This document discusses hyperkalemia, or high levels of potassium in the blood. It begins by listing the normal potassium range and then describes some common causes of hyperkalemia, including the release of potassium from cells due to conditions like rhabdomyolysis or tumor lysis syndrome, and decreased renal excretion of potassium due to renal failure or medications. Clinical manifestations of hyperkalemia are then outlined, such as weakness, paralysis, arrhythmias, and ECG changes including peaked T waves. The document concludes by presenting two case histories of patients with hyperkalemia and CKD and recommends treatment approaches starting with calcium gluconate for cardiac instability and then other options to increase potassium excretion or remove it through dialysis if

1. HYPERKALEMIA
DR ANKIT GAJJAR
MD, IDCCM, IFCCM, EDIC
CONSULTANT INTENSIVIST

2. Potassium
•Normal range : 3.5 – 5 mEq/L

3. Causes of Hyperkalemia
- Potassium release from cells
- Decreased renal loss
- Iatrogenic

4. Potassium release from cells
• Intravascular hemolysis
• Tumor Lysis Syndrome
• Rhabdomyolysis
• Metabolic acidosis
• Severe Digitalis toxicity
• Beta-blockers
• Succinylcholine; especially in case massive trauma, burns or
neuromuscular disease

5. Decreased renal loss
• Renal failure
• Decreased distal flow
• Decreased K+ secretion
Impaired Na+ reabsorption
adrenal insufficiency
drugs: ACEi, NSAIDS, heparin, K+-sparing
diuretics, trimethoprim, pentamidine
distal type 4 RTA

6. Clinical Manifestations
• Weakness, which can progress to flaccid paralysis and
hypoventilation.
Secondary to prolonged partial depolarization from
the elevated K+ , which impairs membrane
excitability.
• Metabolic acidosis, which further increases K+
Secondary to hyperkalemia impairing renal
ammoniagenesis and absorption, and thus net acid
excretion.
• Altered electrical activity of heart, cardiac
arrhythmias.

7. ECG Changes of Hyperkalemia
• Easily Distinguished ECG signs:
– peaked T wave.
– prolongation of the PR interval
– ST changes (which may mimic myocardial infarction)
– very wide QRS, which may progress to a sine wave pattern and
asystole.
• Patients may have severe hyperkalemia with minimal ECG
changes, and prominent ECG changes with mild hyperkalemia.

8. ECG changes
All of the illustrations are from lead V3.
A. Serum [K+] = 6.8 mEq/L
note the peaked T waves together with
normal sinus rhythm.
B. Serum [K+] = 8.9 mEq/L
note the peaked T waves and absent P
waves.
C. Serum [K+] = >8.9 mEq/L
note the classic sine wave with absent P
waves, marked prolongation of the QRS
complex, and peaked T waves

9. Case history
• 55 years old female
A.
H/O fever
CKD
On evaluation,
S.K+ - 6.5
No ECG changes
What next?
B.
H/O fever
CKD
On evaluation,
S.K+ - 6.5
ECG – peaked T wave
What next?

10. 1st Line option

11. OTHER THERAPIES
● Hypertonic saline, where calcium administration is
contraindicated
● NaHCO3 infusion – only in metabolic acidosis (pH < 7.2)
pts
- Need to consider side effects like volume
overload, hypernatremia, hypocalcemia
- Dose - ?????
K-BIND SACHETS???
• HEMODIALYSIS.
. Peritoneal is only 15% as effective as hemodialysis

12. ● STEP 1 – Calcium Gluconate, if cardiac
instability
● STEP 2 – Discontinue offending agent
● STEP 3 – GI drip (1st choice)
- B2 agonist nebulisation
- NaHCO3 if Metabolic acidosis (Ph<7.2)
● STEP 4 – Increase potassium excretion
- Loop diuretics
- K BIND
● STEP 5 – Dialysis

13. THANK YOU