Hyperkalemia Policy

• Description

  • This policy defines when to check potassium before a procedure and how to proceed with elevated patient potassium levels.

• Rationale

  • Patients with hyperkalemia are at increased risk of adverse events when undergoing procedures, especially procedures that may irritate the right atrium. 

• Definitions

  • Moderate Hyperkalemia:  

    • K= 5.5 - 6.4 mmol/L without ECG changes

  • Severe Hyperkalemia (Hyperkalemia Emergency): 

    • K > 6.4 mmol/L

    • K > 6.0 mmol/L with ECG changes or symptoms of hyperkalemia (weakness, flaccid paralysis, palpitations, or paresthesia)

    • K > 5.5 and renal impairment (CrCl < 30 ml/min) and ongoing tissue breakdown (rhabdomyolysis, tumor lysis, gut ischemia) or increased potassium absorption due to GI bleed. 

• Policy & Procedure

  • Severe Hyperkalemia (Hyperkalemia Emergency)

    • All procedures will be canceled, delayed, or rescheduled.

    • Exceptions:

      1. Non-tunneled lines where procedure service cannot obtain access (to be performed without moderate sedation)

      2. Life-saving procedures (IE emergent embolization or placement of unconventional dialysis access for patient with no other access options) with anesthesia present

• • Moderate Hyperkalemia

    • Obtain ECG

      1. If abnormal, follow the policy for severe hyperkalemia

      2. If normal, follow nephrology guidance to lower potassium within 6-12 hours (to be performed by the primary team)

         1. • Consider dialysis in patients with reduced kidney function or ESRD

            • Zirconium cyclosilicate 10 g every 8 hours x 48 hours

            • Diuretics if hypervolemic

            • Modification or discontinuation of ACEI, ARB, spironolactone, or trimethoprim-sulfamethoxazole dosing in patients who are not receiving chronic dialysis

            • Bicarbonate if metabolic acidosis present

            • Stop NSAIDs

            • Correct hypovolemia when present

            • Consider using potassium cation exchange resin such as zirconium cyclosilicate (outpatient or inpatient) or patiromer calcium on an outpatient basis.

      3. If normal and the case cannot be delayed, only proceed with a single agent and temporary line placement.

• • Laboratory Tests

    • All patients with hemodialysis require potassium levels on the procedure day.

David Mauro MD