12.1.4. III Hyperkalaemia in Resuscitation (Guidelines 26.1 – 26.2)

III Hyperkalaemia in Resuscitation (Guidelines 26.1 – 26.2)

Guideline 26.1 – Hyperkalaemia; Prevention of Cardiac Arrest in Hyperkalaemia

We recommend that hyperkalaemia is treated urgently in patients with severe hyperkalaemia (K⁺ ≥ 6.5 mmol/l) and in those with ECG changes suggestive of severe hyperkalaemia. (1C)

Guideline 26.2 – Hyperkalaemia; Prevention of Cardiac Arrest in Hyperkalaemia

We recommend continuous cardiac monitoring for patients with severe hyperkalaemia (K⁺ ≥ 6.5 mmol/l) in a setting appropriate for the level of care required. (1C)

Rationale (Guidelines 26.1 – 26.2)

The outcome of hyperkalaemic cardiac arrest is generally poor, therefore efforts to avoid its occurrence in the first instance is the best approach.

Early recognition, a high index of suspicion in patients at risk and prompt intervention can reduce the risk of cardiac arrest in patients with hyperkalaemia. Initiation of treatment prior to confirmation of hyperkalaemia is warranted if the suspicion of hyperkalaemia is high. Look for toxic ECG changes which may precede cardiac arrest wide QRS complex, bradycardia or sine wave (Guidelines 14.1 14.2; Figure 3). Limb weakness is an ominous sign. Cardiac monitoring is essential to detect arrhythmias.

The ECG is a helpful tool in risk stratification. Durfey et al found that adverse events including symptomatic bradycardia (n=22), VT (n=2), CPR (n=2) and death (n=4) occurred prior to administration of IV calcium and all but one event occurred before administration of K⁺ lowering medication.¹ This highlights the importance of timely treatment to prevent arrhythmias and cardiac arrest.

IV calcium is a crucial step in the prevention of arrhythmias and cardiac arrest in hyperkalaemia.² Ensure that the appropriate dose is administered (30ml Calcium Gluconate over 10 minutes IV) to stabilise the heart. Adverse events have been noted when an inappropriate dose of IV calcium is administered.³ Vigilance is also required as toxic ECG changes may recur when the effect of IV calcium has worn off after approximately 30 60 minutes.

Unfortunately, delays in treatment are well recognised and has resulted in patient harm.^4,5 The potential for clinical deterioration may not be appreciated by medical or nursing staff prior to cardiac arrest. Refer early for specialist advice particularly for patients with ESRD and those who do not respond to medical treatment. Blood monitoring is essential to assess efficacy of treatment and for re bound hyperkalaemia. Rebound may also occur after dialysis and may be exaggerated if temporising drugs have been used.⁶

There are a few fallacies related to hyperkalaemia that require clarification:

• Patients with pacemakers are not protected from hyperkalaemic cardiac arrest. Indeed, pacemaker failure has been well documented in this circumstance.^7,8
• The presence of a normal ECG in the context of severe hyperkalaemia is not protective against arrhythmias.
• Severe hyperkalaemia can occur in the presence of near normal renal function, but may be assumed to be spurious. An urgent ECG and repeat blood sample using a blood gas analyser should confirm the presence of hyperkalaemia.
• Patients receiving longterm haemodialysis do not have a ‘tolerance’ to severe hyperkalaemia and are also at risk of cardiac arrest. Medical treatment will only temporarily lower the serum K⁺, therefore urgent dialysis is indicated.

References

1. 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.
2. Batterink, J., T.A. Cessford, and R.A.I. Taylor, Pharmacological interventions for the acute management of hyperkalaemia in adults. Cochrane Database of Systematic Reviews, 2015.
3. Medicines & Healthcare products Regulatory Agency (MHRA): Drug Safety Update. Calcium chloride, calcium gluconate: potential risk of underdosing with calcium gluconate in severe hyperkalaemia. Volume 16 (Issue 22); June 2023. https://www.gov.uk/drug safety update/calcium chloride calcium gluconate potential risk of underdosing with calcium gluconate in severe hyperkalaemia.
4. NHS Improvement. Patient Safety Alert. Resources to support safe and timely management of hyperkalaemia (high level of potassium in the blood). August 2018. Alert reference number: NHS/PSA/RE/2018/006
5. Freeman, K., et al., Effects of presentation and electrocardiogram on time to treatment of hyperkalemia. Acad Emerg Med, 2008. 15(3): p. 239 49.
6. Ahmed, J. and L.S. Weisberg, Hyperkalemia in dialysis patients. Seminars in Dialysis, 2001. 14(5): p. 348 356.
7. Barold, S.S. and B. Herweg, The effect of hyperkalaemia on cardiac rhythm devices. Europace, 2014. 16(4): p. 467 76.
8. Schiraldi, F., G. Guiotto, and F. Paladino, Hyperkalemia induced failure of pacemaker capture and sensing. Resuscitation, 2008. 79(1): p. 161 4.