Hyperkalemia is a life-threatening electrolyte disturbance with significant implications for patient care. Despite its seriousness, several myths persist in clinical practice. In this article, we'll address these myths and provide evidence-based recommendations.
Introduction to hyperkalemia
Hyperkalemia affects 2.6-2.7% of the U.S. population and is associated with increased healthcare costs and mortality. Treatment usually involves stabilizing cardiac depolarization, shifting potassium intracellularly, and eliminating potassium from the body. EKG findings guide treatment urgency due to the risk of dysrhythmias. Read more "Be skilled in controlling POTASSIUM levels for patients with heart failure".
Myth #1: Kayexalate is safe and useful
Kayexalate (Sodium polystyrene sulfonate, SPS) has been used for decades despite limited evidence of efficacy.
- Studies show minor reductions in serum potassium, and it’s associated with serious gastrointestinal side effects like colonic necrosis.
- Newer resins like patiromer and sodium zirconium cyclosilicate are safer and more effective.
- SPS should not be routinely used in acute hyperkalemia management due to potential harm and lack of efficacy.
Myth #2: Lactated Ringer’s is contraindicated in hyperkalemia
Lactated Ringer’s (LR) contains a small amount of potassium (4-5 mEq/L) and is often avoided in hyperkalemia. However, studies show no significant difference in serum potassium levels between LR and normal saline (NS).
- LR may even be preferable due to a lower risk of hyperchloremic metabolic acidosis.
- LR is safe and appropriate for use in hyperkalemia.
Myth #3: EKG changes from hyperkalemia are predictable and reliable
EKG changes in hyperkalemia vary widely and are not always predictable. Severe hyperkalemia can occur without classic EKG changes, making EKG an important but not definitive tool.
- A normal EKG does not exclude hyperkalemia but is associated with a lower risk of adverse outcomes.
- EKG changes may help predict high-risk patients.
Myth #4: All patients with hyperkalemia should be treated with calcium
IV calcium stabilizes cardiac myocytes and is crucial in treating hyperkalemia-induced dysrhythmias. However, its use should be reserved for patients with EKG changes indicative of hyperkalemia, as it carries risks like soft tissue injury and exacerbation of digoxin toxicity. Use IV calcium judiciously.
Summary and clinical recommendations
Debunking myths surrounding hyperkalemia is essential for accurate and effective treatment.
- Avoid the routine use of SPS, consider LR as a safe option, use EKG judiciously, and administer calcium carefully.
- Always balance the benefits and risks when treating hyperkalemia.
References
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Gupta, A. A., Self, M., Mueller, M., Wardi, G., & Tainter, C. (2022). Dispelling myths and misconceptions about the treatment of acute hyperkalemia. The American journal of emergency medicine, 52, 85–91. https://doi.org/10.1016/j.ajem.2021.11.030
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