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Guideline for the Management of Hyperkalaemia in Adults

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Guideline for the Management of Hyperkalaemia in Adults WAHT-REN-009 It is the responsibility of every individual to check that this is the latest version/copy of this document. GUIDELINE FOR THE MANAGEMENT OF HYPERKALAEMIA IN ADULTS This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in consultation with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this guidance. Introduction This guideline is to provide education and guidance to prescribers and healthcare professionals involved in treating adult patients with hyperkalaemia. The guideline outlines the management and treatment of adult patients with proven hyperkalaemia reported on a laboratory blood sample (WAHT reference range for potassium is: 3.5 – 5.3 mmol/L). The guideline is based on the latest national hyperkalaemia management guidelines produced by GAIN in 2008 (Guidelines and Audit Implementation Network) accessed via: http://www.gain-ni.org/Publications/Guidelines/hyperkalaemia guidelines.pdf and the UK Renal Association July 2012 accessed via: www.renal.org/guidelines in May 2013. This guideline is for use by the following staff groups : All qualified healthcare professionals involved in the care and management of adult patients with hyperkalaemia. Lead Clinician(s) Dr Martin Ferring Consultant Renal Medicine, WRH Dr Stephen Spencer Consultant Renal Medicine, WRH Approved by Clinical Management Committee on: 20 th November 2013 Approved by Medicines Safety Committee on: 15th October 2013 Extension approved by TMC on: 22nd July 2015 This guideline should not be used after end of: 20th November 2017 Key amendments to this guideline Date Amendment By: October 2013 New guideline February 2015 Document extended for 12 months as per TMC paper TMC approved on 22nd July 2015 December Further 12 months extension to document TMC 2016 Guideline for the management of Hyperkalaemia in adults WAHT-REN-009 Page 1 of 19 Version 1.2 WAHT-REN-009 It is the responsibility of every individual to check that this is the latest version/copy of this document. GUIDELINE FOR THE MANAGEMENT OF HYPERKALAEMIA IN ADULTS Introduction The incidence of hyperkalaemia in hospitalised patients is between 1-10%. The majority of cases are drug-induced in the patient in conjunction with pre-existing or newly diagnosed renal failure. Hyperkalaemia should be regarded as a medical emergency as it can be life- threatening. A precipitating medication should be considered for all patients presenting with hyperkalaemia and promptly discontinued. Severe hyperkalaemia requires urgent treatment, but needs to be distinguished from spurious hyperkalaemia (high in blood sample but not in patient). To be effective, medications for the treatment of hyperkalaemia need to be given correctly; to be safe, they require appropriate monitoring, so as to avoid serious complications such as hypoglycaemic coma after insulin-glucose administration. This guideline outlines a standardised approach to the treatment of hyperkalaemia in adults to minimise the potential risks associated with its management. Causes There can be several different causes of hyperkalaemia, including: Renal failure - including Acute kidney injury (AKI), advanced chronic kidney disease (CKD) stages 4 & 5 or renal tubular acidosis (type IV). Spurious hyperkalaemia: o Sample taken from a limb infused with IV fluids containing potassium. o Wrong sequence of blood collection i.e. EDTA (purple top) sample for FBC collected before serum tube (gold type). o Cell lysis – potassium release from cells (tumour lysis syndrome, rhabdomyolysis, trauma, burns) o High platelet count and high white blood cell counts – can artificially raise serum potassium. o Prolonged tourniquet time. o Haemolysed samples due to difficult collection or delayed transport to lab of more than 4 hours. o In all cases a repeat serum potassium should be ordered urgently. Metabolic acidosis (transcellular shift of K+ from intracellular to extracellular compartments) Drugs – see below Addison’s disease – and other adrenal insufficiency /resistance states including hypoadrenalism. Drug-induced hyperkalaemia: This is not an exhaustive list. Contact your ward Pharmacist or Medicines Information (ext: 30235) for more advice. If essential drug(s) are the underlying cause and need discontinuing please contact relevant specialities/senior staff for advice and to check if alternative drug(s) are required; ACE-inhibitors (e.g. ramipril, lisinopril, perindopril) Angiotensin II receptor blockers (e.g. candesartan, losartan, olmesartan) Spironolactone & other potassium sparing diuretics (e.g. co-amilofruse, amiloride) Potassium supplements (Sando K®, Slow K® tablets, Kay-Cee-L® syrup) Intravenous fluids containing potassium (e.g. Hartmanns) Aliskiren (Direct renin inhibitor) Guideline for the management of Hyperkalaemia in adults WAHT-REN-009 Page 2 of 19 Version 1.2 WAHT-REN-009 It is the responsibility of every individual to check that this is the latest version/copy of this document. Less common causative drugs: NSAIDs (it it safe to continue low dose aspirin 75mg or 150mg daily) Potassium containing laxatives (Movicol® or Laxido®, Klean-prep®) Beta-blockers – may increase transcellular shift of K+ to extracellular compartments Digoxin – in toxicity states hyperkalaemia & arrhythmias can result Heparins (rarely) Trimethoprim Classification Of Hyperkalaemia WAHT reference range for serum potassium: 3.5 – 5.3mmol/L Severity of hyperkalaemia: Severe Moderate Mild K ≥ 6.5 mmol/L K 6.1 to 6.4 mmol/L AND K ≤ 6 mmol/L AND OR ECG normal AND ECG normal AND ECG changes* present with a No symptoms No symptoms present K+ >5.5mmol/l OR Neuromuscular symptoms Spurious hyperkalaemia? (potassium high in blood sample but not in patient) (*) ECG changes of life-threatening hyperkalaemia: Absent P-waves Prolonged PR QRS widening / sine wave QRST Heart block Cardiac arrest (Tented T-waves alone are NOT life-threatening and not treated routinely) Signs And Symptoms Patients may be asymptomatic but hyperkalaemia can cause: ECG changes (as above) Syncope (due to arrhythmia) Neuromuscular symptoms (paraesthesia) PRESENCE OF THESE SYMPTOMS INDICATE SEVERE Muscle weakness HYPERKALAEMIA & URGENT Hypotension TREATMENT IS NEEDED Bradycardia Guideline for the management of Hyperkalaemia in adults WAHT-REN-009 Page 3 of 19 Version 1.2 WAHT-REN-009 It is the responsibility of every individual to check that this is the latest version/copy of this document. Initial Clinical Assessment It is recommended all patients with suspected or confirmed hyperkalaemia undergo the following: Urgent assessment by medical & Nursing staff to assess clinical status using the ABCDE approach (Ref: appendix II page 9). A detailed history & examination – to determine cause of raised potassium. A review of their drug history, prescription chart, Intravenous fluid chart or enteral feeds for potential potassium promoting drugs or infusions (Ref: list page 3). Seek advice from a Pharmacist as soon as possible. THE CAUSE FOR HYPERKALAEMIA MUST BE SEARCHED FOR AND TREATED URGENTLY. An appropriate escalation plan should be put in place for the patient taking into account their symptoms may include arrhythmias. Investigations & Monitoring Repeat urea & electrolytes (U & Es) – mark ‘URGENT’ & inform Lab. If out of hours telephone lab to inform them of urgent request to ensure it is processed as a quickly as possible. Repeating serum potassium urgently is necessary to exclude spurious hyperkalaemia, especially if hyperkalaemia is unexpected or an isolated finding and there are no ECG changes in the patient. Review serum creatinine for possible AKI or CKD. Arterial blood gas sample. Serum potassium levels may be assessed on an arterial or venous blood sample using a point of care blood-gas analyser in emergencies whilst awaiting a formal laboratory result. Monitor U &Es and venous bicarbonate – for possible Acidosis (e.g. renal failure, renal tubular acidosis, hypocortisolism). Continue to monitor serum potassium and response to treatment or possible potassium rebound by rechecking U & Es: - 1 hour after treatment commenced - At least every 6 hours until potassium within normal range Conduct a 12-lead ECG – this is mandatory for all patients with raised serum potassium levels prior to treatment of hyperkalaemia. Note the ECG may not demonstrate changes even in the presence of severe hyperkalaemia. Monitor blood glucose levels to exclude hypoglycaemia prior to commencing treatment. If hypoglycaemia is present treat according to trust’s hypoglycaemia management pathway (Ref: Hypoglycaemia management WAHT- END-004). Referral Ask for immediate ITU input or advice from the renal team for all SEVERE hyperkalaemia cases. Discuss with the renal team any patients with asymptomatic hyperkalaemia <6.5 mmol/L if serum potassium levels are not normalising in the patient following treatment. Guideline for the management of Hyperkalaemia in adults WAHT-REN-009 Page 4 of 19 Version 1.2 WAHT-REN-009 It is the responsibility of every individual to check that this is the latest version/copy of this document. Treatment Overview Remember the majority of treatments discussed below including calcium gluconate injection, calcium chloride injection, insulin/glucose infusion and salbutamol nebules only work short- term and may need repeating to be effective. These treatment options may be sufficient if the underlying cause for hyperkalaemia
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