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12. Section III Management of Hyperkalaemia in Resuscitation

12. Section III Management of Hyperkalaemia in Resuscitation

III: Hyperkalaemia in Resuscitation (Guidelines 23 – 27)

Introduction

Hyperkalaemia is an uncommon, but potentially reversible cause of cardiac arrest.1,2 It most often occurs in patients with pre existing renal disease or in the context of an AKI. Patients with ESRD receiving long term haemodialysis (HD) are most at risk of hyperkalaemia. Cardiac arrest can occur in hospital, within an out patient dialysis unit or out of hospital, but hyperkalaemia should be considered in all settings in patients at risk.

Patients on long term HD are one of the highest risk groups for out of hospital cardiac arrest (OHCA), occurring 20 times more frequently than in the general population.3 Hsieh et al (2022) reported that patients with ESRD had a higher risk of OHCA (adjusted HR = 2.11, p<0.001) but had a higher odds of attaining ROSC (adjusted OR = 2.47, p<0.001) and better 30 day hospital survival than non ESRD patients.4 Therefore, futility should not be assumed in patients with ESRD.

The reported incidence of in hospital hyperkalaemic cardiac arrest is variable. Wallmuller et al found hyperkalaemia as the primary aetiology in only 1% of in hospital cardiac arrests (n=1041) although it was the most common metabolic cause (47%).5 In contrast, Wang et al6 reported an incidence of 12% (n=1114) and Saarinen et al7 reported an incidence of 13% (n=104) in patients with PEA as the initial rhythm following in hospital cardiac arrest (IHCA).

Patients with all stages of CKD have a higher prevalence of cardiovascular disease, but the mortality risk is estimated to be 57% higher in patients with eGFR < 60 ml/min per 1.73 m2 compared with the general population without CKD.8 Cardiovascular disease is highly prevalent in the dialysis population and the added insult of hyperkalaemia may contribute to sudden death, presumably from cardiac arrest.

Pre dialysis hyperkalaemia and hypokalaemia have both been shown to be associated with higher all cause mortality.9 Pun et al demonstrated a 49% increase in risk of cardiac arrest with each 1 mmol/l decrease in serum K+ below 5.1 mmol/l and a 38% increased risk with each 1 mmol/l increase above 5.1 mmol/l.10 There was no advantage of using a low K+ dialysate. The intermittent nature of HD treatment is a further consideration. Bleyer et al demonstrated that HD patients are susceptible to SCD in the first 12 hours from start of the HD session, but the highest risk period is the last 12 hours of the 2 day inter dialytic interval.11 In this study, hyperkalaemia (K+ ≥ 6.0 mmol/l) was present in 6.5% of patients with SCD.

Optimising and controlling K+ levels in dialysis patients is challenging. Kovesdy et al demonstrated greater survival in long term HD patients with a pre dialysis serum K+ of 4.6 – 5.3 mmol/l.9 The conventional thrice weekly HD schedule is difficult to overcome, but evidence suggests that careful dialysis prescription with the avoidance of low K+ dialysates and fistula access reduces the risk of cardiac arrest. Other factors associated with a favourable outcome after cardiac arrest in dialysis patients were the use of beta blockers, RAASi and calcium channel blockers at the time of the event.12

This section of the guideline will cover:

  1. Special considerations in the resuscitation of patients receiving haemodialysis including aetiology, out patient dialysis setting, dialysis access, and defibrillation practice,
  2. Medical management of hyperkalaemic cardiac arrest, and
  3. Approach to treatment of refractory hyperkalaemic cardiac arrest including dialysis initiation during CPR and the use of ECMO.

References

  1. Tirkkonen, J., et al., Aetiology of in hospital cardiac arrest on general wards. Resuscitation, 2016. 107: p. 19 24.
  2. Bergum, D., et al., Causes of in hospital cardiac arrest incidences and rate of recognition. Resuscitation, 2015. 87: p. 63 8.
  3. Pun, P.H., et al., Outcomes for Hemodialysis Patients Given Cardiopulmonary Resuscitation for Cardiac Arrest at Outpatient Dialysis Clinics. J Am Soc Nephrol, 2019.
  4. Hsieh, M.S., et al., End Stage Renal Disease Patients Undergoing Hemodialysis Have Higher Possibility of Return of Spontaneous Circulation during Out of Hospital Cardiac Arrest and Non Inferior Short Term Survival. J Clin Med, 2022. 11(21).
  5. Wallmuller, C., et al., Causes of in hospital cardiac arrest and influence on outcome. Resuscitation, 2012. 83(10): p. 1206 11.
  6. 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.
  7. Saarinen, S., et al., Does appropriate treatment of the primary underlying cause of PEA during resuscitation improve patients’ survival? Resuscitation, 2012. 83(7): p. 819 22.
  8. Webster, A.C., et al., Chronic Kidney Disease. The Lancet, 2017. 389(10075): p. 1238 1252.
  9. Kovesdy, C.P., et al., Serum and dialysate potassium concentrations and survival in hemodialysis patients. Clin J Am Soc Nephrol, 2007. 2(5): p. 999 1007.
  10. Pun, P.H., et al., Modifiable risk factors associated with sudden cardiac arrest within hemodialysis clinics. Kidney Int, 2011. 79(2): p. 218 27.
  11. Bleyer, A.J., et al., Characteristics of sudden death in hemodialysis patients</em