Pt with diastolic heart failure and CKD stage 3 and CHF. Potassium 7.
What is the best initial management to reduce his potassium level? Answer: Intravenous insulin and glucose.
Potassium of 7 is severe hyperkalemia. You want to urgently bring down the potassium. IV insulin followed by glucose will shift potassium intracellularly and is an effective treatment for severe hyperkalemia.
Kayexalate takes time to work.
Dx: Hyperkalemia with ECG changes.
Pt with ESRD getting dialysis 3 times per week presents with K> 9 on admission. Pt was due for dialysis on day-of-admission but didn’t get it because of symptoms of leg pain and abd. pain.
In the ED, pt already received 1g of calcium chloride x2, insulin, 2L IVFs, morphine, sodium bicarb, D50, and was scheduled for emergency dialysis so that pt would not develop any arrhythmias that are incompatible with life.
Admit patient to ICU (a place where the pt can get emergency hemodialysis. NB: This pt is already a dialysis pt )
Consult nephrology – Nephrologist already saw pt.
Emergent hemodialysis per nephrologist on call.
1g of CaCl q45mins for QRS widening per nephrologist until dialysis is done and hyperkalemia resolves.
IVFs
Beta-agonist
Cont insulin as needed to drive K+ into cells.
Additional bicarb as needed
*After emergent dialysis, K+ came down to 4.7 and the widened QRS resolved. The QRS duration came down from 235 to 126 as measured by the machine.
Sample ECG strips.
References
Potassium disorders: Hypokalemia and hyperkalemia. Am Fam Physician 2015;92(6):487-495.