Pediatric Hyperkalemia Treatment & Management

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

Medical Care

Hyperkalemia is a true medical emergency, with 3 primary goals of immediate management (in addition to prompt discontinuation of potassium-containing fluids and medications that lead to hyperkalemia):[15]

  • 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
  • Enhance cellular uptake of potassium
    • Sodium bicarbonate IV
    • Regular insulin and glucose IV
    • Beta-adrenergic agents, such as albuterol (used to manage hyperkalemia with variable results), terbutaline, dobutamine
  • Enhancing total body potassium elimination
    • Sodium polystyrene sulfonate (Kayexalate) orally (PO)/rectally (PR)
    • Furosemide (only if renal function is maintained)
    • Emergent hemodialysis

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.
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Surgical Care

Tumor debulking may be considered to decrease the risk of hyperkalemia from tumor lysis syndrome for solid tumors.[16]

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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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Diet

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

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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

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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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