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Pediatric Hyperkalemia Treatment & Management

  • Author: Michael J Verive, MD, FAAP; Chief Editor: Timothy E Corden, MD  more...
 
Updated: Jan 08, 2016
 

Medical Care

Hyperkalemia, by itself, is not a disease and is generally the result of diseases such as congenital adrenal hyperplasia, acute renal failure, rhabdomyolysis, or tumor lysis syndrome.

Hyperkalemia is a true medical emergency, with three primary goals of immediate management (in addition to prompt discontinuation of potassium-containing fluids and medications that lead to hyperkalemia), as summarized below.[17, 18]

Goals of management

Stabilization of myocardial cell membrane

Stabilize the myocardial cell membrane to prevent lethal cardiac arrhythmia (and to gain time to shift potassium intracellularly and enhance potassium elimination - Intravenous (IV) calcium chloride or gluconate

Enhancement of cellular uptake of potassium

This achieved with the following:

  • Sodium bicarbonate IV
  • Regular insulin and glucose IV
  • Beta-adrenergic agents, such as albuterol (used to manage hyperkalemia with variable results), terbutaline, dobutamine

Enhancement of total body potassium elimination

This achieved with the following:

  • Sodium polystyrene sulfonate (Kayexalate) orally (PO)/rectally (PR)
  • Furosemide (only if renal function is maintained)
  • Emergent hemodialysis

Clinical management

Arrhythmias due to hyperkalemia are very difficult to treat with defibrillation, epinephrine, or antiarrhythmic drugs without emergently lowering the serum potassium level.

After initial stabilization, further workup should be performed to diagnose the etiology of the hyperkalemia. Children with acquired Addison disease or other primary adrenal disease require stress-dose steroid supplementation and children with hypoaldosteronism require mineralocorticoid supplementation.

Emergent hemodialysis is sometimes necessary to treat severe symptomatic hyperkalemia that is resistant to drug therapy, particularly in patients without adequate renal function.

Even in patients with severe hyperkalemia and a high gradient, peritoneal dialysis (PD) is not as efficient as hemodialysis in the removal of potassium. Rates of removal with PD are almost equal to the removal rate using sodium polystyrene sulfonate (Kayexalate).

Continuous arteriovenous hemofiltration with dialysis (CAVHD) or continuous veno-venous hemofiltration with dialysis (CVVHD) have also been used to remove potassium. However, potassium removal with these methods is similar to that of PD and sodium polystyrene sulfonate (Kayexalate). CVVHD or CAVHD may be used for long-term removal of potassium, but in acute, severe, life-threatening hyperkalemia unresponsive to medical therapy, hemodialysis remains the procedure of choice.

Following emergent management and stabilization of hyperkalemia, the patient should be hospitalized, and further workup should be initiated to determine the inciting cause and to prevent recurrence.

Transfer

Patients with acute life-threatening hyperkalemia should receive care in a pediatric or neonatal ICU capable of providing emergent hemodialysis.

Any child who develops hyperkalemia as a result of renal failure should be referred to a pediatric nephrologist for continuing care.

Diet

Potassium intake must be closely monitored (and possibly restricted) in patients with renal failure.

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Surgical Care

Tumor debulking may be considered to decrease the risk of hyperkalemia from tumor lysis syndrome for solid tumors.[19]

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Consultations

Consultations with the following specialists may be necessary in cases of hyperkalemia that result from certain conditions or disease states:

  • Pediatric intensivist or neonatologist - Management of life-threatening hyperkalemia (hyperkalemia with ECG changes)
  • Nephrologist - Hyperkalemia associated with renal failure
  • Hematologist/oncologist - Hyperkalemia resulting from tumor lysis syndrome
  • Social services specialist - Children who develop hyperkalemia following unintentional ingestions or poisonings
  • Nutritional support specialist - Particularly for patients whose hyperkalemia is caused by renal failure, which requires close regulation of potassium and sodium intake
  • Endocrinologist - Patients with suspected mineralocorticoid abnormalities such as congenital adrenal hyperplasia
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Contributor Information and Disclosures
Author

Michael J Verive, MD, FAAP Pediatrician, UP Health System Portage

Michael J Verive, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, Society for Pediatric Sedation

Disclosure: Nothing to disclose.

Specialty Editor Board

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, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

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, Wisconsin Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

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/ Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Director, Palliative Care Team, Holtz Children's Hospital; Medical Manager, FEMA, South Florida Urban Search and Rescue, Task Force 2

G Patricia Cantwell, MD, FCCM 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, Wilderness Medical Society

Disclosure: Nothing to disclose.

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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
Aldosterone Decrease Increases sodium resorption, and increases K+ excretion
Insulin Decrease Stimulates K+ entry into cells by increasing sodium efflux (energy-dependent process)
Beta-adrenergic agents Decrease Increases skeletal muscle uptake of K+
Alpha-adrenergic agents Increase Impairs cellular K+ uptake
Acidosis (decreased pH) Increase Impairs cellular K+ uptake
Alkalosis (increased pH) Decrease Enhances cellular K+ uptake
Cell damage Increase Intracellular K+ release
Succinylcholine Increase Cell membrane depolarization
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