Pediatric Hyperkalemia Workup

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

Laboratory Studies

Laboratory studies depend on the etiology of hyperkalemia but may include the following:

  • Serum electrolyte tests
  • Serum BUN and creatinine tests
  • Urinalysis (UA)

Depending on the etiology or on clinical suspicion, other studies to consider include the following:

  • Arterial or free-flowing venous blood gas sampling (for acid-base disorders): Capillary blood gas sampling should not routinely be used to evaluate for hyperkalemia due to significant risks of factitious hyperkalemia.
  • Serum uric acid and phosphorous tests (for tumor lysis syndrome)
  • Serum creatinine phosphokinase (CPK) and calcium measurements (for rhabdomyolysis)
  • Urine myoglobin test (for crush injury or rhabdomyolysis; suspect if UA reveals blood in the urine but no RBCs are seen on urine microscopy)
  • Specific drug level tests for suspected toxicity (digoxin)
  • CBC count (for thrombocytosis, leukocytosis, or malignancy)
  • Urine electrolyte tests, including potassium and osmolality (osm) tests
  • Plasma osm test

When the etiology of hyperkalemia remains unclear, calculation of the transtubular potassium gradient (TTKG) using the following formula may be useful: TTKG = (K+ urine X Osm plasma)/(K+ plasma X Osm urine)

The normal TTKG varies from 5-15. In the setting of hyperkalemia with normal renal excretion of potassium, the TTKG should be greater than 10. A TTKG of less than 8 in the setting of hyperkalemia implies inadequate potassium excretion, which is usually secondary to aldosterone deficiency or unresponsiveness. Checking a serum aldosterone level may be helpful.

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Imaging Studies

Imaging studies are not generally indicated, except to assess the primary disease state (eg, excluding obstructive uropathy as a cause for acute renal failure).

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Other Tests

An ECG is essential in all children in whom hyperkalemia is suspected. ECG reveals the sequence of changes as follows:

Serum K+ 5.5-6.5 mEq/L - Tall, peaked T waves with narrow base, best seen in precordial leads (as is shown in the image below)

Peaked T waves. Peaked T waves.

Serum K+ 6.5-8.0 mEq/L - Peaked T waves, prolonged PR interval, decreased or disappearing P wave, widening of QRS, amplified R wave

Serum K+ greater than 8.0 mEq/L - Absence of P wave; progressive QRS widening, intraventricular/fascicular/bundle branch blocks; progressive widening of QRS, eventually merging with the T wave just before cardiac arrest, forming the sine wave pattern (as is shown in the image below)

Sinusoidal wave. Sinusoidal wave.
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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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