Hyperkalaemia in Hospitalised Adult Patients NOT Receiving Regular dialysis - ( aged 16 years or more )

Publication: 03/03/2008  --
Last review: 30/04/2019  
Next review: 30/04/2022  
Clinical Guideline
CURRENT 
ID: 1209 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

LTHT Clinical Guideline for the Treatment of Hyperkalaemia in hospitalised adult patients

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Guidance & Monitoring for Acute Hyperkalaemia

Management documentation completed by nursing staff

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Aim of the guideline

This clinical guideline concerns the immediate issues around detection, management and documentation of hyperkalaemia in adults. The guideline also suggests some general measures which may reduce the risk of hyperkalaemia in hospitalised patients.

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Pathophysiology

Extracellular potassium concentration is normally tightly controlled despite wide variations in dietary intake. The serum potassium concentration is determined by the relationship between potassium intake, the distribution of potassium between the cells and the extracellular fluid, and urinary potassium excretion. Intracellular potassium concentrations are far higher than extracellular concentrations, a state maintained by the activity of the Na-K-ATPase pump in the cell membrane. The activity of this pump can be increased by insulin and adrenergic β-2 agonists which tend to lower serum potassium.

Clinically hyperkalaemia is usually caused by:

  • Increased potassium administration (rarely)
  • Potassium retention in the setting of impaired renal function
  • Acute redistribution of intracellular stores

This guideline does not cover hyperkalaemia in children (aged less than 16 years) or patients receiving regular dialysis (discuss with the renal team).

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Who is this guideline for?

This guideline is for use in all clinical areas across Leeds Teaching Hospitals Trust where adult patients are seen (with the exception of patients receiving regular dialysis). It is intended for all clinical staff working in these areas. It applies to adult patients aged 16 and over.

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Why have a guideline for hyperkalaemia?

Hyperkalaemia is a potentially fatal condition that may remain completely asymptomatic up until the point of cardiac arrest. Symptoms generally become manifest when serum potassium exceeds 7.0 mmol/L unless the rise is very rapid. Since such levels lead to significant cardiac conduction abnormalities it is essential that hyperkalaemia is recognised early and treated promptly.

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Definition of hyperkalaemia

For the purposes of this guideline:

  • Hyperkalaemia means serum blood potassium > 5.5 mmol/L.

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Causes of hyperkalaemia

In the hospital setting the commonest cause of hyperkalaemia is the use of potassium retaining medications (e.g. ACEis, ARBs or spironolactone) in the setting of pre-existing or newly developing renal failure. Ensure potential causes of hyperkalaemia are treated e.g. use laxatives for constipation, sodium bicarbonate for acidosis.

Increased Potassium intake

  • Inappropriate intravenous fluids
  • High potassium dietary sources
    • Oral nutritional supplements
    • Enteral tube feeds
    • Parenteral nutrition
  • Blood Transfusion
  • Constipation

Reduced urinary excretion

  • Renal failure (acute or chronic)
  • Hypoaldosteronism (Type IV Renal Tubular Acidosis - RTA)
  • Low effective circulating volume
  • Hyperkalaemic Type I Renal Tubular Acidosis
  • Ureterojejunostomy

Intracellular release of Potassium

  • Pseudohyperkalaemia
  • Metabolic acidosis
  • Insulin deficiency, hyperglycaemia and hyperosmolality
  • Increased tissue catabolism e.g. rhabdomyolysis, compartment syndrome, release of tourniquet after surgery, tumour lysis syndrome
  • adrenergic blockade
  • Exercise
  • Rarely – digitalis overdose, periodic paralysis, succinylcholine

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Recognising hyperkalaemia

There are few symptoms and signs of hyperkalaemia and these tend to occur only at very high levels (i.e. K+ > 6.5 mmol/L). Effects occur due to changes in the excitability of polarised cells, in particularly muscle cells of the skeletal and cardiac varieties:

  • Severe muscle weakness or paralysis - Usually starts in lower extremities and progresses to trunk and upper limbs. Respiratory muscle weakness is rare
  • Cardiac conduction abnormalities - in order of development: Peaked T waves and shortened QT interval; Lengthening of PR interval and QRS duration; disappearance of P and development of sinusoidal QRS; and finally flatline with ventricular standstill. However this sequence will not always be followed in a linear and predictable fashion and a normal ECG does not exclude hyperkalaemia.

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Diagnosing hyperkalaemia

Clinical suspicion may be raised but generally hyperkalaemia will be discovered incidentally on a blood test:

The patient should be asked about symptoms of hyperkalaemia (Muscle weakness, paralysis, palpitations and paraesthesias) and an ECG should be performed.

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Confirming hyperkalaemia:

Pseudohyperkalaemia can occur and should be considered/exluded (This should not delay treatment however)

  • Mechanical trauma during venepuncture (haemolysis), resulting in the release of potassium from red blood cells which usually (though not always) imparts a characteristic reddish tint to the serum due to the concomitant release of haemoglobin
  • Abnormally leaky cells after blood collection - hereditary spherocytosis, marked thrombocythaemia or leukocytosis in myeloproliferative disease
  • Delay in sample transit - the longer the plasma / serum is in contact with cells the greater the opportunity for potassium to leach out of erythrocytes, falsely elevating potassium concentrations in vitro. This is clearly more of a problem for GP / OPD locations but does happen for inpatients if samples are not transported from ward to lab in a timely fashion
  • Incorrect order of draw for blood samples - if blood is collected into lavender-top Full Blood Count tubes before the lithium heparin / clot accelerator (U+E and other biochem) tubes, the potassium + EDTA anticoagulant in the lavender top tube is transferred into the U+E tube. This is a source of exogenous potassium that is not often realised - if a high potassium result is unexpected in a patient who has also had a full blood count requested we would advise a fresh sample is collected for U+E only and sent to the lab asap, or if available, potassium is checked on a blood gas machine, before treatment is initiated.

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Managing Hyperkalaemia

Management of hyperkalaemia depends on an immediate assessment of the severity depending on the serum concentration and the presence of symptoms or ECG changes. Management of hyperkalaemia is presented according to following categories:

  • SEVERE - Potassium (K+) ≥6.5mmol/L , presence of symptoms (Muscle weakness, paralysis, palpitations and paraesthesias) or ECG changes
  • MODERATE - Potassium (K+) 6.0 - 6.4 mmol/L - no symptoms or ECG changes
  • MILD - Potassium (K+) 5.5 - 5.9 mmol/L - asymptomatic

Please refer to the algorithm at the top of this guideline for advice on management and treatment of hyperkalaemia

The aim of treatment is to achieve a serum K <6mmol/L within 2 hours of initiation of treatment.

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Appendix 1: Low Potassium Diet

This diet should be instigated if potassium remains high after treatment while the patient is in hospital. Please also refer to a dietician. Please ensure patients are provided with the 'low potassium diet for home' information (see link below) and refer for dietetic support.

Foods to Avoid which are High in
Potassium

Suitable Alternatives

Potatoes
Fried, oven, microwave or frozen chips, instant mashed potato, jacket potatoes, potato waffles, potato croquettes

Boiled or mashed potatoes; up to 3 small potatoes/day, boiled rice, boiled pasta e.g. macaroni, spaghetti, bread (all types), chapatis, plain naan, pittas, crumpets

Vegetables
Baked beans, butter beans, chick peas, lentils, red kidney beans, haricot beans, mung beans, spinach, mushrooms, tinned tomatoes, tomato puree, sprouts, parsnips

French or green beans, carrots, broccoli, cabbage, cauliflower, leeks, swede, sweetcorn, onions, peas, pepper, mange tout, beansprouts, courgette, celery, mixed vegetables, 1 small tomato a day, lettuce, cucumber

Fruit
Apricots, banana, damsons, rhubarb, grapes, cantaloupe melon, dried fruit e.g. raisins, sultanas, blackberries, redcurrants, blackcurrants, avocado, cherries, starfruit

Apples, grapefruit, pear, peach, small orange, pineapple, strawberries, raspberries, kiwi fruit, lemon, mandarin, small nectarine, plum, tangerine, satsuma, tinned fruit in syrup

Drinks
Coffee, cocoa, fruit juice, blackcurrant squash, Horlicks, Ovaltine, Bournvita,
stout, cider, barley wine, liqueurs, red wine, sweet white wine, sweet sherry Limit your milk intake to ½ pint per day

Water, tea, orange or lemon squash, lemonade, cola drinks, 7-up, Tango, Sprite, Lilt, soda and tonic water, spirits, dry white wine
*If diabetic, choose light, diet and no-added sugar options*

Snacks
Potato crisps, nuts, chocolate, liquorice, fudge, marzipan, peanut butter, cakes and biscuits containing chocolate, coconut, coffee and dried fruit

Maize snacks e.g. Skips, Monster Munch, Wotsits
Sweets, mints, chewing gum
Plain and cream cakes, plain biscuits, jelly.

Cereals
Any containing dried fruit and nuts, All
Bran, muesli, Fruit & Fibre, Sultana Bran, Nutrigrain, Weetaflake n’ raisin, Weetos, Ready Brek, Oatcakes, rye crispbread

Porridge, cornflakes, Weetabix, Rice Krispies, Cheerios, Sugar Puffs, Shredded wheat, Shreddies, Special K, Frosties,
Cream Crackers

Miscellaneous
Spaghetti in tomato sauce
Tomato sauce - limit to 1 teaspoon only
Curry powder, Lo Salt

Vinegar, pepper, herbs and spices

For more detailed advice go to:
http://lthweb/sites/nutrition-and-dietetics/therapeutic-dietary-information/Potassium_Diet_sheet_v_2_Sept_2014_2.pdf/view for advice in hospital and to:
http://lthweb/sites/nutrition-and-dietetics/therapeutic-dietary-information/Potassium_%28advice_for_home%29.pdf/view for advice at home

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Appendix 2: Recommendations to clinical areas to reduce risk of hyperkalaemia.

  1. Identify patients at risk of hyperkalaemia by reference to the list of causes of hyperkalaemia. Particularly caution should be exercised in patients with deteriorating renal function who are taking drugs that cause potassium retention. The Biochemistry laboratory will report all potassium levels greater than 6.5 to the ward or referring doctor.

Appendix 3: Recommendations concerning training

The successful use of these guidelines requires that in each clinical area all clinical staff (doctors, dentists and trained nursing and midwifery staff) are aware of them and know how to access them rapidly when required.

Staff having frequent contact with patients at risk of hyperkalaemia should have read the guidelines and have a clear understanding of the clinical scenarios causing hyperkalaemia which could occur in their clinical area.

We propose that these guidelines form part of the induction package for ward nursing staff and medical staff.

Consideration should be given to setting up regular assessment of the understanding of these guidelines by ward nursing and medical staff

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Appendix 4: Drugs commonly associated with hyperkalaemia

Drugs that alter transmembrane potassium movement

  • β blockers
  • Digoxin
  • Potassium-containing drugs
  • Potassium supplements
  • Salt substitutes
  • Hyperosmolar solutions (mannitol, glucose)
  • Suxamethonium
  • Intravenous cationic amino acids
  • Stored red blood cells (haemolysis releases potassium)
  • Herbal medicines (such as alfalfa, dandelion, horsetail, milkweed, and nettle)

Drugs that reduce aldosterone secretion

  • ACE inhibitors; Angiotensin II receptor blockers
  • NSAIDs
  • Heparins
  • Antifungals (ketoconazole, fluconazole, itraconazole)
  • Ciclosporin
  • Tacrolimus

Drugs that block aldosterone binding to mineralocorticoid receptor

  • Spironolactone
  • Eplerenone
  • Drospirenone
  • Drugs that inhibit activity of epithelial sodium channel
  • Potassium sparing diuretics (amiloride, triamterene)
  • Trimethoprim
  • Pentamidine

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Appendix 5: How to prepare 10 units of Soluble Insulin (Actrapid®) in 50mL of Glucose 50% for the treatment of Hyperkalaemia

Provenance

Record: 1209
Objective: This guideline concerns the immediate issues around detection, management and documentation of hyperkalaemia in adults. The guideline also suggests some general measures which may reduce the risk of hyperkalaemia in hospitalised patients.
Clinical condition: Hyperkalaemia
Target patient group: Patients with hyperkalaemia
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Allied Health Professionals
Adapted from:

Evidence base

Evidence base

  1. UK Renal Association. Clinical Practice Guideline: Treatment of Acute Hyperkalaemia in Adults. 2014
    renal.org/wp-content/uploads/2017/06/hyperkalaemia-guideline-1.pdf
  2. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances
    ercguidelines.elsevierresource.com/european-resuscitation-council-guidelines-resuscitation-2015-section-4-cardiac-arrest-special
  3. UK Resuscitation Council Advanced Life Support guidelines
    https://www.resus.org.uk/resuscitation-guidelines/adult-advanced-life-support/
  4. American Heart Association CPR guidelines. Part 11.1: Cardiac Arrest Associated With Life-Threatening Electrolyte Disturbances. 2015
  5. Mount, D. Treatment and Prevention of Hyperkalaemia in Adults. In: UpToDate, Sterns, R. (Ed), UpToDate, Waltham, MA, 2016.
  6. Guidelines and Audit Implementation Network (GAIN). Guidelines for the Treatment of Hyperkalaemia in Adults. 2014.
  7. Batterink, J. Cessford, T. Taylor R. Pharmacological interventions for the acute management of hyperkalaemia in adults. Cochrane Database of Systematic Reviews. 2015.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.1

Related information

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