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Treatment for Hyperkalemia: A nurse’s comprehensive guide to high potassium levels

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Treatment for Hyperkalemia is essential in the hospital and acute care settings, as it can be deadly!

Hyperkalemia is when a patient’s serum potassium level rises above 5.0 mEq/L. This potentially life-threatening medical condition is one that nurses must be familiar with, as this can lead to cardiac arrhythmias and cardiac arrest. 

Nurses are crucial in preventing, detecting, and managing hyperkalemia through various nursing interventions and treatment options. This article will discuss the causes of hyperkalemia, nursing interventions, and treatment of hyperkalemia, providing nurses with the knowledge and tools necessary to identify and manage this deadly condition.

If you haven’t read the article on Hypokalemia, be sure to read that post first as it has some great background information about how the body regulates potassium in the body!

Learn about the causes, nursing assessment, and treatment for hyperkalemia in this comprehensive guide for nurses and medical professionals.

Hyperkalemia And Normal Potassium Levels

Potassium Levels

The normal range for potassium levels within the body is 3.5-5.0 mEq/L. Hyperkalemia is any level that is higher than 5.0 mEq/L

 

  • Normal = 3.5 – 5.0 mEq/L
  • Mild Hyperkalemia: 5.1 – 5.9 mEq/L
  • Moderate Hyperkalemia: 6.0 – 6.9 mEq/L
  • Severe Hyperkalemia: > 7.0 mEq/L

The higher the level, the more likely your patient will experience side effects or complications from hyperkalemia.

Remember that this is the level of potassium that is OUTSIDE the cells of the body. The actual amount (3.5-5mEq/L) is very low. However, the inside of the cell usually has 120-150mEq/L… That’s 30 times the level from the outside! This is why conditions that cause lysis of cells on a large scale can cause large increases in hyperkalemia.

Causes Of Hyperkalemia:

We discussed in the previous article about how potassium regulates the body and understanding how potassium works and then also what causes high potassium levels is important to understand before diving into the treatment for hyperkalemia.

There are various causes of hyperkalemia, including:

Renal Failure

The kidneys are the main way the body regulates potassium levels. When potassium levels are too high, the kidneys will excrete excess potassium. When the kidneys don’t work like they should and can’t filter out the excess potassium like usual, this is really the primary reason you’ll see potassium levels rise significantly in the blood. This can be from acute or chronic kidney disease.

A bottle of medications that are prescription

Medications

Certain medications can cause an increase in serum potassium levels, such as lisinopril, potassium-sparing diuretics (like Spironolactone), and even NSAIDs. These impact how the kidneys normally excrete potassium. Beta-blockers even can increase potassium levels, but to a lesser degree (usually < 0.5 mEq/L elevation).

A liquid drop with "H+" indicating acid or acidity or hydrogen ions

Metabolic Acidosis

Acidosis, when a buildup of hydrogen ions in the blood, causes a potassium shift from inside to outside the cells, leading to hyperkalemia.

What about Respiratory acidosis?

Respiratory acidosis is largely caused by an excess buildup of CO2 in the blood. Since CO2 is a small, uncharged molecule, it can easily diffuse across the cell membrane and does not directly affect potassium levels within cells. Therefore, in respiratory acidosis, potassium levels in the blood are generally not significantly affected.

An organic chemistry representation of aldosterone the hormone

Hormones

Insulin and aldosterone both impact potassium levels.

A deficiency in insulin (such as with DKA) leads to potassium accumulation outside the cell.

In hypoaldosteronism (Addison’s disease), there is not enough aldosterone. Aldosterone normally promotes potassium excretion in the kidney. So not having enough leads to higher potassium levels.

You’ll see later that we can utilize one of these hormones in the actual treatment for hyperkalemia!

A red cell that is bursting open, releasing its contents into the extracellular space

Hemolysis & Tissue Injury

When a cell lyses or splits open, its contents are released into the extracellular space. As we discussed, potassium concentration is much higher in the cells.

Whenever a condition or injury leads to massive destruction and lysis of cells, this can lead to hyperkalemia.

These conditions include major trauma, crush injuries, tumor-lysis syndrome, rhabdomyolysis, major burns, and hemolytic anemia.

A bottle of medications that are prescription

Medications that Can Cause Hyperkalemia

  • ACEI/ARBs: Lisinopril, ramipril, and losartan can all cause increased potassium levels by reducing/blocking aldosterone.
  • Potassium-Sparing Diuretics: Potassium-sparing diuretics like Aldactone, Spironolactone, and amiloride block the action of aldosterone in the kidneys, leading to decreased potassium excretion.
  • NSAIDs: NSAIDs, such as Ibuprofen or Toradol, interfere with the production of prostaglandins, which regulate potassium levels in the kidneys.
  • Beta-Blockers: While this is usually a mild effect, non-selective beta-blockers (like propranolol or atenolol) decrease potassium uptake into cells, which can lead to a mild increase in potassium.
  • Digoxin: Digoxin can interfere with the sodium-potassium pump and increase blood potassium levels.

    Part of the treatment for hyperkalemia is avoiding these medications!

    A strand of DNA

    Risk Factors for Hyperkalemia

    • CKD: Chronic kidney disease can lead to the inability to regulate potassium levels efficiently
    • Diabetes: Especially with uncontrolled type 1 diabetes, the absolute lack of insulin can lead to elevated potassium levels.
    • Older age: Older patients have less efficient kidneys, as well as often have comorbid conditions.
    • Trauma or Burn patients: As stated above, trauma and burns can cause rapid release of potassium into the blood from damaged tissue.
    • Addison’s Disease: These patients are at increased risk of hyperkalemia due to a lack of aldosterone.

    What is PseudoHyperkalemia?

    Pseudohyperkalemia is essentially a “false positive” elevation of potassium. This occurs during the blood draw or after the blood has been drawn. It’s important to recognize cases of “fake” high potassium before implementing treatment for hyperkalemia, as this can lead to hypokalemia!

    Possible causes of pseudohyperkalemia include:

    Red blood cells bursting open, indicating hemolysis

    Hemolysis of the blood sample

    Blood sample hemolysis usually occurs when drawing blood draw from mechanical trauma. This often occurs if the catheter is against the vein wall and causes red blood cell lysis during the draw. This blood can have a red tint due to released hemoglobin.

    An animal cell with arrows pointing in and out of the cell membrane, indicating redistribution of potassium across the cell membrane

    Potassium Shifts

    Repeated fist-clenching can cause potassium to shift out of the muscles temporarily. This can lead to elevations by more than 1-2 mEq/L in that forearm.

    A half-eaten banana, indicating low potassium levels

    Leukocytosis or Thrombocytosis

    Significant elevations in platelet levels and very high WBCs (in the setting of chronic lymphocytic leukemia) can cause false potassium elevations, since the white blood cells are very fragile and break after the draw.

    A strand of DNA

    Genetic Condition

    Certain forms of hereditary pseudohyperkalemia exist due to potassium shifting out of red blood cells.

    Whenever a high potassium level comes back and the clinical picture doesn’t make sense (such as normal renal function, no symptoms, and no other findings), then suspect pseudo-hyperkalemia.

    Nursing Assessment Of Hyperkalemia

    Symptoms

    Symptoms of hyperkalemia will vary depending on the patient and how severe the hyperkalemia is. The higher the potassium level, the more likely the patient will exhibit symptoms, and the worse they often are, the more quickly treatment for hyperkalemia will need to be initiated!

    Some possible symptoms of hyperkalemia or high potassium include:

    A weak arm with no muscle, indicating muscle weakness

    Muscle Weakness

    Muscle weakness can also be a sign of hyperkalemia, just as it can be a sign of hypokalemia. As potassium levels rise, there can initially be increased contractions and cause spasms and twitches.

    However, as the potassium level continues to rise, skeletal muscle excitability decreases, resulting in muscle weakness and even paralysis.

    A cardiac monitor showing ventricular tachycardia

    Cardiac Arrhythmias

    Symptoms of cardiac arrhythmias may occur if the patient is experiencing an arrhythmia, such as palpitations, chest pain, Shortness of breath, dizziness, or syncope.

    The colon with liquid diarrhea dripping out

    GI Symptoms

    High potassium levels can affect the smooth muscles of the GI tract, leading to nausea, vomiting, and possibly abdominal pain/cramping or diarrhea.

    A hand with blue electric bolts indicating tingling

    Paresthesias

    Like with hypokalemia, hyperkalemia can also cause numbness or tingling, typically in the extremities or the face.

    A kidney with low fluid levels

    Shortness of breath

    This is usually only in severe cases with severe muscle fatigue of the respiratory muscles, and the patient may even need to be intubated.

    A silhouette of a head with red and orange markings above the head, indicating anxiety

    Anxiety & Irritability

    High potassium levels can also agitate the central nervous system, leading to anxiety or restlessness.

    PHYSICAL EXAM

    The physical assessment of a patient with hyperkalemia will also depend on the severity of the potassium and other factors, but most patients will have no specific physical findings.

    Vital Signs

    • HR: May be fast or slow, depending on any arrhythmias. It may also be abnormal.
    • BP: Severe hyperkalemia can cause hypotension.
    • Respirations: usually normal, but may be increased or decreased if respiratory failure is present
    • SPO2: Usually normal
    • Temp: Normal

    Inspection

    • Abdominal distention or bloating
    • Bradycardia or arrhythmias on the monitor
    • Respiratory distress in severe cases
    • Patient may appear anxious or irritable, restless, or even confused

    Auscultation

    • Listen for slow or irregular heart rhythm, which may be caused by ectopy or arrhythmia from the hyperkalemia. May also have diminished or absent S3 and S4 heart sounds.
    a gloved hand palpating unspecified skin

    Palpation

    • Muscle weakness in the lower or upper extremities, particularly in the legs. These muscles may be tender to palpation.
    • Weak or thready pulses in the extremities (radial pulse)
    • Abdominal tenderness or discomfort

    Treatment for Hyperkalemia

    The treatment for hyperkalemia depends on the underlying cause, severity, and serum potassium level.

    When you get your patient’s results back, and they show hyperkalemia, especially >5.5 mEq/L, then follow the following general interventions:

    Assess the Patient

    Ensure they don’t have any symptoms and are stable, including recent vital signs.

    Cardiac Monitor

    Make sure your patient is on the cardiac monitor. Obtain an ECG if it still needs to be done. Close cardiac monitoring is essential when infusing electrolytes through the IV as well, as some electrolytes like calcium are essential in the treatment for hyperkalemia!

    Notify the Provider

    Notify the provider of the potassium levels, your assessment, and their cardiac rhythm. The treatment for hyperkalemia will be ordered by them!

    Ensure IV access

    Make sure there is at least one IV site, but place a second line if the hyperkalemia is severe.

    Evaluate Medications

    Evaluate if they are on any medications which may lead to hyperkalemia listed above.

    Administer Treatment For Hyperkalemia

    Administer medications that are ordered (discussed below).

    Treatment for Hyperkalemia

    The treatment of hyperkalemia will depend on how severe the level is and any symptoms or cardiac arrhythmias the patient is currently experiencing. The patient’s Provider team will order this. Treatment generally includes:

    The kidneys, with the left one transected so you can see the inside

    Address Underlying Causes

    Identifying and addressing the underlying causes of hyperkalemia. The first thing would be to look at their renal function on their labs – if it is elevated, the high potassium level is likely true. Ensure it is true hyperkalemia instead of pseudohyperkalemia as above.

    A bottle of potassium supplements

    Avoid More Potassium

    Avoid potassium supplements or foods rich in potassium until the potassium has normalized. All medications which can worsen hyperkalemia should be stopped.

    A 10-ml vial of calcium gluconse 10% with 10mL drawn up into a syringe

    IV Calcium

    Calcium is a very important part of the treatment for hyperkalemia. When given, it stabilizes cardiac conduction and decreases the risk of arrhythmias such as Vfib or VTACH.

    Calcium gluconate is preferred, with the dose being 1,000mg (10mL of 10% solution) infused over 2-3 minutes. This dose can be repeated if ECG changes persist.

    As with any electrolyte, your patient should be on the cardiac monitor during this infusion.

    What about Calcium Chloride?

    Calcium chloride (from the code cart) can also be given in a similar dose (500-1000mg).  This does actually deliver 3-times the concentration of elemental calcium. However, it does irritate the vein and can cause tissue necrosis if extravasation occurs.

    IV inuslin bottle with insulin syringe drawn up to 10 units

    IV Insulin

    IV insulin is given to all patients (not just patients with diabetes) with moderate to severe hyperkalemia when dialysis is not readily available/indicated, since insulin drives potassium into the cells. This is a temporary fix but will decrease potassium levels by about 1 mEq/L pretty quickly, lasting for about 4-6 hours. The dose may need to be repeated at that time.

    Please note this should be given with dextrose so it doesn’t cause hypoglycemia. Patients who’s glucose is > 250 can receive the insulin alone.

    Glucose monitoring should be monitored every hour for 5-6 hours.

    A code cart box of dextrose 50% with the auto-injector ready to inject

    IV Dextrose

    Dextrose is given with insulin to prevent hypoglycemia but can also lead to endogenous insulin secretion, which further enhances the potassium-reducing effect.

    The dosage is typically 25gm, or 1 full amp (the total amount in the code cart). This is pushed slowly and is very thick and sticky.

    Even with one amp given, hypoglycemia still occurs in many patients. It’s recommended to start a 10% dextrose infusion at 50-75ml/hr until 5-6 hours after administering the insulin.

    A person with a nebulizer on their face

    Beta-2 Adrenergic Agonist

    Beta-agonists, such as albuterol, are sometimes used as a treatment for hyperkalemia to cause a shift of potassium into the cells (similar to the effect of insulin). This is not always ordered but should be considered in patients with significant symptoms or ECG changes despite the above treatment.

    Beta-agonists can reduce potassium levels by 0.5 – 1.5 mEq/L, and is usually given in an hour-long treatment. SubQ Terbutaline is an alternative to albuterol.

    This will also increase heart rate, and patients with heart disease and at risk for cardiac complications may be better off not getting a beta-agonist.

    A code cart box of sodium bicarb with the auto-injector ready to inject

    IV Sodium Bicarb

    Sodium bicarbonate can reduce potassium levels in patients with metabolic acidosis. 1 amp (50 mEq) can be given in 50ml, or alternatively 150mEq can be given in 1 L of 5% Dextrose over 2-4 hours.

    This treatment for hyperkalemia should be limited to patients with metabolic acidosis, and multiple doses can lead to hypernatremia.

    A bottle of kayexalate

    Remove Potassium from the Body

    Shifting the potassium into the cells is a great short-term solution to prevent complications from hyperkalemia. Still, the true treatment for hyperkalemia is removing excess potassium from the body.

    Removing potassium from the body is done in 3 main ways.

    1. Through the Urine: Giving loop diuretics, like Lasix, to patients who do not have severe kidney failure can help excrete excess potassium in the urine. This is often given in addition to IV fluids to maintain fluid balance (unless they are hypervolemic to begin with).
    2. Through the Stool: The administration of potassium-binders is standard to remove excess potassium. Traditionally this was usually Kayexalate (sodium polystyrene sulfonate), and is still often used. HOWEVER, there is newer cation exchangers that are preferred with less complications – namely Patiromer (Veltassa) or Sodium Zirocinum Cyclosilicate (SZC). Veltassa is preferred since it has a more rapid onset and is less likely to cause bowel necrosis (a rare complication from Kayexlate).If the patient is NPO for whatever reason, these can also be given as an enema.
    3. Through a Machine: Hemodialysis should be done in patients with severe kidney function impairment and is usually the best option for severe hyperkalemia, especially if the patient already has dialysis access or is newly diagnosed with severe renal failure.

    Monitoring after Treatment for Hyperkalemia:

    Patients with hyperkalemia need good monitoring, especially if they have moderate to severe hyperkalemia.

    A Gold top blood vial filled with blood

    Potassium Levels

    Potassium levels will be redrawn and assessed depending on the severity and what type of treatment for hyperkalemia was ordered.

    Mild to moderate levels can be rechecked in 4-6 hours, but severe hyperkalemia may need to be checked more frequently.

    A Gold top blood vial filled with blood

    Glucose Levels

    If insulin is given, glucose levels must be checked hourly for 4-6 hours, as hypoglycemia is common (even if you administer dextrose).

    A Gold top blood vial filled with blood

    Other Labs

    Closely monitor the patient’s renal function (BUN & Creatinine), other electrolytes, and acid-base balance (CO2).

    A Gold top blood vial filled with blood

    Cardiac Monitoring

    As discussed, high potassium levels can lead to bradycardia and arrhythmias. Continuous cardiac monitoring should be maintained, and intermittent ECGs may also be warranted.

    A Gold top blood vial filled with blood

    Respiratory Function

    Severe hyperkalemia can cause respiratory failure, so monitoring their breathing, lung sounds, respiratory rate, and pulse ox is important.

    A Gold top blood vial filled with blood

    Vital Signs

    Vital signs should be checked per facility protocol.

    A graduated cylinder with urine in it

    Urine Output

    Monitoring urine output is important, especially in patients where loop diuretics are given, and potassium is being wasted through the kidneys.

    Hyperkalemia and Cardiac Arrhythmias

    Potassium is very important in the heart’s conductive system and for each heartbeat. The higher the potassium level, the more likely ECG changes may be seen, and the higher chance that an arrhythmia may occur.

    The more common arrhythmias associated with hyperkalemia are sinus bradycardia, AV blocks, VTACH, Vfib, and asystole.

    On the ECG, hyperkalemia can manifest in a few ways, including:

    • P Waves: Decreased amplitude of P waves is common
    • PR interval: The PR interval is prolonged and delayed, indicating slower transit of the electrical impulse from the SA node through the AV node.
    • QRS: The QRS often widens with hyperkalemia
    • T waves: Tall peaked “tented Ts” are common with hyperkalemia.

    Whenever there are ECG changes, the treatment for hyperkalemia becomes even more essential, as patients with ECG changes are more likely to experience deadly arrhythmias.

    The ECG changes seen on the PQRST with hyperkalemia, which includes P wave flattening, PR prolongation, QRS widening, and Tented or peaked T waves

    Want to learn more?

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    In conclusion, nurses should have an essential understanding of electrolyte abnormalities and the treatment for hyperkalemia.

    Through medications that protect the patient from cardiac arrhythmias (like calcium), medications that shift potassium into cells temporarily (like insulin, albuterol, or sodium bicarb), and treatments for hyperkalemia that remove potassium from the body (like Lasix, Kayexalate, or dialysis), we can successfully reduce our patient’s potassium and save their lives!

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