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1
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Emektar E. Acute hyperkalemia in adults. Turk J Emerg Med 2023; 23:75-81. [PMID: 37169032 PMCID: PMC10166290 DOI: 10.4103/tjem.tjem_288_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/05/2022] [Accepted: 12/06/2022] [Indexed: 03/06/2023] Open
Abstract
Hyperkalemia is a common, life-threatening medical situation in chronic renal disease patients in the emergency department (ED). Since hyperkalemia does not present with any specific symptom, it is difficult to diagnose clinically. Hyperkalemia causes broad and dramatic medical presentations including cardiac arrhythmia and sudden death. Hyperkalemia is generally determined through serum measurement in the laboratory. Treatment includes precautions to stabilize cardiac membranes, shift potassium from the extracellular to the intracellular, and increase potassium excretion. The present article discusses the management of hyperkalemia in the ED in the light of current evidence.
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2
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Severe bradycardia from severe hyperkalemia: Patient characteristics, outcomes and factors associated with hemodynamic support. Am J Emerg Med 2022; 55:117-125. [DOI: 10.1016/j.ajem.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/24/2022] [Accepted: 03/05/2022] [Indexed: 11/22/2022] Open
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3
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Lano G, Lefevre F, Buffat C, Schlegel L, Dho E, Jantzen R, Resseguier N, Robert T. Pseudo-hyperkalemia in ambulatory samples: the never-ending story? Nephrol Dial Transplant 2021; 37:991-993. [PMID: 34918109 DOI: 10.1093/ndt/gfab355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Guillaume Lano
- Centre de néphrologie et transplantation rénale, Hôpital de la conception AP-HM Marseille, France.,Aix Marseille Univ, INSERM, INRA, C2VN, Marseille, France
| | - Flora Lefevre
- Centre de néphrologie et transplantation rénale, Hôpital de la conception AP-HM Marseille, France
| | - Christophe Buffat
- Département de biochimie Hôpital de la conception AP-HM Marseille, France
| | | | - Emmanuel Dho
- Centre de néphrologie et transplantation rénale, Hôpital de la conception AP-HM Marseille, France
| | - Rodolphe Jantzen
- Department of Public Health, Sorbonne Universite´, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique IPLESP, AP-HP, Saint-Antoine Hospital, Paris, France
| | - Noémie Resseguier
- Support Unit for Clinical Research and Economic Evaluation, Assistance Publique-Hôpitaux de Marseille, Marseille 13385, France.,Aix-Marseille University, EA 3279 CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | - Thomas Robert
- Centre de néphrologie et transplantation rénale, Hôpital de la conception AP-HM Marseille, France.,MMG, Bioinformatics & Genetics, UMR_S910, Aix-Marseille Université, Marseille, France
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4
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McGrath CA, Borgeat K, Wilson HE. Third-degree atrioventricular block with narrow QRS complexes in a case of hypoadrenocorticism in a dog. J Small Anim Pract 2021; 63:559-562. [PMID: 34888882 DOI: 10.1111/jsap.13464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 10/01/2021] [Accepted: 11/16/2021] [Indexed: 11/28/2022]
Abstract
A 4-year-old dog presented with lethargy and bradycardia (heart rate 40 bpm). Electrocardiogram diagnosed third-degree atrioventricular block with narrow QRS complexes. An atropine response test did not result in a change of the heart rate. Venous blood gas documented moderate hyperkalaemia and an adrenocorticotrophic hormone stimulation test was consistent with hypoadrenocorticism. The patient repeatedly converted to sinus rhythm with normalisation of serum potassium levels following medical treatment. This is the first report of third-degree atrioventricular block in a patient with hypoadrenocorticism that was not vagally mediated and did not require pacemaker implantation, with conversion to sinus rhythm following treatment of the hyperkalaemia.
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Affiliation(s)
- C A McGrath
- Langford Vets Small Animal Referral Hospital, Langford, Bristol BS40 5DU, UK
| | - K Borgeat
- Langford Vets Small Animal Referral Hospital, Langford, Bristol BS40 5DU, UK
| | - H E Wilson
- Langford Vets Small Animal Referral Hospital, Langford, Bristol BS40 5DU, UK
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Valdivielso JM, Balafa O, Ekart R, Ferro CJ, Mallamaci F, Mark PB, Rossignol P, Sarafidis P, Del Vecchio L, Ortiz A. Hyperkalemia in Chronic Kidney Disease in the New Era of Kidney Protection Therapies. Drugs 2021; 81:1467-1489. [PMID: 34313978 DOI: 10.1007/s40265-021-01555-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 12/20/2022]
Abstract
Despite recent therapeutic advances, chronic kidney disease (CKD) is one of the fastest growing global causes of death. This illustrates limitations of current therapeutic approaches and, potentially, unidentified knowledge gaps. For decades, renin-angiotensin-aldosterone system (RAAS) blockers have been the mainstay of therapy for CKD. However, they favor the development of hyperkalemia, which is already common in CKD patients due to the CKD-associated decrease in urinary potassium (K+) excretion and metabolic acidosis. Hyperkalemia may itself be life-threatening as it may trigger potentially lethal arrhythmia, and additionally may limit the prescription of RAAS blockers and lead to low-K+ diets associated to low dietary fiber intake. Indeed, hyperkalemia is associated with adverse kidney, cardiovascular, and survival outcomes. Recently, novel kidney protective therapies, ranging from sodium/glucose cotransporter 2 (SGLT2) inhibitors to new mineralocorticoid receptor antagonists have shown efficacy in clinical trials. Herein, we review K+ pathophysiology and the clinical impact and management of hyperkalemia considering these developments and the availability of the novel K+ binders patiromer and sodium zirconium cyclosilicate, recent results from clinical trials targeting metabolic acidosis (sodium bicarbonate, veverimer), and an increasing understanding of the role of the gut microbiota in health and disease.
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Affiliation(s)
- José M Valdivielso
- Vascular and Renal Translational Research Group, UDETMA, REDinREN del ISCIII, IRBLleida, Lleida, Spain.
| | - Olga Balafa
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Robert Ekart
- Clinic for Internal Medicine, Department of Dialysis, University Medical Center Maribor, Maribor, Slovenia
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases, Ospedali Riuniti, 89124, Reggio Calabria, Italy
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Patrick Rossignol
- Inserm 1433 CIC-P CHRU de Nancy, Inserm U1116 and FCRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Alberto Ortiz
- School of Medicine, IIS-Fundacion Jimenez Diaz, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain
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Soe KK, Seto AH. Sliding with the sines − fatal hyperkalemia: A case report. World J Cardiol 2021; 13:230-236. [PMID: 34367507 PMCID: PMC8326152 DOI: 10.4330/wjc.v13.i7.230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/19/2021] [Accepted: 07/06/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Classic electrocardiographic manifestations of hyperkalemia starting with peaked symmetrical T-waves are widely recognized in daily clinical practice but little evidence is documented how quickly it can evolve in real-time.
CASE SUMMARY An elderly diabetic and hypertensive male presented with acute renal failure and rhabdomyolysis. He experienced cardiac arrest with moderate hyperkalemia despite medical treatment and hemodialysis. Telemetry changes were retrospectively studied and found to have significant rhythm changes that occurred just less than 10 minutes prior to the cardiac arrest.
CONCLUSION In hyperkalemia, telemetry rhythm can change instantaneously in a significant way. Rapidly rising potassium could be life threatening and may require more than medical treatment.
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Affiliation(s)
- Kyaw Khaing Soe
- Internal Medicine, Methodist Hospital of Southern California, Arcadia, CA 91007, United States
- Graduate Medical Education, St. Mary Medical Center, Long Beach, CA 90813, United States
| | - Arnold Hoo Seto
- Department of Medicine, University of California Irvine, Orange, CA 92868, United States
- Interventional Cardiology, Long Beach VA Medical Center, Long Beach, CA 90822, United States
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Lemoine L, Le Bastard Q, Batard E, Montassier E. An Evidence-Based Narrative Review of the Emergency Department Management of Acute Hyperkalemia. J Emerg Med 2021; 60:599-606. [PMID: 33423833 DOI: 10.1016/j.jemermed.2020.11.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/02/2020] [Accepted: 11/22/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The normal range for potassium is within narrow limits. Hyperkalemia is an electrolyte disorder that frequently affects patients in the emergency department (ED), and can result in significant morbidity and mortality if not identified and treated rapidly. OBJECTIVE This article provides an evidence-based narrative review of the management of hyperkalemia, with focused updates for the emergency clinician. METHODS We searched in MEDLINE, EMBASE, Web of Science, and Scopus databases for articles in English published in peer-reviewed journals and indexed up until May 2020. We used multiple search terms, including hyperkalemia, potassium, acute hyperkalemia, emergency department, dyskalemia, potassium disorders, kidney disease, epidemiology, electrolyte disturbance, severe hyperkalemia, and emergency management. DISCUSSION In the ED, interventions aimed to protect patients from the immediate dangers of elevated serum potassium are divided into the following: stabilizing cardiac membrane potentials, reducing serum potassium levels through shift from the extracellular fluid to intracellular fluid, and elimination of potassium through excretion via urinary or fecal excretion. Calcium is widely recommended to stabilize the myocardial cell membrane, but additional research is necessary to establish criteria for use, dosages, and preferred solutions. Redistribution of potassium ions from the bloodstream into the cells is based on intravenous insulin or nebulized β2-agonists. CONCLUSIONS Hyperkalemia is a frequent electrolyte disorder in the ED. Because of the risk of fatal dysrhythmia due to cardiac membrane instability, hyperkalemia is a medical emergency. There is a lack of scientific evidence on the optimal management of hyperkalemia and more research is needed to establish optimal strategies to manage acute hyperkalemia in the emergency department.
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Affiliation(s)
- Loic Lemoine
- Department of Emergency Medicine, Nantes University Hospital, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nantes, France
| | - Quentin Le Bastard
- Department of Emergency Medicine, Nantes University Hospital, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nantes, France; Microbiota, Hôtes, Antibiotiques et Résistances Laboratory, Université de Nantes, Nantes, France
| | - Eric Batard
- Department of Emergency Medicine, Nantes University Hospital, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nantes, France; Microbiota, Hôtes, Antibiotiques et Résistances Laboratory, Université de Nantes, Nantes, France
| | - Emmanuel Montassier
- Department of Emergency Medicine, Nantes University Hospital, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nantes, France; Microbiota, Hôtes, Antibiotiques et Résistances Laboratory, Université de Nantes, Nantes, France
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Lindinger MI, Cairns SP. Regulation of muscle potassium: exercise performance, fatigue and health implications. Eur J Appl Physiol 2021; 121:721-748. [PMID: 33392745 DOI: 10.1007/s00421-020-04546-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/29/2020] [Indexed: 12/30/2022]
Abstract
This review integrates from the single muscle fibre to exercising human the current understanding of the role of skeletal muscle for whole-body potassium (K+) regulation, and specifically the regulation of skeletal muscle [K+]. We describe the K+ transport proteins in skeletal muscle and how they contribute to, or modulate, K+ disturbances during exercise. Muscle and plasma K+ balance are markedly altered during and after high-intensity dynamic exercise (including sports), static contractions and ischaemia, which have implications for skeletal and cardiac muscle contractile performance. Moderate elevations of plasma and interstitial [K+] during exercise have beneficial effects on multiple physiological systems. Severe reductions of the trans-sarcolemmal K+ gradient likely contributes to muscle and whole-body fatigue, i.e. impaired exercise performance. Chronic or acute changes of arterial plasma [K+] (hyperkalaemia or hypokalaemia) have dangerous health implications for cardiac function. The current mechanisms to explain how raised extracellular [K+] impairs cardiac and skeletal muscle function are discussed, along with the latest cell physiology research explaining how calcium, β-adrenergic agonists, insulin or glucose act as clinical treatments for hyperkalaemia to protect the heart and skeletal muscle in vivo. Finally, whether these agents can also modulate K+-induced muscle fatigue are evaluated.
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Affiliation(s)
- Michael I Lindinger
- Research and Development, The Nutraceutical Alliance, Burlington, ON, L7N 2Z9, Canada
| | - Simeon P Cairns
- SPRINZ, School of Sport and Recreation, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, 1020, New Zealand.
- Health and Rehabilitation Research Institute, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, 1020, New Zealand.
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Lemoine L, Legrand M, Potel G, Rossignol P, Montassier E. Prise en charge de l’hyperkaliémie aux urgences. ANNALES FRANCAISES DE MEDECINE D URGENCE 2019. [DOI: 10.3166/afmu-2018-0108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L’hyperkaliémie est l’un des désordres hydroélectrolytiques les plus fréquemment rencontrés aux urgences. Les étiologies principales sont l’insuffisance rénale aiguë ou chronique, le diabète et l’insuffisance cardiaque. L’hyperkaliémie aiguë peut être une urgence vitale, car elle est potentiellement létale du fait du risque d’arythmie cardiaque. Sa prise en charge aux urgences manque actuellement de recommandations claires en ce qui concerne le seuil d’intervention et les thérapeutiques à utiliser. Les thérapeutiques couramment appliquées sont fondées sur un faible niveau de preuve, et leurs effets secondaires sont mal connus. Des études supplémentaires sont nécessaires pour évaluer l’utilisation de ces traitements et celle de nouveaux traitements potentiellement prometteurs. Nous faisons ici une mise au point sur les données connues en termes d’épidémiologie, de manifestations cliniques et électrocardiographiques, et des différentes thérapeutiques qui peuvent être proposées dans la prise en charge de l’hyperkaliémie aux urgences.
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10
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Yeung SMH, Vogt L, Rotmans JI, Hoorn EJ, de Borst MH. Potassium: poison or panacea in chronic kidney disease? Nephrol Dial Transplant 2018; 34:175-180. [DOI: 10.1093/ndt/gfy329] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 09/20/2018] [Indexed: 11/15/2022] Open
Affiliation(s)
- Stanley M H Yeung
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Liffert Vogt
- Department of Internal Medicine, Section of Nephrology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Joris I Rotmans
- Department of Internal Medicine (Nephrology), Leiden University Medical Center, Leiden, The Netherlands
| | - Ewout J Hoorn
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Martin H de Borst
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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11
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Long B, Warix JR, Koyfman A. Controversies in Management of Hyperkalemia. J Emerg Med 2018; 55:192-205. [DOI: 10.1016/j.jemermed.2018.04.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Revised: 02/07/2018] [Accepted: 04/10/2018] [Indexed: 12/24/2022]
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Trefz FM, Lorenz I, Constable PD. Electrocardiographic findings in 130 hospitalized neonatal calves with diarrhea and associated potassium balance disorders. J Vet Intern Med 2018; 32:1447-1461. [PMID: 29943868 PMCID: PMC6060331 DOI: 10.1111/jvim.15220] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 03/26/2018] [Accepted: 04/25/2018] [Indexed: 12/15/2022] Open
Abstract
Background Hyperkalemia in neonatal diarrheic calves can potentially result in serious cardiac conduction abnormalities and arrhythmias. Objectives To document electrocardiographic (ECG) findings and the sequence of ECG changes that are associated with increasing plasma potassium concentrations (cK+) in a large population of neonatal diarrheic calves. Animals One hundred and thirty neonatal diarrheic calves (age ≤21 days). Methods Prospective observational study involving calves admitted to a veterinary teaching hospital. Results Hyperkalemic calves (cK+: 5.8‐10.2, blood pH: 6.55‐7.47) had significantly (P < .05) longer QRS durations as well as deeper S wave, higher T wave, and higher ST segment amplitudes in lead II than calves, which had both venous blood pH and cK+ within the reference range. The first ECG changes in response to an increase in cK+ were an increase in voltages of P, Ta, S, and T wave amplitudes. Segmented linear regression indicated that P wave amplitude decreased when cK+ >6.5 mmol/L, S wave amplitude voltage decreased when cK+ >7.4 mmol/L, QRS duration increased when cK+ >7.8 mmol/L, J point amplitude increased when cK+ >7.9 mmol/L, and ST segment angle increased when cK+ >9.1 mmol/L. P wave amplitude was characterized by a second common break point at cK+ = 8.2 mmol/L, above which value the amplitude was 0. Conclusions and Clinical Importance Hyperkalemia in neonatal diarrheic calves is associated with serious cardiac conduction abnormalities. In addition to increased S and T wave amplitude voltages, alterations of P and Ta wave amplitudes are early signs of hyperkalemia, which is consistent with the known sensitivity of atrial myocytes to increased cK+.
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Affiliation(s)
- Florian M Trefz
- Clinic for Ruminants with Ambulatory and Herd Health Services at the Centre for Clinical Veterinary Medicine, LMU Munich, Sonnenstraße 16, 85764 Oberschleißheim, Germany
| | - Ingrid Lorenz
- Bavarian Animal Health Service (Tiergesundheitsdienst Bayern e.V.), Senator-Gerauer-Str. 23, 85586 Poing, Germany
| | - Peter D Constable
- Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana-Champaign, Illinois
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Gilligan S, Raphael KL. Hyperkalemia and Hypokalemia in CKD: Prevalence, Risk Factors, and Clinical Outcomes. Adv Chronic Kidney Dis 2017; 24:315-318. [PMID: 29031358 DOI: 10.1053/j.ackd.2017.06.004] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 06/20/2017] [Indexed: 01/13/2023]
Abstract
Abnormalities of serum potassium are common in patients with CKD. Although hyperkalemia is a well-recognized complication of CKD, the prevalence rates of hyperkalemia (14%-20%) and hypokalemia (12%-18%) are similar. CKD severity, use of medications such as renin-angiotensin-aldosterone system inhibitors and diuretics, and dietary potassium intake are major determinants of serum potassium concentration in CKD. Demographic factors, acid-base status, blood glucose, and other comorbidities contribute as well. Both hyperkalemia and hypokalemia are associated with similarly increased risks of death, cardiovascular disease, and hospitalization. On the other hand, limited evidence suggests a link between hypokalemia, but not hyperkalemia, and progression of CKD. This article reviews the prevalence rates and risk factors for hyperkalemia and hypokalemia, and their associations with adverse outcomes in CKD.
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Lábadi Á, Nagy Á, Szomor Á, Miseta A, Kovács GL. Factitious hyperkalemia in hematologic disorders. Scandinavian Journal of Clinical and Laboratory Investigation 2016; 77:66-72. [PMID: 27739333 DOI: 10.1080/00365513.2016.1238506] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Árpád Lábadi
- a Department of Laboratory Medicine University of Pécs , Hungary.,b 1st Department of Internal Medic University of Pécs , Hungary
| | - Ágnes Nagy
- b 1st Department of Internal Medic University of Pécs , Hungary
| | - Árpád Szomor
- b 1st Department of Internal Medic University of Pécs , Hungary
| | - Attila Miseta
- a Department of Laboratory Medicine University of Pécs , Hungary
| | - Gábor L Kovács
- a Department of Laboratory Medicine University of Pécs , Hungary.,c Szentágothai Research Centre, University of Pécs , Hungary
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Ideguchi T, Tsuruda T, Sato Y, Kitamura K. Coexisting Hyponatremia and Decline in Diastolic Blood Pressure Predispose to Atrial Standstill in Hyperkalemic Patients. Circ J 2016; 80:1781-6. [PMID: 27301330 DOI: 10.1253/circj.cj-16-0283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Atrial standstill is one of the important clinical consequences on the heart in severe hyperkalemia, but it occurs even at modest potassium ion elevation. The extent to which other factors might potentiate the electrocardiographic changes induced by hyperkalemia remains unclear. METHODS AND RESULTS This was a retrospective review of the data on 12,639 hospital admissions over a 15-year period. A total of 778 patients with hyperkalemia were identified, 28 of whom had atrial standstill, and had several parameters measured prior to any treatment of hyperkalemia. Patients with atrial standstill were older (P=0.036), had lower diastolic blood pressure (DBP; P<0.0001) and serum sodium concentration (P<0.0001), higher serum potassium (P<0.0001), and high prevalence of angiotensin converting-enzyme inhibitor (ACEI; P=0.009) or mineral corticoid receptor (MR)-blocker (P=0.006), compared with those without atrial standstill. On multivariate logistic regression, DBP <67 mmHg (P=0.006), serum sodium ion <135 mmol/L (P=0.006) and serum potassium ion >6.1 mmol/L (P=0.018) were identified as independent indicators of atrial standstill, after adjusting for sex, age, chronic maintenance hemodialysis, diuretics use or ACEI/angiotensin receptor blocker and MR blocker. CONCLUSIONS Hyponatremia and decline in DBP are associated with atrial standstill in patients with hyperkalemia. (Circ J 2016; 80: 1781-1786).
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Affiliation(s)
- Takeshi Ideguchi
- Department of Internal Medicine, Circulatory and Body Fluid Regulation, Faculty of Medicine, University of Miyazaki
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16
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Robert T, Algalarrondo V, Mesnard L. Hyperkaliémie sévère ou menaçante : le diable est dans les détails. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s13546-015-1125-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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18
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Truhlář A, Deakin CD, Soar J, Khalifa GEA, Alfonzo A, Bierens JJLM, Brattebø G, Brugger H, Dunning J, Hunyadi-Antičević S, Koster RW, Lockey DJ, Lott C, Paal P, Perkins GD, Sandroni C, Thies KC, Zideman DA, Nolan JP, Böttiger BW, Georgiou M, Handley AJ, Lindner T, Midwinter MJ, Monsieurs KG, Wetsch WA. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation 2015; 95:148-201. [PMID: 26477412 DOI: 10.1016/j.resuscitation.2015.07.017] [Citation(s) in RCA: 539] [Impact Index Per Article: 53.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Hradec Králové, Czech Republic.
| | - Charles D Deakin
- Cardiac Anaesthesia and Cardiac Intensive Care, NIHR Southampton Respiratory Biomedical Research Unit, Southampton University Hospital NHS Trust, Southampton, UK
| | - Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | | | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | | | - Guttorm Brattebø
- Bergen Emergency Medical Services, Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Hermann Brugger
- EURAC Institute of Mountain Emergency Medicine, Bozen, Italy
| | - Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | | | - Rudolph W Koster
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - David J Lockey
- Intensive Care Medicine and Anaesthesia, Southmead Hospital, North Bristol NHS Trust, Bristol, UK; School of Clinical Sciences, University of Bristol, UK
| | - Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-Universitaet, Mainz, Germany
| | - Peter Paal
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, Queen Mary University of London, London, UK; Department of Anaesthesiology and Critical Care Medicine, University Hospital Innsbruck, Austria
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Claudio Sandroni
- Department of Anaesthesiology and Intensive Care, Catholic University School of Medicine, Rome, Italy
| | | | - David A Zideman
- Department of Anaesthetics, Imperial College Healthcare NHS Trust, London, UK
| | - Jerry P Nolan
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK; School of Clinical Sciences, University of Bristol, UK
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Nakhoul GN, Huang H, Arrigain S, Jolly SE, Schold JD, Nally JV, Navaneethan SD. Serum Potassium, End-Stage Renal Disease and Mortality in Chronic Kidney Disease. Am J Nephrol 2015; 41:456-63. [PMID: 26228532 DOI: 10.1159/000437151] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 06/18/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND/AIMS Hypokalemia and hyperkalemia are often noted in chronic kidney disease (CKD) patients, but their impact on mortality and end-stage renal disease (ESRD) is less well understood. We aimed at studying the associations between potassium disorders, and mortality and progression to ESRD in a CKD population. METHODS Using our electronic health record-based CKD registry, 36,359 patients with eGFR <60 ml/min/1.73 m(2) and potassium levels measured from January 1, 2005 to September 15, 2009 were identified. We examined factors associated with hypokalemia (<3.5 mmol/l) and hyperkalemia (>5.0 mmol/l) using logistic regression models and associations between serum potassium levels (both as continuous and categorical variables) and all-cause mortality or ESRD using Cox-proportional hazards models. RESULTS Serum potassium <3.5 mmol/l was noted among 3% and >5.0 mmol/l among 11% of the study population. In the multivariable logistic regression analysis, lower eGFR, diabetes and use of ACE inhibitors or Angiotensin-Receptor Blockers were associated with higher odds of having hyperkalemia. Heart failure and African American race were factors associated with higher odds of hypokalemia. After adjustment for covariates including kidney function, serum potassium <4.0 and >5.0 mmol/l were significantly associated with increased mortality risk, but there was no increased risk for progression to ESRD. Time-dependent repeated measures analysis confirmed these findings. When potassium was examined as a continuous variable, there was a U-shaped association between serum potassium levels and mortality. CONCLUSION In patients with stage 3-4 CKD, serum potassium levels <4.0 and >5.0 mmol/l are associated with higher mortality but not with ESRD.
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Affiliation(s)
- Georges N Nakhoul
- Department of Nephrology and Hypertension, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Vemula P, Abela OG, Narisetty K, Rhine D, Abela GS. Potassium toxicity at low serum potassium levels with refeeding syndrome. Am J Cardiol 2015; 115:147-9. [PMID: 25456880 DOI: 10.1016/j.amjcard.2014.09.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 09/23/2014] [Accepted: 09/23/2014] [Indexed: 11/30/2022]
Abstract
Refeeding syndrome is a life-threatening condition occurring in severely malnourished patients after initiating feeding. Severe hypophosphatemia with reduced adenosine triphosphate production has been implicated, but little data are available regarding electrolyte abnormalities. In this case, we report electrocardiographic changes consistent with hyperkalemia during potassium replacement after a serum level increase from 1.9 to 2.9 mEq/L. This was reversed by lowering serum potassium back to 2.0 mEq/L. In conclusion, the patient with prolonged malnutrition became adapted to low potassium levels and developed potassium toxicity with replacement.
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Affiliation(s)
- Praveen Vemula
- Department of Medicine, Michigan State University, East Lansing, Michigan
| | - Oliver G Abela
- Department of Medicine, Michigan State University, East Lansing, Michigan
| | - Keerthy Narisetty
- Department of Medicine, Michigan State University, East Lansing, Michigan; Division of Cardiology, Department of Medicine, East Lansing, Michigan
| | - David Rhine
- Transthoracic Cardiovascular Institute/Sparrow Hospital, Lansing, Michigan
| | - George S Abela
- Department of Medicine, Michigan State University, East Lansing, Michigan; Division of Cardiology, Department of Medicine, East Lansing, Michigan.
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Hyperkalemia and ventricular tachycardia after outpatient ureteral valve reimplantation: a case report. Pediatr Emerg Care 2013; 29:650-2. [PMID: 23640146 DOI: 10.1097/pec.0b013e31828ec00a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed to report on a toddler who presented with progressively worsening abdominal pain and obstructive uropathy 1 week after ureteral valve reimplantation. Acute renal failure resulted in critical hyperkalemia. METHODS Chart review of presentation, physical examination, laboratory tests, and treatment. RESULTS Initial potassium level was 10 mEq/L; ventricular tachycardia was observed and treated. CONCLUSIONS More commonly, hyperkalemia results from overuse/overdose of supplementation or in patients with known renal failure. Although less common, obstructive uropathy should be considered in any patient with recent instrumentation of the urinary tract and coincident complications can be significant.
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Turner JM. Treatment of hyperkalemia. Expert Opin Orphan Drugs 2013. [DOI: 10.1517/21678707.2013.794692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Green D, Green HD, New DI, Kalra PA. The clinical significance of hyperkalaemia-associated repolarization abnormalities in end-stage renal disease. Nephrol Dial Transplant 2012; 28:99-105. [DOI: 10.1093/ndt/gfs129] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Sarafidis PA, Blacklock R, Wood E, Rumjon A, Simmonds S, Fletcher-Rogers J, Ariyanayagam R, Al-Yassin A, Sharpe C, Vinen K. Prevalence and factors associated with hyperkalemia in predialysis patients followed in a low-clearance clinic. Clin J Am Soc Nephrol 2012; 7:1234-41. [PMID: 22595825 DOI: 10.2215/cjn.01150112] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Recent studies evaluated the prevalence of hyperkalemia and related risk factors in patients with CKD of various stages, but there is limited relevant information in predialysis patients. This study aimed to examine the prevalence and factors associated with hyperkalemia in the structured environment of a low-clearance clinic. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In a cross-sectional fashion over a prespecified period of 4 months, information on serum potassium and relevant laboratory variables, comorbidities, medications, and dietician input in patients with advanced CKD under follow-up in the low-clearance clinic of our department was recorded. Univariate and multiple logistic regression analyses were used to identify factors associated with serum potassium ≥ 5.5 meq/L. RESULTS The study population consisted of 238 patients aged 66.2 ± 4.2 years with estimated GFR of 14.5 ± 4.8 ml/min per 1.73 m(2). The prevalence of hyperkalemia. defined as potassium > 5.0, ≥ 5.5, and ≥ 6.0 meq/L., was at 54.2%, 31.5%, and 8.4%, respectively. In univariate comparisons, patients with potassium ≥ 5.5 meq/L had significantly higher urea and lower estimated GFR and serum bicarbonate; also, they were more often using sodium bicarbonate and had received potassium education and attempts for dietary potassium lowering. Use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers was not associated with hyperkalemia. In multivariate analyses, estimated GFR<15 ml/min per 1.73 m(2) and sodium bicarbonate use were independently associated with hyperkalemia. CONCLUSIONS The prevalence of hyperkalemia in predialysis patients with CKD is high. Even at this range of renal function, low estimated GFR seems to be the most important factor associated with hyperkalemia among the wide range of demographic, clinical, and laboratory characteristics studied.
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Affiliation(s)
- Pantelis A Sarafidis
- Academic Department of Renal Medicine, King's College Hospital, London, United Kingdom
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Einhorn LM, Zhan M, Hsu VD, Walker LD, Moen MF, Seliger SL, Weir MR, Fink JC. The frequency of hyperkalemia and its significance in chronic kidney disease. ARCHIVES OF INTERNAL MEDICINE 2009; 169:1156-62. [PMID: 19546417 PMCID: PMC3544306 DOI: 10.1001/archinternmed.2009.132] [Citation(s) in RCA: 455] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hyperkalemia is a potential threat to patient safety in chronic kidney disease (CKD). This study determined the incidence of hyperkalemia in CKD and whether it is associated with excess mortality. METHODS This retrospective analysis of a national cohort comprised 2 103 422 records from 245 808 veterans with at least 1 hospitalization and at least 1 inpatient or outpatient serum potassium record during the fiscal year 2005. Chronic kidney disease and treatment with angiotensin-converting enzyme inhibitors and/or angiotensin II receptor blockers (blockers of the renin-angiotensin-aldosterone system [RAAS]) were the key predictors of hyperkalemia. Death within 1 day of a hyperkalemic event was the principal outcome. RESULTS Of the 66 259 hyperkalemic events (3.2% of records), more occurred as inpatient events (n = 34 937 [52.7%]) than as outpatient events (n = 31 322 [47.3%]). The adjusted rate of hyperkalemia was higher in patients with CKD than in those without CKD among individuals treated with RAAS blockers (7.67 vs 2.30 per 100 patient-months; P < .001) and those without RAAS blocker treatment (8.22 vs 1.77 per 100 patient-months; P < .001). The adjusted odds ratio (OR) of death with a moderate (potassium, >or=5.5 and <6.0 mEq/L [to convert to mmol/L, multiply by 1.0]) and severe (potassium, >or=6.0 mEq/L) hyperkalemic event was highest with no CKD (OR, 10.32 and 31.64, respectively) vs stage 3 (OR, 5.35 and 19.52, respectively), stage 4 (OR, 5.73 and 11.56, respectively), or stage 5 (OR, 2.31 and 8.02, respectively) CKD, with all P < .001 vs normokalemia and no CKD. CONCLUSIONS The risk of hyperkalemia is increased with CKD, and its occurrence increases the odds of mortality within 1 day of the event. These findings underscore the importance of this metabolic disturbance as a threat to patient safety in CKD.
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Affiliation(s)
- Lisa M. Einhorn
- University of Maryland School of Medicine, Departments of Medicine, Baltimore, MD
| | - Min Zhan
- Epidemiology and Preventive Medicine, Baltimore, MD
| | - Van Doren Hsu
- University of Maryland School of Pharmacy, Pharmaceutical Research Computing, Baltimore, MD
| | - Lori D. Walker
- University of Maryland School of Pharmacy, Pharmaceutical Research Computing, Baltimore, MD
| | - Maureen F. Moen
- University of Maryland School of Medicine, Departments of Medicine, Baltimore, MD
| | - Stephen L. Seliger
- University of Maryland School of Medicine, Departments of Medicine, Baltimore, MD
- Epidemiology and Preventive Medicine, Baltimore, MD
| | - Matthew R. Weir
- University of Maryland School of Medicine, Departments of Medicine, Baltimore, MD
| | - Jeffrey C. Fink
- University of Maryland School of Medicine, Departments of Medicine, Baltimore, MD
- Epidemiology and Preventive Medicine, Baltimore, MD
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Epstein M. Hyperkalemia as a Constraint to Therapy With Combination Renin-Angiotensin System Blockade: The Elephant in the Room. J Clin Hypertens (Greenwich) 2009; 11:55-60. [DOI: 10.1111/j.1751-7176.2008.00071.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
A 10-day-old boy treated in the intensive care unit and operating room due to hyperkalemia and renal failure. After admission to the intensive care unit and treatment for hyperkalemia, the patient required insertion of dialysis catheter in the operating room. Treatment for hyperkalemia continued while the patient was under general anesthesia. The operation was carried out successfully and cardiac signs and symptoms of hyperkalemia did not occur despite of potassium blood levels of 8.1 mEq x l(-1). General anesthesia could be safe in hyperkalemic patients as long as the treatment for hyperkalemia is initiated before and during the surgery and hyperkalemia inducing agents are avoided.
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Affiliation(s)
- Mohanad Shukry
- Department of Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, OK, USA.
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Freeman K, Feldman JA, Mitchell P, Donovan J, Dyer KS, Eliseo L, White LF, Temin ES. Effects of presentation and electrocardiogram on time to treatment of hyperkalemia. Acad Emerg Med 2008; 15:239-49. [PMID: 18304054 DOI: 10.1111/j.1553-2712.2008.00058.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To assess the time to treatment for emergency department (ED) patients with critical hyperkalemia and to determine whether the timing of treatment was associated with clinical characteristics or electrocardiographic abnormalities. METHODS The authors performed a retrospective chart review of ED patients with the laboratory diagnosis of hyperkalemia (potassium level > 6.0 mmol/L). Patients presenting in cardiac arrest or who were referred for hyperkalemia or dialysis were excluded. Patient charts were reviewed to find whether patients received specific treatment for hyperkalemia and, if so, what clinical attributes were associated with the time to initiation of treatment. RESULTS Of 175 ED visits that occurred over a 1-year time period, 168 (96%) received specific treatment for hyperkalemia. The median time from triage to initiation of treatment was 117 minutes (interquartile range [IQR] = 59 to 196 minutes). The 7 cases in which hyperkalemia was not treated include 4 cases in which the patient was discharged home, with a missed diagnosis of hyperkalemia. Despite initiation of specific therapy for hyperkalemia in 168 cases, 2 patients died of cardiac arrhythmias. Among the patients who received treatment, 15% had a documented systolic blood pressure (sBP) < 90 mmHg, and 30% of treated patients were admitted to intensive care units. The median potassium value was 6.5 mmol/L (IQR = 6.3 to 7.1 mmol/L). The predominant complaints were dyspnea (20%) and weakness (19%). Thirty-six percent of patients were taking angiotensin-converting enzyme (ACE) inhibitors. Initial electrocardiograms (ECGs) were abnormal in 83% of patient visits, including 24% of ECGs with nonspecific ST abnormalities. Findings of peaked T-wave morphology (34%), first-degree atrioventricular block (17%), and interventricular conduction delay (12%) did not lead to early treatment. Vital sign abnormalities, including hypotension (sBP < 90 mmHg), were not associated with early treatment. The chief complaint of "unresponsive" was most likely to lead to early treatment; treatment delays occurred in patients not transported by ambulance, those with a chief complaint of syncope and those with a history of hypertension. CONCLUSIONS Recognition of patients with severe hyperkalemia is challenging, and the initiation of appropriate therapy for this disorder is frequently delayed.
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Affiliation(s)
- Kalev Freeman
- Department of Surgery, University of Vermont College of Medicine, Burlington, VT, USA.
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Mitra JK, Pandia MP, Dash HH, Tomar AK. Moderate hyperkalaemia without ECG changes in the intraoperative period. Acta Anaesthesiol Scand 2008; 52:444-5. [PMID: 18269396 DOI: 10.1111/j.1399-6576.2007.01498.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Merrill GF, Merrill JH, Golfetti R, Jaques KM, Hadzimichalis NS, Baliga SS, Rork TH. Antiarrhythmic properties of acetaminophen in the dog. Exp Biol Med (Maywood) 2007; 232:1245-52. [PMID: 17895533 DOI: 10.3181/0701-rm-19] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Mongrel dogs bred for research and weighing 25 +/- 3 kg were used to test the hypothesis that acetaminophen has antiar-rhythmic properties. Only ventricular arrhythmias defined by the Lambeth Conventions were investigated. Dogs were exposed either to 60 mins of regional myocardial ischemia followed by 180 mins of reperfusion (n = 14) or were administered a high dose of ouabain (n = 14). Both groups of 14 dogs were further divided into vehicle and acetaminophen treatment groups (n = 7 in each). During selected 10-min intervals, we recorded the numbers of ventricular premature beats, ventricular salvos, ventricular bigeminy, ventricular tachycardia (nonsustained and sustained), and we recorded the heart rate, systemic arterial blood pressure, and left ventricular function. Neither heart rate nor the number of ventricular arrhythmias differed significantly under baseline conditions. Conversely, the combined average number of ventricular ectopic beats during ischemia and reperfusion was significantly less in the presence of acetaminophen (28 +/- 4 vs. 6 +/- 1; P < 0.05). Similarly, percent ectopy during reperfusion in vehicle- and acetaminophen-treated dogs was 1.4 +/- 0.4 and 0.4 +/- 0.2, respectively (P < 0.05). The number of all ventricular ectopic beats except ventricular salvos was also significantly reduced in the presence of acetaminophen. Similar results were obtained with ouabain. Our results reveal that systemic administration of a therapeutic dose of acetaminophen has previously unreported antiarrhythmic effects in the dog.
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Affiliation(s)
- Gary F Merrill
- Division of Life Sciences, Department of Cell Biology and Neurosciences, Rutgers University, Piscataway, New Jersey 08854, USA.
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Gupta H, Sharma S, Ghosh M, Padmanabhan A. Severe hyperkalemia with normal electrocardiogram. Indian J Crit Care Med 2007. [DOI: 10.4103/0972-5229.37718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Malouin A, Milligan JA, Drobatz KJ. Assessment of blood pressure in cats presented with urethral obstruction. J Vet Emerg Crit Care (San Antonio) 2007. [DOI: 10.1111/j.1476-4431.2006.00178.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Carvalhana V, Burry L, Lapinsky SE. Management of severe hyperkalemia without hemodialysis: Case report and literature review. J Crit Care 2006; 21:316-21. [PMID: 17175417 DOI: 10.1016/j.jcrc.2005.10.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2005] [Revised: 08/13/2005] [Accepted: 10/07/2005] [Indexed: 11/29/2022]
Abstract
PURPOSE To report a case of severe hyperkalemia successfully managed without the use of hemodialysis and to provide a review of the literature regarding the management of severe hyperkalemia. METHODS A clinical case report from the medical-surgical intensive care unit of a teaching hospital and a literature review are presented. The case involves a 59-year old man with diabetes mellitus, essential hypertension, and gout, who presented to hospital with severe hyperkalemia (K(+) = 10.4 mEq/L) and normal renal function. He was treated with intravenous fluids, sodium bicarbonate, calcium chloride, insulin, calcium resonium, and furosemide. RESULTS The hyperkalemia resolved with conservative treatment within 8 hours, and dialytic therapy was not required. The literature review supported an initial conservative management approach in stable patients with intact renal function. CONCLUSIONS Hemodialysis is not necessary for all cases of severe hyperkalemia and should be reserved for patients with acute or chronic renal failure or those with life-threatening hyperkalemia unresponsive to more conservative measures.
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Abstract
Potassium is the principal intracellular cation, and maintenance of the distribution of potassium between the intracellular and the extracellular compartments relies on several homeostatic mechanisms. When these mechanisms are perturbed, hypokalemia or hyperkalemia may occur. This review covers hyperkalemia, that is, a serum potassium concentration exceeding 5 mmol/L. The review includes a discussion of potassium homeostasis and the etiologies of hyperkalemia and focuses on the prompt recognition and treatment of hyperkalemia. This disorder should be of major concern to clinicians because of its propensity to cause fatal arrhythmias. Hyperkalemia is easily diagnosed, and rapid and effective treatments are readily available. Unfortunately, treatment of this life-threatening condition is often delayed or insufficiently attentive or aggressive.
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Affiliation(s)
- Kimberley J Evans
- Duke University Medical Center, Department of Medicine, Division of Nephrology, Durham, NC 27710, USA.
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Vereckei A. Inferior wall pseudoinfarction pattern due to hyperkalemia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 26:2181-4. [PMID: 14622325 DOI: 10.1046/j.1460-9592.2003.00341.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pseudoinfarction pattern is a rare ECG manifestation of marked hyperkalemia. Case reports characteristically describe the occurrence of anteroseptal pseudoinfarction pattern and four cases of anteroseptal together with inferior wall pseudoinfarction pattern associated with hyperkalemia. We report a case with isolated inferior wall pseudoinfarction pattern due to hyperkalemia.
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Affiliation(s)
- Andras Vereckei
- 3rd Department of Medicine, Semmelweis University, School of Medicine, Budapest, Hungary.
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Evans K, Reddan DN, Szczech LA. Review Articles: Nondialytic Management of Hyperkalemia and Pulmonary Edema Among End-Stage Renal Disease Patients: An Evaluation of the Evidence. Semin Dial 2004; 17:22-9. [PMID: 14717808 DOI: 10.1111/j.1525-139x.2004.17110.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Congestive heart failure (CHF) and hyperkalemia are the two leading reasons for emergency dialysis among individuals with end-stage renal disease (ESRD). While hemodialysis provides definitive treatment of both hyperkalemia and volume overload among ESRD patients, for those who present outside of "regular dialysis hours," institution of dialysis may be delayed. Nondialytic management can be instituted immediately and should be the initial therapy in the management of hyperkalemia and CHF in these individuals. Current available evidence does not allow conclusions as to whether treatment with nondialytic strategies alone results in different outcomes than nondialytic strategies coupled with emergent hemodialysis. Therefore, whether or not nondialytic management alone is appropriate remains a matter of individual judgment that should be decided on a case-by-case basis.
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Affiliation(s)
- Kimberley Evans
- Department of Medicine, Division of Nephrology, Duke University Medical Center, Durham, North Carolina 27705, USA.
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Olson RP, Schow AJ, McCann R, Lubarsky DA, Gan TJ. Absence of adverse outcomes in hyperkalemic patients undergoing vascular access surgery. Can J Anaesth 2003; 50:553-7. [PMID: 12826545 DOI: 10.1007/bf03018639] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The decision to cancel vascular access surgery because of hyperkalemia requires knowledge of the risks vs benefits. This study sought to identify and characterize cases where surgery had been performed in patients with uncorrected hyperkalemia. METHODS One thousand four hundred and seventy-two consecutive cases of vascular access surgery at an academic medical centre between 1995 and 2000 by a single surgeon were analyzed retrospectively. RESULTS Eight cases had clear documentation that the case proceeded with hyperkalemia. Anesthesia techniques were one general anesthetic, one regional block, five monitored anesthesia care (MAC), and one local infiltration only. Mean potassium was 6.9 mmol x L(-1) (range 6.1-8.0). In this series of selected asymptomatic hyperkalemic patients undergoing low risk surgery, no adverse results occurred. CONCLUSION While this review of eight cases (only one receiving general anesthesia) cannot be used to prove the safety of proceeding to surgery with uncorrected hyperkalemia, it does suggest that asymptomatic hyperkalemia may not be an absolute contraindication to vascular access surgery.
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Affiliation(s)
- Ronald P Olson
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Abstract
Serious hyperkalemia is common in patients with end-stage renal disease (ESRD) and accounts for considerable morbidity and death. Mechanisms of extrarenal disposal of potassium (gastrointestinal excretion and cellular uptake) play a crucial role in the defense against hyperkalemia in this population. In this article we review extrarenal potassium homeostasis and its alteration in patients with ESRD. We pay particular attention to the factors that influence the movement of potassium across cell membranes. With that background we discuss the emergency treatment of hyperkalemia in patients with ESRD. We conclude with a review of strategies to reduce the risk of hyperkalemia in this population of patients.
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Affiliation(s)
- J Ahmed
- Duane L. Waters Hospital, Jackson, Michigan, USA
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40
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O'Neill M, Ryan DM, Paterson DJ. Effect of verapamil on restoration of cardiac performance in raised [K+]o by adrenergic stimulation in the rabbit. ACTA PHYSIOLOGICA SCANDINAVICA 1995; 154:367-76. [PMID: 7572234 DOI: 10.1111/j.1748-1716.1995.tb09920.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Modulation of the L-type calcium channel by catecholamines improves action potential parameters in single ventricular myocytes depolarized by high [K+]o Tyrode. Whether this modulation is important in offsetting the negative effects of hyperkalaemia in the whole heart is not known. We tested the effects of the calcium channel antagonist, verapamil, on restoration of cardiac performance by adrenergic stimulation in high [K+]o in anaesthetized rabbits and isolated perfused working rabbit hearts. Raised [K+]o decreased SBP, LVP and LVdP/dtmax in vivo ([K+]a 8.6 +/- 0.2 mM; n = 10) and aortic flow (AF) in the isolated heart (8 mM [K+]o Tyrode; n = 25). However, the negative effects of raised [K+]a were offset by isoprenaline (Iso, 1 microgram kg-1 min-1 i.v.) in vivo and by noradrenaline (NA, 80 nM) in the isolated heart. Verapamil (0.15 mg kg-1 i.v.; 15 nM isolated heart) markedly potentiated the negative inotropic effects of raised [K+]o in both preparations. Verapamil attenuated the effect of isoprenaline in vivo but in the isolated heart, the protective effect of NA in 8 mM [K+] Tyrode (AF 97 +/- 10 mL min-1 in 8 mM [K+]o compared with AF 141 +/- 8.5 mL min-1 in 8 mM [K+]o + NA) was offset by the drug (90 +/- 8 mL min-1 in 8 mM [K+]o + NA + V). Furthermore, verapamil abolished aortic flow in 8 mM [K+]o alone. These findings suggest that the heart may be critically dependent on modulation of intracellular calcium in order to tolerate concentrations of K+ similar to those seen during a short burst of intensive exercise ([K+]a 8.6 mM).
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Affiliation(s)
- M O'Neill
- University Laboratory of Physiology, Oxford, UK
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O'Neill M, Paterson DJ. Role of the sympathetic nervous system in cardiac performance during hyperkalaemia in the anaesthetized pig. ACTA PHYSIOLOGICA SCANDINAVICA 1995; 153:1-11. [PMID: 7625163 DOI: 10.1111/j.1748-1716.1995.tb09828.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Cardiovascular performance was studied in 18 alpha-chloralose anaesthetized pigs when arterial potassium ([K+]a) was raised to levels observed in heavy exercise. The effects of hyperkalaemia were then studied during cardiac sympathetic nerve stimulation or during an infusion of noradrenaline. Elevation of [K+]a up to ca. 10 mM caused a progressive decline in cardiovascular performance. However, right cardiac sympathetic nerve stimulation elevated all cardiovascular parameters in the presence of raised [K+]a and offset the negative cardiac effects of hyperkalaemia. Electrical pacing of the right atrium to heart rates (HRs) equivalent to those observed during right cardiac sympathetic nerve stimulation did not offset the depressive effects of hyperkalaemia and, indeed, hastened the decline in cardiovascular performance. Infusion of noradrenaline (1 microgram kg min-1 i.v.) during hyperkalaemia caused an increase in all cardiovascular parameters similar to that seen during sympathetic nerve stimulation. After propranolol (0.5 mg kg-1 i.v.), sympathetic nerve stimulation slightly increased HR, systolic blood pressure (SBP) and dP/dtmax. Elevation of [K+]a occurred more rapidly after propranolol, but the heart was still protected from hyperkalaemia during cardiac sympathetic stimulation. Infusion of noradrenaline elicited arrhythmias in six pigs. Infusion of KCl reduced the incidence of arrhythmias and in some cases abolished them. These findings may be related to how the heart is protected from exercise-induced changes in potassium and catecholamines.
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Affiliation(s)
- M O'Neill
- University Laboratory of Physiology, Oxford, UK
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Abstract
We report the case of a 70-year-old man who developed cardiac arrest secondary to hyperkalemia that complicated severe chronic renal failure due to obstructive uropathy. The patient experienced electromechanical dissociation and approximately 26 minutes of asystole after which the resuscitation was suspended. However, 8 to 10 minutes after declaration of death, the patient was noted to have developed spontaneous return of circulation as the emergency department personnel were preparing to transport him to the morgue. The patient survived and was discharged without apparent neurologic sequelae. This case demonstrates the challenges facing physicians to predict the outcome of hyperkalemic cardiac arrest based on usual parameters. It also highlights the relative paucity of resuscitation guidelines to assist in the management of this medical emergency.
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Affiliation(s)
- G Quick
- Division of Emergency Medicine, St Louis University Medical Center, Missouri
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Paterson DJ, Rogers J, Powell T, Brown HF. Effect of catecholamines on the ventricular myocyte action potential in raised extracellular potassium. ACTA PHYSIOLOGICA SCANDINAVICA 1993; 148:177-86. [PMID: 8352029 DOI: 10.1111/j.1748-1716.1993.tb09547.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
We describe the relationship between catecholamines and raised extracellular potassium ([K+]o) on action potential parameters and calcium currents in isolated ventricular myocytes of the guinea-pig and relate these findings to the problem of understanding how the heart is protected from exercise-induced hyperkalaemia ([K+]a up to 8.5 mM). Action potential duration (APD90), amplitude and upstroke velocity were recorded in stimulated (2Hz) guinea-pig ventricular myocytes using whole-cell patch electrode recordings (37 degrees C). Cells were superfused with normal K+ Tyrode and with raised K+ Tyrode in the presence of either noradrenaline, adrenaline or raised calcium. Inward calcium current was measured using voltage clamp. Raised K+ (8, 12, 16 mM K+ Tyrode) caused a significant (P < 0.01) depolarisation, shortened the APD90 and decreased the action potential amplitude and upstroke velocity. In raised K+ Tyrode addition of noradrenaline (0.08-0.1 microM) or adrenaline (0.1-0.2 microM) increased action potential amplitude (P < 0.01), APD90 (P < 0.01) and upstroke velocity (P < 0.01) (measured only in 16 mM K+ Tyrode). In 12 mM K+ Tyrode raised Ca2+ (5-6 mM) increased action potential amplitude (P < 0.05) and shortened APD90 (P < 0.05). Addition of NA (0.08-0.1 microM) increased the inward Ca2+ current. All effects were fully reversible. In raised [K+]o increases in catecholamines and [Ca2+]o cause changes in action potential parameters that would be expected to maintain propagation of the cardiac action potential in the whole heart. Thus, in the ventricular myocyte the increase in conductance to Ca2+ caused by catecholamines may be one factor that is important in minimising the potentially adverse effects of exercise-induced hyperkalaemia.
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Kuwahara M, Chiku K, Shiono T, Tsubone H, Sugano S. ECG changes under hyperkalemia with nephrectomy in the rat. J Electrocardiol 1992; 25:215-9. [PMID: 1645061 DOI: 10.1016/0022-0736(92)90006-l] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Electrolyte abnormalities have become an increasingly important cause of arrhythmias. Although the electrocardiographic (ECG) changes under hyperkalemia in the rat are poorly understood, it is conceivable that excess plasma potassium may also alter the cardiac excitations in the rat. Further, effects of hyperkalemia on ECG in the rat may differ from other species that have ST-segment and longer QT intervals in ECG. The present study was designed to determine the diagnostic criteria for ECG manifestations to various levels of plasma potassium concentration. For this purpose, hyperkalemia was induced by nephrectomy with and without infusions. Because it was difficult to produce various levels of plasma potassium concentration by only nephrectomy, we used two kinds of infusions to obtain especially moderate levels of nephrectomy-induced hyperkalemia. ECGs were recorded 24, 36, and 48 hours after nephrectomy. Plasma potassium concentration and number of abnormal ECGs were increased time-dependently. Increased T wave amplitude was present with mild hyperkalemia. The typical T wave change observed with so-called sinoventricular conduction levels of potassium concentration in species with long QT intervals did not occur in the rat. PR interval and QRS duration became slightly shorter within moderate hyperkalemia. P wave disappeared in most rats at potassium levels above 8.0 mEq/l. In advanced hyperkalemia (plasma potassium concentration above 7.5 mEq/l), conduction in all parts of the heart was suppressed. Moreover, sinoventricular conduction appeared. Thus, the diagnostic criteria for ECG manifestations to various levels of plasma potassium concentration in the rat were demonstrated.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- M Kuwahara
- Department of Comparative Pathophysiology, Faculty of Agriculture, University of Tokyo, Japan
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Abstract
STUDY OBJECTIVE To determine whether physicians blinded to the serum potassium level can predict hyperkalemia (potassium concentration of more than 5.0 mmol/L) from the ECG. DESIGN ECGs of patients at high risk for hyperkalemia were interpreted retrospectively by two physicians blinded not only to the specific clinical diagnosis of the patient and to their serum potassium measurement but also to each other's interpretation. The physicians predicted the presence or absence of hyperkalemia as well as the severity of hyperkalemia on a nominal scale (mild, moderate, or severe). SETTING The emergency department of a university-affiliated urban county hospital. PATIENTS Two hundred twenty consecutive patients admitted to the hospital from the ED with a diagnosis of renal failure or hyperkalemia. Eighty-seven patients had hyperkalemia, and 133 did not. RESULTS The sensitivities of the readers for predicting hyperkalemia were .43 and .34, respectively (best positive predictive value, .65). The respective specificities for detecting hyperkalemia were .85 and .86 (best negative predictive value, .69). When only patients with moderate-to-severe hyperkalemia (potassium of more than 6.5 mmol/L) were analyzed, sensitivities were .62 and .55. The readers' ability to predict the severity of hyperkalemia was equally poor. CONCLUSION The ECG is not a sensitive method of detecting hyperkalemia, even in high-risk patients. The specificity of the ECG is better for hyperkalemia, but empiric treatment of hyperkalemia based on the ECG alone will lead to mistreatment of at least 15% of patients.
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Affiliation(s)
- K D Wrenn
- Division of Emergency Medicine, University of Rochester, New York
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Abstract
Three patients with systemic hypotension and sinus bradycardia that were initially refractory to conventional therapy responded well to intravenous calcium administration. Two-dimensional echocardiography revealed immediate reversal of severe left ventricular dysfunction after intravenous administration of calcium in two instances. Common factors were hyperkalemia and verapamil therapy. This interaction was examined further by evaluation of contractility, heart rate, and arterial blood pressure in anesthetized dogs. Controls (n = 9) received saline infusion, and a second group (n = 10) received saturated potassium chloride (approximately 0.2 ml/min intravenously). In control dogs, administration of verapamil (1195 +/- 181 micrograms/kg intravenously) reduced systemic arterial pressure from 113 +/- 7 mm Hg to 74 +/- 5 mm Hg, and heart rate from 147 +/- 9 beats/min to 86 +/- 11 beats/min. Potassium chloride infusion alone increased blood [K+] from 3.4 +/- 0.1 to 6.2 +/- 0.2 mEq/L, but was without hemodynamic effects. In hyperkalemic dogs, a significantly lower dose of verapamil (428 +/- 42 micrograms/kg intravenously) reduced systemic arterial pressure from 102 +/- 8 mm Hg to 36 +/- 4 mm Hg, and heart rate from 150 +/- 5 beats/min to 104 +/- 15 beats/min. Myocardial contractile function was examined with right ventricular isometric contractile force and left ventricular segment length changes. In normokalemic and hyperkalemic groups, contractility was decreased by verapamil. Effects of verapamil on arterial pressure and contractility could be reversed significantly by administration of calcium, 0.4 mEq/kg intravenously. The present results support the theory that the negative hemodynamic effects of verapamil may be exaggerated to a harmful degree by concomitant hyperkalemia. These adverse events may be reversed by calcium administration.
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Affiliation(s)
- B Surawicz
- Krannert Institute of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis 46202
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Pelleg A, Mitamura H, Price R, Kaplinsky E, Menduke H, Dreifus LS, Michelson EL. Extracellular potassium ion dynamics and ventricular arrhythmias in the canine heart. J Am Coll Cardiol 1989; 13:941-50. [PMID: 2926046 DOI: 10.1016/0735-1097(89)90240-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The relation between extracellular potassium ion activity [( K+]o) and ventricular tachyarrhythmias was studied in an open chest canine model with the use of two protocols. In Protocol I, potassium chloride was administered into the proximal left anterior descending coronary artery at a rate of 0.125 mEq/min for either 20 min or until [K+]o = 20 mEq/liter, whichever came first. In Protocol II, the proximal left anterior descending coronary artery was occluded in one step and was reperfused 20 min later. Fifteen dogs were subjected to Protocol I, nine of which were also subjected to Protocol II. In the latter group, a recovery period of greater than or equal to 1 h separated the two protocols. Local K+ and intramyocardial activities were recorded with use of bifunctional ion-sensitive plunge electrodes at multiple sites located in the region of the left ventricle perfused by the left anterior descending artery and at one site outside of this region. The following variables were recorded and analyzed: Lead II electrocardiogram, heart rate, systemic arterial blood pressure, local [K+]o and its time derivative (dK+/dt), local electrograms and ventricular arrhythmias. Maximal [K+]o and dK+/dt were 23 +/- 3 mEq/liter and 9 +/- 1 mEq/liter per min in Protocol I and 14 +/- 1 mEq/liter and 3 +/- 1 mEq/liter per min in Protocol II, respectively. In both protocols, the occurrence of ventricular arrhythmias correlated with [K+]o (p less than 0.02) as well as with dK+/dt (p less than 0.05). Ventricular arrhythmias were more frequent and more severe in Protocol II than in Protocol I (p less than 0.05). Therefore, whereas K+ dynamics were more pronounced in Protocol I, ventricular arrhythmias were more severe in Protocol II. This occurrence was apparently due, at least in part, to less heterogeneous changes in K+ gradients during constant K+ infusion. It was concluded that, in addition to the magnitude of [K+]o, the rate of change of this variable (that is, dK+/dt) apparently plays an important role in the genesis of ischemic ventricular arrhythmias.
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Affiliation(s)
- A Pelleg
- Lankenau Medical Research Center, Cardiovascular Division, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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Selsby DS. Anesthetic complications of a weight reducing regimen. BMJ (CLINICAL RESEARCH ED.) 1989; 298:51. [PMID: 2492864 PMCID: PMC1835368 DOI: 10.1136/bmj.298.6665.51] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Freeman AG. Monitoring the acute phase response. BMJ (CLINICAL RESEARCH ED.) 1989; 298:50-1. [PMID: 2492863 PMCID: PMC1835349 DOI: 10.1136/bmj.298.6665.50-c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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