Hyperkalemia: Management of a Critical Electrolyte Disturbance K+ Ann Crawford, RN, PhD, CNS, CEN Balancing Fluid Intracellular fluid (ICF) Extracellular fluid (ECF) Intravascular interstitial Hormonal Influence Antidiuretic hormone (ADH) Renin-angiotensin-aldosterone feedback system Atrial natriuretic peptide (ANP) Electrolyte Overview What are they: Salts & minerals Electrically charged Responsible for: Fluid balance, Muscle contraction, Energy generation, Biochemical reactions Na, K, Cl, Ca, Mg, etc. 1
K+ Fun Facts Discovered by: Sir Humphrey Davy on October 6, 1807 Named for Potash (POH) Denoted on periodic table: K+ for Latin word kalium Potassium K+ Most abundant intracellular cation 98% intracellular 2% extracellular Normal serum level: 3.5 5 meq/l ICF/ECF K+ control: Na-K pump; Insulin; catecholamine; acid-base balance Potassium Excretion Renal System Aldosterone Rate and flow of Na/K through nephron GI tract In feces Sweat 2
Hyperkalemia Definition serum level >5.0 Potentially life-threatening Degree of elevation Mild: 5.5 6.5 meq/l Moderate: 6.5 7.5 meq/l Severe: >7.5 meq/l Rapidity of onset Cause: High Intake/Absorption Rare if have good kidney function Dietary (salt substitutes) Potassium supplements (oral & parental) Stored blood Potassium-containing medications Cause: Impaired Elimination Renal Failure (acute; chronic) Tubular defect in K+ excretion Hypoaldosteronism Addison s Congenital adrenal hyperplasia Drug-induced Constipation 3
Cause: Transcellular Shifts Acidosis Hypertonicity Insulin deficiency Drug related: digitalis toxicity; beta-blockers; succinylcholine Exercise Hyperkalemic periodic paralysis Cause: Cellular Injury Rhabdomyolysis Severe intravascular hemolysis Acute tumor lysis syndrome Burns Crush injury Diagnosis Elevated serum K+ level Assessment findings Labs: CBC, ABG, serum osmolality, electrolytes, BUN/Cr, liver enzymes, UA EKG Pseudohyperkalemia false elevation 4
Cardiac Manifestations ECG changes: peaked T Loss of P wave Widened QRS Dysrhythmias AV blocks V-fib Asystole PEA Other Manifestations Neurological fatigue, irritability, and mental confusion Neuromuscular muscle cramps, weakness, paresthesias, paralysis GI hyperactivity Nausea, diarrhea, abdominal cramping Treatment: K+ Source Removal Low-potassium diet Stop IV and oral potassium Supplements D/C meds causing or aggravating hyperkalemia 5
Treatment: Shifting K+ to ICF Calcium Salts calcium gluconate, calcium carbonate Sodium Bicarbonate (NaHCO3) Insulin with glucose Beta 2 Agonists albuterol, ventolin Treatment: K+ Excretion Exchange resin sodium polystyrene sulphonate (Kayexalate) Diuretics (loop or thiazides) furosemide (Lasix) hydrochlorothiazide (HCTZ) Dialysis hemodialysis; peritoneal Nursing Interventions Good history Thorough head-to toe assessment Assess VS, I&O, card monitor Monitor lab values Watch: s/s hyperkalemia & hypokalemia (p tx) Patient education 6
Thank you QUESTIONS??? References Barold, S. S., Leonelli, F., & Herweg, B. (2007). Hyperkalemia during cardiac pacing. PACE, vol 30. 1-3. Crawford, A., & Harris, H. (2011). Balancing act: Na+ sodium K+ potassium. Nursing 2011, 41(7), 44-50. Elliott, M. J., Ronksley, P. E., Clase, C. M., Ahmed, S. B., & Hemmelgarn, B. R. (2010). Management of patient with acute hyperkalemia. CMAJ, 182(15), 1631-1635. Humphreys, M. (2007). Potassium disturbances and associated electrocardiogram changes. Emergency Nurse, 15(5), 28-34 References (cont) Gibbs, M. A., & Tayal, V. S. (2010) Electrolyte disturbances (chapter 123). In Marx, J. A., Hockberger, R. S., & Walls, R. M. (eds.). Rosen s Emergency Medicine: Concepts and Clinical Practice. Phildelphia, PA: Elsevier. Hankins, J. (2010). Fluids and electrolytes. In M. Alexander, A. Corregan, L. Gorski, & R. Perucca (Eds.), Infusion Nursing: An Evidence-Based Approach. St. Louis, MO: Saunders Elsevier. Lazzari, M. (2009). A harmful banana? Medical Laboratory Observer, April, 2009, 50-52. 7
References (cont) Hsieh, M., & Power, D. A. (2009). Abnormal renal function and electrolyte disturbances in older people. Journal of Pharmacy Practice and Research, 39(3), 230-234. Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing. Patient-centered collaborative care (6 th ed.). St. Louis, MO: Saunders Elsevier. Krost, W. S., Mistovich, J. J., & Limmer, D. D. (2009). Beyond the basics: Electrolyte disturbances. EMS, April, 2009, 47-55. References (cont) Lehnhardt, A., & Kemper, M. J. (2011). Pathogenesis, diagnosis, and management of hyperkalemia. Pediatric Nephrology, 26, 377-384. Miller, W. & Graham, M. G. (2006). Life-threatening electrolyte abnormalities. Patient Care, December, 2006, 19-27. www.patientcareonline.com. O Neill, P. (2007). Helping your patient to restrict potassium. Nursing 2007, 37(4), 64hn6-64hn8. Porth, C. M. (2010). Essentials of pathophysiology concepts of altered health states (3 rd ed.). Philadelphia, PA: Lippincott, Williams, & Wilkins. References (cont) Segal, A. (2013). Potassium and dyskalemias. In Mount, D. B., Sayegh,M. H. & Singh, A. K (Eds.) Core Concepts in the Disorders of fluid, Electrolytes, and Acid-Base Balance. New York: Springer. Sterns, R. H., Rojas, M., Bernstein, P., & Chennupati, S. (2010). Ion-exchange resins for the treatment of hyperkalemia: Are they safe and effective? JASN. February 18, 2010, doi: 10.1681/ASN.2010010079. http://jasn.asnjournals.org/ Stover, J. (2006). Issues in renal nutrition: Non-dietary causes of hyperkalemia. Nephrology Nursing Journal, 33(2), 221-222. 8