eMedicine Specialties > Emergency Medicine > Endocrine & Metabolic

Hyperkalemia: Follow-up

Author: David Garth, MD, Attending Physician, Department of Emergency Medicine, Mary Washington Hospital
Contributor Information and Disclosures

Updated: Aug 6, 2009

Follow-up

Further Inpatient Care

  • Order continuous cardiac monitoring for patients who are hyperkalemic.
  • Definitive therapy is dialysis in patients with renal failure or when pharmacologic therapy is not sufficient. Any patient with significantly elevated potassium levels should undergo dialysis, as pharmacologic therapy alone is not likely to adequately bring down the potassium levels in a timely fashion.
  • Monitor serial potassium levels.
  • Resolve acid-base problems.
  • Correct coexistent electrolyte disturbances.
  • Treat digoxin toxicity, if present.

Further Outpatient Care

  • Adjust diet to decrease potassium dietary load.
  • Adjust medications that predispose to or exacerbate hyperkalemia.
  • Repeat potassium level tests in 2-3 days.
  • Reevaluate renal function if signs of renal insufficiency are present.

Transfer

  • If unable to correct hyperkalemia with pharmacologic therapy and dialysis is unavailable, stabilize the patient and transfer to a center where dialysis can be performed.

Deterrence/Prevention

  • Avoid foods high in potassium.
  • Avoid medications that predispose to hyperkalemia.

Complications

  • Life-threatening cardiac arrhythmias may ensue.
  • Hypokalemia may result from the treatment of hyperkalemia.

Prognosis

  • Expect full resolution with correction of the underlying etiology.
  • Reduction of plasma potassium should begin within the first hour of initiation of treatment.

Patient Education

  • Pursue diet modification.
  • Discontinue use of medications that may worsen hyperkalemia.
  • Encourage adherence to dialysis schedule if patient is noncompliant.

Miscellaneous

Medicolegal Pitfalls

  • Ascertain whether the elevated potassium level is real or factitious. In a patient who does not have a predisposition to hyperkalemia, repeat the blood test before any actions are taken to bring down the potassium levels unless ECG changes are present.
  • Continuous ECG monitoring is essential if the patient is found to be hyperkalemic.
  • An ECG is essential to assess for cardiac conduction disturbances related to hyperkalemia.
  • Liability is associated with failure to order the ECG quickly or failure to recognize and treat the condition based on the ECG. Severe hyperkalemia with ECG changes is a life-threatening emergency. Intravenous calcium is the initial treatment of choice to stabilize the cardiac membrane.
  • Liability also can result from a delay in instituting definitive therapy after initial successful stabilization of the patient's condition. Medications, such as calcium, insulin, glucose, and sodium bicarbonate, are temporizing measures. Definitive loss of excess potassium can be achieved only with resin-binding agents, dialysis, or increased renal excretion. Begin administration of a resin-binding agent soon after the other drugs have been administered.
  • Watch for overcorrection of potassium level.
  • Liability may result from failure to adjust therapy for concurrent conditions. For example, in diabetic ketoacidosis (DKA) and in many other types of metabolic acidosis, the extracellular potassium level is elevated, yet the patient may have a total body deficit of potassium. Once the clinician initiates therapy for DKA, the extracellular potassium level decreases spontaneously.
  • If the patient is taking digoxin, look for evidence of digitalis toxicity.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of the previous chief editor, Rick Kulkarni, MD, to this article.



More on Hyperkalemia

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Multimedia: Hyperkalemia
References
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Further Reading

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Keywords

hyperkalemia, high potassium level, electrolyte imbalance, sodium-potassium pump, potassium level greater than 5.5 mEq/L, acute renal failure, chronic renal failure, potassium-sparing diuretics, urinary obstruction, sickle cell disease, Addison disease, systemic lupus erythematosus, SLE, rhabdomyolysis, hemolysis, acidosis, acute digitalis toxicity, beta-blockers toxicity, succinylcholine toxicity, pseudohyperkalemia

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Contributor Information and Disclosures

Author

David Garth, MD, Attending Physician, Department of Emergency Medicine, Mary Washington Hospital
David Garth, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Howard A Bessen, MD, Professor of Medicine, Department of Emergency Medicine, UCLA School of Medicine; Program Director, Harbor-UCLA Medical Center
Howard A Bessen, MD is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

 
 
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