Pediatric Hyperkalemia Clinical Presentation

  • Author: Michael J Verive, MD; Chief Editor: Timothy E Corden, MD   more...
 
Updated: Nov 14, 2011
 

History

History for a previously well child with acute hyperkalemia should focus on how the blood sample was obtained, potassium intake or recent blood product transfusion, risk factors for transcellular shift of potassium (acidosis) or tissue death/necrosis, medication use (by the child, other family members, pets, etc) associated with hyperkalemia, and presence or signs of renal insufficiency.

Specific questions may be focused on the following:

  • Urine output (last void or number of wet diapers) and fluid intake
  • Cola-colored urine (which may indicate acute glomerulonephritis)
  • Bloody stool (which may indicate hemolytic-uremic syndrome [HUS])
  • Presence of drugs in the household (or used by recent visitors), such as potassium preparations, digoxin, and diuretics
  • Any history of trauma (crush injuries) or thermal injury (burns)

Medical history, family history, and review of systems should be explored for any of the following:

  • Acute or chronic renal failure
  • Hypertension
  • Diabetes
  • Adrenogenital syndromes
  • Malignancy (tumor lysis syndrome)

Family history (hyperkalemic periodic paralysis, miscarriages, deaths of very young siblings)

  • Neuromuscular disorders
  • Malignant hyperthermia
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Physical

High potassium levels interfere with repolarization of the cellular membrane following completion of the action potential. Findings depend on the degree of hyperkalemia and primarily relate to the deleterious effects of elevated plasma potassium levels on cardiac conduction. Children with hyperkalemia can present with cardiac arrest due to wide-complex tachycardia or ventricular fibrillation.

Symptoms short of circulatory collapse/cardiac arrest include respiratory failure and weakness that progresses to paralysis. Patients may report nausea, vomiting, and paresthesias (eg, tingling). Most often, patients with hyperkalemia are asymptomatic, with the first clinical manifestation of the condition either ECG changes (peaked T waves) or sudden cardiac arrest.

Nonspecific findings can include muscle weakness (skeletal, respiratory), fatigue, ileus with hypoactive or absent bowel sounds, and depression.

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Causes

Although the etiology of hyperkalemia can be multifactorial, differential diagnoses include fictitious hyperkalemia and hyperkalemia due to increased potassium intake, transcellular potassium shift, or decreased potassium excretion.

  • Fictitious hyperkalemia
    • Hemolysis, tissue lysis, or tissue ischemia during phlebotomy
    • Contamination of blood sample with potassium-containing fluids
    • Thrombocytosis or leukocytosis (affects serum K+ but not plasma K+)
  • Hyperkalemia due to increased K+ intake
    • Blood transfusion (increasing risk with increased duration of cell storage)
    • Intravenous (IV) or oral potassium
    • Maintenance K+ in IV or oral solutions combined with decreased renal function
  • Hyperkalemia due to transcellular K+ shift
    • Metabolic acidosis
    • Beta-adrenergic blockade[9, 10]
    • Acute tubular necrosis
    • Electrical burns
    • Thermal burns
    • Cell depolarization
    • Head trauma
    • Rhabdomyolysis
    • Digitalis toxicity
    • Fluoride toxicity[11]
    • Cyclosporin A[12]
    • Methotrexate[13]
    • Propofol infusion syndrome
    • Tumor lysis syndrome
    • Succinylcholine use in a child with neuromuscular disease, prolonged bed rest (including patients in ICUs), or more than 24 hours after crush or burn injury[14]
  • Hyperkalemia due to decreased K+ excretion
    • Acute renal failure
    • Primary adrenal disease (Addison disease, salt-wasting congenital adrenal hyperplasia)
    • Hyporeninemic hypoaldosteronism
    • Renal tubular disease
  • Medications (eg, potassium sparing diuretics, ACE inhibitors, angiotensin II blockers, trimethoprim, nonsteroidal anti-inflammatory agents [NSAIDs])
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Contributor Information and Disclosures
Author

Michael J Verive, MD  Medical Director, Pediatric Intensive Care, Department of Pediatrics, St Mary's Hospital for Women and Children

Michael J Verive, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, Pediatric Sedation, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

G Patricia Cantwell, MD  FCCM, Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami, Leonard M Miller School of Medicine; Medical Director, Palliative Care Team, Director, Pediatric Critical Care Transport, Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Manager, FEMA, Urban Search and Rescue, South Florida, Task Force 2; Pediatric Medical Director, Tilli Kids – Pediatric Initiative, Division of Hospice Care Southeast Florida, Inc

G Patricia Cantwell, MD is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Barry J Evans, MD  Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Mary E Cataletto, MD  Director of Children's Sleep Services, Winthrop Sleep Disorders Center, Mineola, NY; Professor of Clinical Pediatrics, State University of New York at Stony Brook, Stony Brook, NY

Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians

Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Timothy E Corden, MD  Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, and Wisconsin Medical Society

Disclosure: Nothing to disclose.

References

  1. Shaffer SG, Kilbride HW, Hayen LK, Meade VM, Warady BA. Hyperkalemia in very low birth weight infants. J Pediatr. Aug 1992;121(2):275-9. [Medline].

  2. Bhananker SM, Ramamoorthy C, Geiduschek JM, et al. Anesthesia-related cardiac arrest in children: update from the Pediatric Perioperative Cardiac Arrest Registry. Anesth Analg. Aug 2007;105(2):344-50. [Medline].

  3. Papaioannou V, Dragoumanis C, Theodorou V, Pneumatikos I. The propofol infusion 'syndrome' in intensive care unit: from pathophysiology to prophylaxis and treatment. Acta Anaesthesiol Belg. 2008;59(2):79-86. [Medline].

  4. Schweiger B, Moriarty MW, Cadnapaphornchai MA. Case report: severe neonatal hyperkalemia due to pseudohypoaldosteronism type 1. Curr Opin Pediatr. Apr 2009;21(2):269-71. [Medline].

  5. Mattu A, Brady WJ, Robinson DA. Electrocardiographic manifestations of hyperkalemia. Am J Emerg Med. Oct 2000;18(6):721-9. [Medline].

  6. Lorenz JM, Kleinman LI, Markarian K. Potassium metabolism in extremely low birth weight infants in the first week of life. J Pediatr. Jul 1997;131(1 Pt 1):81-6. [Medline].

  7. Schweiger B, Moriarty MW, Cadnapaphornchai MA. Case report: severe neonatal hyperkalemia due to pseudohypoaldosteronism type 1. Curr Opin Pediatr. Apr 2009;21(2):269-71. [Medline].

  8. Gurnaney H, Brown A, Litman RS. Malignant hyperthermia and muscular dystrophies. Anesth Analg. Oct 2009;109(4):1043-8. [Medline].

  9. Sánchez-Carpintero I, Ruiz-Rodriguez R, López-Gutiérrez JC. Propranolol in the treatment of infantile hemangioma: clinical effectiveness, risks, and recommendations. Actas Dermosifiliogr. Jul 18 2011;[Medline].

  10. Pavlakovic H, Kietz S, Lauerer P, Zutt M, Lakomek M. Hyperkalemia complicating propranolol treatment of an infantile hemangioma. Pediatrics. Dec 2010;126(6):e1589-93. [Medline].

  11. Cummings CC, McIvor ME. Fluoride-induced hyperkalemia: the role of Ca2+-dependent K+ channels. Am J Emerg Med. Jan 1988;6(1):1-3. [Medline].

  12. Suzuki H, Terai M, Hamada H, Honda T, Suenaga T, Takeuchi T, et al. Cyclosporin A treatment for Kawasaki disease refractory to initial and additional intravenous immunoglobulin. Pediatr Infect Dis J. Oct 2011;30(10):871-6. [Medline].

  13. Nowicki TS, Bjornard K, Kudlowitz D, Sandoval C, Jayabose S. Early recognition of renal toxicity of high-dose methotrexate therapy: a case report. J Pediatr Hematol Oncol. Dec 2008;30(12):950-2. [Medline].

  14. Piotrowski AJ, Fendler WM. Hyperkalemia and cardiac arrest following succinylcholine administration in a 16-year-old boy with acute nonlymphoblastic leukemia and sepsis. Pediatr Crit Care Med. Mar 2007;8(2):183-5. [Medline].

  15. [Guideline] Advanced life support. In: 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 2005 Nov 29;112(22 Suppl):III25-54. [Full Text].

  16. Bercovitz RS, Greffe BS, Hunger SP. Acute tumor lysis syndrome in a 7-month-old with hepatoblastoma. Curr Opin Pediatr. Nov 18 2009;[Medline].

  17. Behrman R, Kliegman R, Jenson H. Nelson Textbook of Pediatrics. 17th Ed. Philadelphia, PA: WB Saunders; 2004.

  18. Brenner B. Brenner & Rector's The Kidney. 7th ed. St Louis, MO: WB Saunders; 2004.

  19. Finberg L, Kravath R, Hellerstein S. Potassium. In: Water and Electrolytes in Pediatrics: Physiology, Pathophysiology, and Treatment. Philadelphia, PA: WB Saunders; 1993:70-1.

  20. Goldfrank LR, ed. Goldfrank's Toxicologic Emergencies. 6th ed. Stanford, CT: Appleton & Lange; 1998.

  21. Kokko, JP, Tannen RL. Potassium disorders. In: Fluids and Electrolytes. Philadelphia, PA: WB Saunders; 1990:195-300.

  22. Lieh-Lai, M, Asi-Bautista, M, Ling-McGeorge, K. Hyperkalemia. In: Pediatric Acute Care Handbook. Philadelphia, PA: Lippincott, Williams, & Wilkins; 1995.

  23. Maxwell MH, Kleeman CR. Maxwell and Kleeman's Clinical Disorders of Fluid and Electrolyte Metabolism. 5th Ed. New York, NY: McGraw-Hill; 1994.

  24. Odegard KC, DiNardo JA, Kussman BD, et al. The frequency of anesthesia-related cardiac arrests in patients with congenital heart disease undergoing cardiac surgery. Anesth Analg. Aug 2007;105(2):335-43. [Medline].

 
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Peaked T waves.
Sinusoidal wave.
Hyperkalemia diagnosis and treatment flow chart.
Table. Select Factors Affecting Plasma Potassium
Factor Effect on Plasma K+Mechanism
AldosteroneDecreaseIncreases sodium resorption, and increases K+ excretion
InsulinDecreaseStimulates K+ entry into cells by increasing sodium efflux (energy-dependent process)
Beta-adrenergic agentsDecreaseIncreases skeletal muscle uptake of K+
Alpha-adrenergic agentsIncreaseImpairs cellular K+ uptake
Acidosis (decreased pH)IncreaseImpairs cellular K+ uptake
Alkalosis (increased pH)DecreaseEnhances cellular K+ uptake
Cell damageIncreaseIntracellular K+ release
SuccinylcholineIncreaseCell membrane depolarization
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