-- Gut Check: repeat K (can check on blood gas) and see if hemolyzing due to high plt or WBC
-- ABCs: STAT EKG (look for peaked T waves, block, arrythmia) and give calcium gluconate; dialysis if severe and intitial temporizing efforts are ineffective
-- Chart Check: ***CKD, dialysis timing
-- Admission Criteria: ***
-- HPI Intake: *** missed dialysis, make urine, central access, new meds, symptoms (cramps, paresthesias, n/v/d), constipation
-- Can't Miss: *** EKG changes, acidosis
-- Admission Orders: *** continuous telemetry; low K diet; CBC, BMP, q2-4LFTs, VBG; consider CK, hemolysis labs, cortisol/aldo
-- Initial Treatment to Consider: In general treat the K if >6, rapid change, or symptoms including EKG changes - Insulin 10 units IV with D50 25mg; furosemide 40+mg IV, Lokelma 10mg TID; treat underlying cause - acidosis, hypovolemia, DKA, hypoaldo, remove meds, etc.
-- History: *** CKD, makes urine, missed dialysis, hyperpigmentation, FHx autoimmune dx
-- Clinical: ***muscle cramps, paresthesias, N/V/D, heart block
-- Exam: *** weakness, paresthesias, arrythmia
-- Data: *** EKG, ABG/VBG
-- Etiology/DDx: *** AKI/CKD, drugs (BB, calcineurin inhibitors, ACE/ARB, NSAIDs, spironolcatone, bactrim), acidosis, hypoaldo/primary adrenal insufficiency, cell lysis (rhabdo, TLS), transfusion reaction, decreased insulin, type IV RTA
The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.
-- Monitor: *** Trend K q *** and EKG q ***; Continuous telemetry
-- Consult renal if c/f dialysis need (unable to temporize with EKG changes or sxs)
-- Consider sending CK, hemolysis labs (LDH), cortisol/aldo/renin
-- Calcium gluconate 1g IV q hour while remaining hyperkalemic; repeat 5min PRN (lasts 30-60 mins)
-- Temporizing: *** Insulin 10 units IV with D50 25mg if BG <250; bicarb amp if pH <7.2
-- Eliminate: *** furosemide 40+mg IV, sodium zirconium (Lokelma) 10mg TID; dialysis if symptoms, EKG changes, unable to lower by other means
-- Low potassium diet
-- If c/f Adrenal Insufficency - hydrocort 15-25mg split 2-3 doses + fludrocort 0.05-0.2 daily
PDF coming soon!
The most common cause of hyperkalemia presenting to the hospital is from ESRD (missed dialysis) and medications. Get an EKG and give calcium gluconate if K >6. You should give insulin 10 units with D50 25mg (if BG <250) if need to temporize and then lasix 40mg+ IV and/or lokelma 10mg TID to eliminate the K. Don't wait to see if elimination will work if there is an indication for dialysis - just do it.