Pediatric Hyperkalemia Medication

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

Medication Summary

Treatment for severe hyperkalemia consists of 3 steps: (1) immediate stabilization of the myocardial cell membrane, (2) rapidly shifting potassium intracellularly, and (3) enhancing total body potassium elimination (see Medical Care).

In addition, all sources of exogenous potassium should be immediately discontinued; including intravenous (IV) and oral (PO) potassium supplementation, total parenteral nutrition, and any blood product transfusion. Drugs associated with hyperkalemia should also be discontinued.

Albuterol and other beta-adrenergic agents induce the intracellular movement of potassium via the stimulation of the sodium/potassium–adenosine triphosphate (Na+/K+ -ATP) pump. Studies have shown that IV salbutamol (not available in the United States) is highly effective in lowering serum potassium levels. Some studies in adults and children using nebulized albuterol indicate that this method of therapy is effective in lowering serum potassium levels. However, peak response is unclear; therefore, it has not been established as the first line of therapy in severe hyperkalemia.

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Myocardium stabilizers

Class Summary

Calcium does not lower serum potassium levels. It is primarily used to protect the myocardium from the deleterious effects of hyperkalemia (ie, arrhythmias) by antagonizing the membrane actions of potassium.

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Calcium chloride

 

IV calcium is indicated in all cases of severe hyperkalemia (ie, >7 mEq/L), especially when accompanied by ECG changes. Calcium chloride contains about 3 times more elemental calcium than an equal volume of calcium gluconate. Therefore, when hyperkalemia is accompanied by hemodynamic compromise, calcium chloride is preferred over calcium gluconate.

Administration of calcium should be accompanied by the use of other therapies that actually help lower the K+ serum levels.

Other calcium salts (eg, glubionate, gluceptate) have even less elemental calcium than calcium gluconate and are generally not recommended for therapy of hyperkalemia. Calcium chloride 1 g = 270 mg (13.5 mEq) of elemental calcium.

Calcium gluconate 1 g = 90 mg (4.5 mEq) of elemental calcium.

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Intracellular transporters

Class Summary

Regular insulin and glucose cause a transcellular shift of potassium into muscle cells, thereby temporarily lowering K+ serum levels.

Insulin and dextrose, IV

 

Regular insulin presence results in intracellular movement of glucose, followed by K+ entry into muscle cells. Although effect is almost immediate, it is temporary, and, therefore, should be followed by therapy that actually enhances potassium clearance (eg, sodium polystyrene sulfonate).

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Alkalinizing agents

Class Summary

Sodium bicarbonate IV is used as a buffer that breaks down to water and carbon dioxide after binding free hydrogen ions.

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Sodium bicarbonate

 

IV infusion helps shift K+ into cells, further lowering serum K+ levels. Can be considered in treatment of hyperkalemia even in absence of metabolic acidosis. Also increases sodium delivery to the kidney, which assists in potassium excretion.

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Exchange resins

Class Summary

Sodium polystyrene sulfonate is an exchange resin that can be used to treat mild-to-moderate hyperkalemia. Each mEq of potassium is exchanged for 1 mEq of sodium.

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Sodium polystyrene sulfonate (Kayexalate)

 

Exchanges sodium for potassium and binds it in the gut, primarily in large intestine, and decreases total body potassium. Onset of action after PO administration ranges from 2-12 hours and is longer when administered PR.

Do not use as a first-line therapy for severe life-threatening hyperkalemia. Use in second stage of therapy to reduce total body potassium.

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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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