ECF to ICF

  12. Sodium Bicarbonate • In presence of acidosis • 8.4% solution • 1ml (1mmol)/ Kg • Diluted to minimum 1:10 with normal saline/ glucose for peripheral venous use (1:5 for central access) • Infusion over 30 minutes • Shifts K from ECF to ICF

  13. Glucose Insulin infusion • Soluble short acting insulin (0.1 U/ Kg) • Mixed in 5 – 10 ml/ Kg of 10% dextrose for peripheral use (2.5 to 5 ml of 20% dextrose for central access) • Infused over 30 minutes • Check BM every 15 minutes by POCT – until 15 minutes after infusion

  14. Calcium Resonium • Oral (not neonates) or rectal • 125-250 mg/ kg qds (maximum 15gm per dose) • If given orally, also use lactulose • Lowers total body K by excretion in stools

  15. Further management • Treatment of underlying cause – DKA management, endocrine, renal etc • Renal replacement modalities • Haemodialysis for rapid effective reduction in K levels • Peritoneal dialysis is as effective but over longer duration • Haemofiltration – if already on ICU

  16. After emergency treatment… • Recheck U&Es after 15 minutes of initial intervention to ensure • treatment is effective • Level is reaching safe range • Recheck after 1 – 2 hours to detect rebound hyperkalemia • Look for underlying cause

  17. ER - update • Required nebulised salbutamol and Ca gluconate at local DGH • Transferred to RMCH and started on dialysis the same day • Had immune work up and renal biopsy • GFR reduced to <10 (ESRD) – CKD5 management • On dialysis • Had living related donor kidney transplant

  18. Case 2 • 3 years, boy, previously well • Presented with fever and frequent URI • Growth, examination normal • Blood tests • FBC normal, mild iron deficiency • Na 135, K 6.8, U 4.5, Creatinine 35 • pH 7.3 BE – 8, sugar 4.8, urine NAD • ECG nSR

  19. Case 2 continues… • Plasma renin and aldosterone low • Synacthen test and 17-OHP normal • Diagnosis?? • Hyporeninemic hypoaldosteronism • Pseudohypoaldosteronism

  20. Gordon’s syndrome (PHA 2) • Tubulopathy affecting chloride channels, decreased potassium excretion (WNK1, WNK4 AR mutation) • Responded well to thiazide diuretics • Younger twin siblings also affected • All currently well with normal K levels on thiazide treatment

  21. Summary • Acute, severe, true hyperkalemia • is a medical emergency • requires prompt recognition and optimum treatment • Not all hyperkalemia is renal in origin • Specialist input required to establish etiology and long term management

  22. Specialist Input

More Related