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Controversies in Management of Hyperkalemia

      Abstract

      Background

      Hyperkalemia is a common electrolyte disorder that can result in morbidity and mortality if not managed appropriately.

      Objectives

      This review evaluates the classic treatments of hyperkalemia and discusses controversies and new medications for management.

      Discussion

      Potassium (K+) plays a key role in determining the transmembrane potentials of “excitable membranes” present in nerve and muscle cells. K+ is the predominant intracellular cation, and clinical deterioration typically ensues when patients develop sufficiently marked elevation in extracellular fluid concentrations of K+ (hyperkalemia). Hyperkalemia is usually detected via serum clinical laboratory measurement. The most severe effect of hyperkalemia includes various cardiac dysrhythmias, which may result in cardiac arrest and death. Treatment includes measures to “stabilize” cardiac membranes, to shift K+ from extracellular to intracellular stores, and to promote K+ excretion. Calcium gluconate 10% dosed 10 mL intravenously should be provided for membrane stabilization, unless the patient is in cardiac arrest, in which case 10 mL calcium chloride is warranted. Beta-agonists and intravenous insulin should be given, and some experts recommend the use of synthetic short-acting insulins rather than regular insulin. Dextrose should also be administered, as indicated by initial and serial serum glucose measurements. Dialysis is the most efficient means to enable removal of excess K+. Loop and thiazide diuretics can also be useful. Sodium polystyrene sulfonate is not efficacious. New medications to promote gastrointestinal K+ excretion, which include patiromer and sodium zirconium cyclosilicate, hold promise.

      Conclusions

      Hyperkalemia can be deadly, and treatment requires specific measures including membrane stabilization, cellular shift, and excretion.

      Keywords

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      Linked Article

      • Hyperkalemia in the Emergency Department: Urgent Need for a Rigorous Evaluation of the First-Line Treatments
        Journal of Emergency MedicineVol. 57Issue 1
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          We have read with great interest the article, “Controversies in Management of Hyperkalemia,” by Long et al. (1). The authors reviewed the classic treatments of hyperkalemia used in the emergency department (ED) and discussed controversies and new medications for management of hyperkalemia. Hyperkalemia is a common presentation in the ED (2). Severe hyperkalemia can impair cardiac function, with life-threatening consequences (3). First-line treatments redistribute potassium ions from the bloodstream into the cells with the aim to push away a life-threatening situation (4).
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