Lenhardt A and Kemper MJ. Pathogenesis, diagnosis and management of hyperkalemia. Pediatr Nephrol. 22 December 2010.

Differential Diagnosis:

1) Lab error/Hemolysis 2) Impaired elimination

a) renal failure (acute or chronic) b) medications interfering with

urinary excretion c) hypoaldosteronism d) pseudohypoaldosteronism e) congenital adrenal hyperplasia f) congestive heart failure g) constipation

3) Increased shift extracellularly a) acidosis b) diabetes mellitus c) acute increase in osmolality

(hyperglycemia, mannitol infusion)

d) cell-tissue breakdown (rhabdomyolysis, tumor-lysis, post-transfusion)

e) drugs (succinylcholine, beta-blockers, digoxin)

f) hyperkalemic periodic paralysis (rare disorder of muscular sodium channel)

HYPERKALEMIA

(Serum K+ >5.5mmol/L)

*Obtain EKG and initiate Telemetry monitoring*

1) Administer Calcium Gluconate 10%: administer 0.5-1 mL/kg IV (or 100-200 mg/kg) over 5-10 min. If unavailable, may give Calcium Chloride 10% 0.1-0.2 mL/kg (or 10-20 mg/kg) IV.

*contraindicated in hypercalcemic states, digoxin toxicity and tumor lysis syndrome

2) Give regular insulin 0.2 units/kg PLUS D10 10 ml/kg (1g/kg) IV over 30 minutes. May also give 20 ml/kg of D5LR (in the PIXIS).

3) May additionally give: a. Kayexalate 0.5-1 g/kg PO/PR b. Lasix 1-2 mg/kg IV (if producing

urine); provide appropriate fluids c. Albuterol 2.5-5 mg nebulized d. Consider NaHCo3 if acidotic (1-2

mmol/kg over 30-60 min) * If giving NaHCO3 and Ca++, remember to flush line between the two as they are not compatible

EKG changes *

*Peaked T waves, Widening QRS, Loss of P wave, ST depression sine wave, v-fib, asystole

Mild Hyperkalemia (5.5-6.5mmol/L) Moderate Hyperkalemia (6.5-7.5 mmol/L) Severe Hyperkalemia (>7.5 mmol/L)

Asymptomatic

Consider Kayexalate 0.5-1 g/kg PO/PR

1) Recheck K+ in 2 hours

2) Admit to ICU

Consider dialysis if refractory to treatment