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12.1.1. III Hyperkalaemia in Resuscitation (Guideline 23.1)

12.1.1. III Hyperkalaemia in Resuscitation (Guideline 23.1)

III Hyperkalaemia in Resuscitation (Guideline 23.1)

Guideline 23.1 – Hyperkalaemia; Cardiac Arrest special circumstance

We recommend that hyperkalaemia is considered in all patients who have a cardiac arrest, as part of identifying and treating a reversible cause using the 4 Hs and 4 Ts approach. (1A)

Audit Measure

  1. All cardiac arrests should be audited – hospital participation in the National Cardiac Arrest Audit is encouraged as part of quality improvement and benchmarking.

Rationale (Guidelines 23.1)

Hyperkalaemia is an important and potentially reversible cause of cardiac arrest, therefore should be considered in all patients, particularly in the presence of renal failure. There may be a window of opportunity to intervene before cardiac arrest, although, An et al reported that approximately 20% of patients presented with cardiac arrest at the time of diagnosis of hyperkalaemia.1 This window is more clearly demonstrated by Durfey et al who found that there was a short time interval (median = 47 minutes) between performing an ECG and onset of an adverse event (symptomatic bradycardia, ventricular tachycardia, cardiac arrest and death).2 All of these events occurred prior to the administration of IV calcium.

There is a perception that HD patients have a degree of tolerance to hyperkalaemia. Some studies have reported that ECG abnormalities and adverse events typically occur at a higher serum K+ level in HD patients compared with patients with preserved renal function.3, 4 In contrast, Durfey et al showed no significant difference between frequency of ECG abnormalities and adverse events in HD compared with non HD patients.2

Early identification of patients at risk and prompt initiation of K+ lowering treatment in patients with severe hyperkalaemia reduces the risk of cardiac arrest. Wang et al (2016) conducted the largest study (n=109) of hyperkalaemic IHCA.5 Chronic dialysis patients (n=25) represented 22.9% of the group. Surprisingly, 20% (5/25) of dialysis patients who suffered a hyperkalaemic cardiac arrest did not receive either intravenous calcium or sodium bicarbonate. Saarinen et al (2011) investigated the impact of appropriate treatment in cases where a reversible cause of cardiac arrest was identified and found that no patients received appropriate treatment when the aetiology was hyperkalaemia.

NHS England issued a National Patient Safety Alert (2018) highlighting 35 cases of cardiac arrest in patients with hyperkalaemia which were reported due to concerns related to treatment and/or monitoring.6 The MHRA has also recently issued a National Patient Safety Alert (2023) following 6 incidents in which an incorrect dosing of calcium gluconate and inadequate monitoring of patients with severe hyperkalaemia resulted in cardiac arrest.7 This emphasises the importance of early recognition and treatment of hyperkalaemia.

The probability of cardiac arrest is likely to correlate with the severity of hyperkalaemia, but the threshold for arrhythmias in hyperkalaemia appears to vary from patient to patient. For these reasons, arrhythmias should be anticipated and may be avoided with prompt treatment.

References

  1. An, J.N., et al., Severe hyperkalaemia requiring hospitalization: predictors of mortality. Crit Care, 2012. 16(6): p. R225.
  2. Durfey, N., et al., Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short term Adverse Events? West J Emerg Med, 2017. 18(5): p. 963 971.
  3. KhattaK, H.K., et al., Recurrent life threatening hyperkalemia without typical electrocardiographic changes. J Electrocardiol, 2014. 47(1): p. 95 7.
  4. McCullough, P.A., et al., Acute and chronic cardiovascular effects of hyperkalemia: new insights into prevention and clinical management. Rev Cardiovasc Med, 2014. 15(1): p. 11 23.
  5. Wang, C.H., et al., The effects of calcium and sodium bicarbonate on severe hyperkalaemia during cardiopulmonary resuscitation: A retrospective cohort study of adult in hospital cardiac arrest. Resuscitation, 2016. 98: p. 105 11.
  6. NHS Improvement Patient Safety Alert – Resources to support safe and timely management of hyperkalaemia (high level of potassium in the blood). Alert reference number: NHS/PSA/RE/2018/006. http://www.england.nhs.uk/publication/patient safety alert safe and timely management of hyperkalaemia/
  7. Medicines & Healthcare products Regulatory Agency (MHRA). National Patient Safety Alert. Potential risk of underdosing with calcium gluconate in severe hyperkalaemia. Ref: NatPSA/2023/007/MHRA. 2023.