Management of Hyperkalaemia in Neonate



Canberra Health ServicesClinical Guideline Management of Hyperkalaemia in Neonates Contents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc59197676 \h 1Guideline Statement PAGEREF _Toc59197677 \h 2Scope PAGEREF _Toc59197678 \h 2Section 1 – Diagnostic Parameters PAGEREF _Toc59197679 \h 3Section 2 – Incidence and Complications PAGEREF _Toc59197680 \h 3Section 3 – Risk Factors PAGEREF _Toc59197681 \h 3Section 4 – Evaluation and Diagnosis PAGEREF _Toc59197682 \h 4Section 5 – Prevention PAGEREF _Toc59197683 \h 5Section 6 – Treatment PAGEREF _Toc59197684 \h 6Implementation PAGEREF _Toc59197685 \h 9Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc59197686 \h 10References PAGEREF _Toc59197687 \h 10Search Terms PAGEREF _Toc59197688 \h 11Guideline StatementBackgroundIncreased potassium levels (hyperkalaemia) is most commonly seen in extremely preterm neonates with or without impaired renal function. Neonatal hyperkalaemia usually peaks in the first 48 hours after birth before declining to normal potassium level by 72 to 96 hours after birth. It is important to recognise neonatal hyperkalaemia in a timely manner because it can lead to life threatening complications including arrhythmias and death.Key ObjectiveThe purpose of this document is to provide clinical guidance to detect, prevent and treat hyperkalaemia in the neonate. This guideline refers to neonates born in, transferred to, or admitted to the Canberra Health Services (CHS).Alerts It is important to recognise neonatal hyperkalaemia in a timely manner because it can lead to life threatening complications including arrhythmias and death.Any potassium level >6mmol/L is considered abnormal and warrants further considerationIf a neonate has a potassium level >6mmol/L, the neonatal Registrar must be notified immediatelyFor doses and guidelines regarding medication used in the treatment of hyperkalaemia mentioned in this document, please refer to the Neonatal Intensive Care Unit (NICU) Drug Manual, which can be found on the Policy Register. Back to Table of ContentsScopeThis document applies to neonates (neonates aged less than 28 days or less than 44 weeks corrected age) cared for in CHS.This document applies to the following CHS staff working within their scope of practice:Medical Officers Registered Nurses and MidwivesStudents working under supervision.Back to Table of ContentsSection 1 – Diagnostic ParametersThe following diagnostic parameters are used in this document:1Normal serum potassium level 3.5 to 6.0 mmol/LHyperkalaemia potassium level >6.0 mmol/LSignificant hyperkalaemia potassium level >7.0 mmol/L.Back to Table of Contents Section 2 – Incidence and ComplicationsHyperkalaemia with potassium level >6.5 mmol/L is common in extremely premature neonates <28 weeks gestation (Figure 1).Figure 1: incidence of hyperkalaemia in neonates <30 weeks gestation.2Elevated levels of potassium constitute a medical emergency due to the concentration-dependent effect on cardiac myocyte membrane potentials, resulting in potential arrhythmias. Hence treatment must be prompt and preferably sustained.1Reported mortality of neonates with hyperkalaemia (potassium level > 7.0 mmol/L) has ranged from 17-30% despite appropriate treatment, most secondary to cardiac arrhythmia or complications of prematurity.3,4Back to Table of Contents Section 3 – Risk FactorsThe most common risk factors of neonatal hyperkalaemia include: 2,5-11Increased production:HaemolysisBlood Transfusion with old bloodIntraventricular HaemorrhageDecreased clearance:Extreme Preterm (<28 weeks gestation)Acute Renal Failure e.g. in perinatal asphyxiaChronic Renal FailureOliguriaLow systemic blood flowTrans-cellular shift:AcidosisOther associations:Non- oliguric hyperkalaemiaIntraventricular HaemorrhageArtefact of collection process (e.g. due to haemolysis)Iatrogenic potassium administration (e.g. oral or Intravenous)?Side effect of medication (e.g. potassium sparing diuretics). HYPERLINK \l "Contents" Back to Table of ContentsSection 4 – Evaluation and DiagnosisExtremely Preterm neonates <28 weeks gestation should have electrolytes checked every 12 hours starting at 6 to 12 hours after birth until at least 48 hours of ageAny neonate with a high serum potassium level should have continuous cardio-respiratory monitoring if this is not already doneHeel prick samples may show falsely high potassium levels due to haemolysis in the sample. Venous samples may also show haemolysis depending on the difficulty of collection. Any doubtful result should be repeated as soon as possible with venous or ideally an arterial sample but repeat testing should not delay treatment if hyperkalaemia is clinically possibleA high serum potassium level after the first few days of life from a heel-prick in a neonate with normal renal function (normal creatinine level and urine output), normal renal tract anatomy and without an iatrogenic source of potassium is almost always a false result. Repeat a sample through a venipuncture specimen Any neonate diagnosed with true hyperkalaemia should be evaluated with a 12 lead Electrocardiogram (ECG)The common ECG changes seen with hyperkalaemia are (Figure 2-3):Potassium level between 5.5 and 6.5 mmol/L: Tall T waves with narrow base and shortening of QT intervalPotassium level between 6.5 to 8.0 mmol/L: Peaked T waves, prolonged PR interval, decreased or disappearing P wave, widening QRS complex, and amplified R wavePotassium level >8.0 mmol/L: Absent P wave, bundle branch block, progressive widening QRS complex that eventually merges with T wave to form a sinusoidal pattern. This is followed by ventricular fibrillation or asystoleFigure 2: Hyperkalaemia leads to tall peaked T waves, ventricular arrhythmias, widening of QRS then sine wave QRS complex (before cardiac arrest).Figure 3: Changes in ECG with increasing hyperkalaemia. Serum K values are mmol/l.1Please note that patients without ECG change but with hyperkalaemia from non-haemolysed blood should always be given appropriate treatment (see section 6).Back to Table of ContentsSection 5 – PreventionThe following may help to prevent hyperkalaemia:Appropriate fluid management in the initial 48 to72 hours after birthFrequent monitoring of serum potassium and electrolytes in at risk neoantesRestricting potassium intake in first 24 to 48 hours after birth especially in extremely preterm neonates.Back to Table of ContentsSection 6 – TreatmentThe aims of treatment are:To reduce chances of arrhythmia associated with :hyperkalaemiaTo redistribute potassium into the intracellular spaceTo remove potassium from the body.Treatment should begin at a potassium level of 6.5mmol/L. Rhythm disturbances are not usually seen unless potassium level is above 7.0 mmol/L.12 If treatment is not initiated until symptoms appear (or the serum level exceeds 7.0 mmol/L), the potential for success is reduced.13 Mortality rates may be as high as 80% once arrhythmias have appeared.14Table 1 below summarises the management options for hyperkalaemia.4,15-20 These options need to be discussed with the neonatology fellow or consultant on call. Please note that the prescription of the following infusions should be obtained using the drug calculation detailed in the Neonatal Intensive Care Unit (NICU) Drug Manual, which can be found on the Policy Register ().The treatment is divided into two options depending on the prescence/absence of ECG changes:6.1 Normal ECG:Serum Potassium level from non-haemolysed blood sampleManagementSerum potassium 6 to 6.4 mmol/L without ECG changesRepeat potassium level in 1 to 2 hourly using blood gas analyser (arterial specimen) and then continue to repeat potassium level 6 to 12 hourly if indicatedStop all potassium supplements, including Total Parenteral Nutrition (TPN) containing potassium Consider stopping medication that may be causing hyperkalaemiaSerum potassium 6.5 to 7.0 mmol/L without ECG changesRepeat potassium level 1 to 2 hourly using blood gas analyser (arterial specimen)Stop all potassium supplement (including TPN containing potassium) and medication that may be causing hyperkalaemiaStart first line treatment with Glucose-insulin infusion (0.15 U/kg/hour insulin in 25% dextrose given as an intravenous (IV) infusion (see NICU Drug Manual for details); monitor Blood glucose level (BGL)If potassium level rise persists despite the above treatment give salbutamol infusion 4 mcg/kg in 5mL of water for injection given over 20 minutes (repeat as necessary)Serum potassium >7 mmol/L with normal ECGStop all potassium supplement (including TPN containing potassium) and medication that may be causing hyperkalaemiaStart first line treatment with Glucose-insulin infusion (0.15 U/kg/hour insulin in 25% dextrose given as an intravenous (IV) infusion (see NICU Drug Manual for details); monitor Blood glucose level (BGL)If potassium level rise persists despite the above treatment give salbutamol infusion 4 mcg/kg in 5mL of water for injection given over 20 minutes (repeat as necessary)Refractory hyperkalaemia i.e. hyperkalaemia resistant to the above measuresConsider:Stop all potassium supplements (including TPN containing potassium) and medication that may be causing hyperkalaemiaGive the following immediately: IV bolus Elemental calcium 0.5 mmol/kg which equates to 2.3 mL/kg of UNDILUTED Calcium Gluconate 10%. Repeat as necessaryIf there is acidosis: give bicarbonate (8.4% NaHCO3 [mL] = weight [kg] x base deficit x 0.5 x 0.3) AFTER the calcium gluconate infusion is completed and flushed well. Alert: Do not give calcium and bicarbonate through the same lineGlucose-insulin infusion (0.15 U/kg/hour insulin in 25% dextrose given as an intravenous infusion; see NICU drug manual for details), monitor BGLSalbutamol infusion 4 mcg/kg in 5mL of water for injection given over 20 minutes (repeat as necessary).Consider the following treatments:Sodium Resonium - A (Sodium polystyrene sulfonate) 1g/kg per rectum (up to 6 hourly as necessary)Red cell transfusion with washed packed red cellsConsult paediatric renal physicians and consider dialysis in patients with ongoing renal impairment.6.2 Abnormal ECG:Serum Potassium level from non-haemolysed blood sampleManagementSerum potassium ≥6 with ECG changes Stop all potassium supplements (including TPN containing potassium) and medication that may be causing hyperkalaemiaGive the following immediately:IV bolus Elemental calcium 0.5 mmol/kg which equates to 2.3 mL/kg of UNDILUTED Calcium Gluconate 10%. Repeat as necessaryIf there is evidence of acidosis: give bicarbonate (8.4% NaHCO3 [mL] = weight [kg] x base deficit x 0.5 x 0.3) AFTER the calcium gluconate infusion is completed and flushed well. Alert :Do not give calcium and bicarbonate through the same IV- lineGlucose-insulin infusion (0.15 U/kg/hour insulin in 25% dextrose given as an intravenous infusion; see NICU drug manual for details), monitor BGLIf potassium level rise persists despite the above treatment, give Salbutamol infusion 4 mcg/kg in 5mL water over 20 minutes (repeat as necessary).Refractory hyperkalaemia i.e. hyperkalaemia resistant to the above measuresConsider:Stop all potassium supplements (including TPN containing potassium) and medication that may be causing hyperkalaemiaGive the following immediately: IV bolus Elemental calcium 0.5 mmol/kg which equates to 2.3 mL/kg of UNDILUTED Calcium Gluconate 10%. Repeat as necessary If there is acidosis: give bicarbonate (8.4% NaHCO3 [mL] = weight [kg] x base deficit x 0.5 x 0.3) AFTER the calcium gluconate infusion is completed and flushed well. Alert: Do not give calcium and bicarbonate through the same lineGlucose-insulin infusion (0.15 U/kg/hour insulin in 25% dextrose given as an intravenous infusion; see NICU drug manual for details), monitor BGLSalbutamol infusion 4 mcg/kg in 5mL of water for injection over 20 minutes (repeat as necessary).Consider the following treatments:Sodium Resonium - A (Sodium polystyrene sulfonate) 1g/kg per rectum (up to 6 hourly as necessary)Red cell transfusion with washed packed red cellsConsult paediatric renal physicians and consider dialysis in patients with ongoing renal impairment.Please note the following important information about management of hyperkalaemia:Always confirm hyperkalaemia by an arterial sample or a free flowing venous sample as heel prick samples are subject to errors due to haemolysisRepeat blood sampling should NOT delay treatment if it is requiredUse a 12 lead ECG instead of a strip from a continuous cardiac monitor to assess ECG changes when potassium level are abnormalAn abnormal ECG should be treated immediately with IV calcium gluconate as shown in Table 1 aboveClosely observe the urine output in neonates with hyperkalaemiaWatch for hyperglycaemia and hypoglycaemia if you treat a neonate with a glucose-insulin infusionWatch for rectal impaction and rectal perforation when using Resonium-A treatment as it is a slow acting ion exchange resin.Correct acidosis as it may increase hyperkalaemia by shifting potassium from intracellular to extracellular spaceDo not give calcium and bicarbonate through the same intravenous line as the solution will precipitate. Ensure line is flushed well between medicationsAlways correct concomitant hypocalcaemiaNever use Salbutamol ALONE for treatment of hyperkalaemiaSalbutamol can also be administered via inhalation. Potential side effects of Salbutamol include tachycardia, hypertension, tremor and hyperglycaemiaBack to Table of ContentsImplementation Implementation will be via:In-service education to staff caring for neonates in Centenary Hospital for Women and Children and at CHS. Staff will receive emails with updated information. All staff will have access to the Policy Register on Intranet to view the current policy. Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPolicies:Health Directorate Nursing and Midwifery Continuing Competence PolicyConsent and TreatmentPatient Identification and Procedure Matching PolicyMedication Handling PolicyProcedures:Healthcare Associated Infections Clinical ProcedurePatient Identification and Procedure Matching ProcedureBlood Collection using Heel Lance Device (Neonates) Procedure Venepuncture Blood Specimen Collection Procedure Blood Borne Virus: Occupational Risk Exposure Management Procedure Patient Identification – Pathology Specimen Labelling ProcedureBlood Glucose and Ketone Point-of-Care Testing ProcedureVenous and Arterial Access and Management in Neonatal Intensive Care ProcedureGuidelineNeonatal Hypoglycaemia GuidelineTotal Parental Nutrition in Neonates GuidelineManual:Neonatal Intensive Care Drug Manual ()LegislationHealth Records (Privacy and Access) Act 1997Human Rights Act 2004Work Health and Safety Act 2011Back to Table of ContentsReferencesMasilamani?K,?van der Voort?J. The management of acute hyperkalaemia in neonates and children. Archives of Disease in Childhood, 2012;97:376-380.Kluckow M, Evans N. Hypoperfusion, Hyperkalaemia and serum lactate in the Preterm infant. APS/SPR Conference 1998, Abstract No 1043.Leslie GI, Carman G, Arnold JD. Early neonatal hyperkalaemia in the extremely premature newborn infant. J Paediatr Child Health, 1990; 26(1): 58-61.Lui K, Thungappa U, Nair A, John E. Treatment with hypertonic dextrose and insulin in severe hyperkalaemia of immature infants. Acta Paediatr, 1992; 81(3): 213-6.Shaffer SG, Kilbride HW, Hayen LK, Meade VM, Warady BA. Hyperkalemia in very low birth weight infants. J Pediatr, 1992; 121(2): 275-9.Brion LP, Schwartz GJ, Campbell D, Fleischman AR. Early hyperkalaemia in very low birthweight infants in the absence of oliguria. Arch Dis Child, 1989; 64(2): 270-2.Shortland D, Trounce JQ, Levene MI. Hyperkalaemia, cardiac arrhythmias, and cerebral lesions in high risk neonates. Arch Dis Child, 1987; 62(11): 1139-43.Sato K, Kondo T, Iwao H, Honda S, Ueda K. Internal potassium shift in premature infants: cause of nonoliguric hyperkalemia. J Pediatr, 1995; 126(1): 109-13.Stefano JL, Norman ME, Morales MC, Goplerud JM, Mishra OP, Delivoria Papadopoulos M. Decreased erythrocyte Na+,K(+)-ATPase activity associated with cellular potassium loss in extremely low birth weight infants with nonoliguric hyperkalemia. J Pediatr, 1993; 122(2): 276-84.Gruskay J, Costarino AT, Polin RA, Baumgart S. Nonoliguric hyperkalemia in the premature infant weighing less than 1000 grams. J Pediatr, 1988; 113(2): 381-6.Lorenz JM, Kleinman LI, Markarian K. Potassium metabolism in extremely low birth weight infants in the first week of life. J Pediatr, 1997; 131: 81-6.Grammatikopoulos T, Greenough A, Pallidis C, et al. Benefits and risks of calcium resonium therapy in hyperkalaemic preterm infants. Acta Paediatr 2003;92:118-27Ditzenberger GR, Collins SD, Binder N. Continuous insulin intravenous infusion therapy for VLBW infants. J Perinat Neonat Nurs 1999;13:70-82Singh BS, Sadiq HF, Noguchi A, et al. Efficacy of albuterol inhalation in treatment of hyperkalemia in premature neonates. J Pediatr 2002;141:16-20Malone TA. Glucose and insulin versus cation-exchange resin for the treatment of hyperkalemia in very low birth weight infants. J Pediatr. 1991; 118: 121-3.Bennett LN, Myers TF, Lambert GH. Cecal perforation associated with sodium polystyrene sulfonate-sorbitol enemas in a 650 gram infant with hyperkalemia. Am J Perinatol. 1996; 13:167-70.Ohlsson A, Hosking M. Complications following oral administration of exchange resins in extremely low-birth-weight infants. Eur J Pediatr. 1987; 146: 571-4.Greenough A, Emery-EF, Brooker R, Gamsu HR. Salbutamol infusion to treat neonatal hyperkalaemia. J Perinat Med. 1992; 20: 437-41.Dilmen U, Toppare M, Senses DA, Kaya IS. Salbutamol in the treatment of neonatal hyperkalemia. Biol Neonate. 1992; 62: 424-6.Setzer ES, Ahmed F, Goldberg RN, Hellman RL, Moscoso P, Ferrer PL, Noto TA. Exchange transfusion using washed red blood cells reconstituted with fresh-frozen for treatment of severe hyperkalemia in the neonate. J Pediatr. 1984; 104: 443-6.Back to Table of ContentsSearch Terms NICU, SCN, Neonate, neonate, newborn, hyperkalaemia, hyperkalemia, potassium, arrhythmia, ECG.Back to Table of ContentsDisclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 15/07/2019Complete ReviewLiz Chatham, ED WY&CCHS Policy CommitteeThis document supersedes the following: Document NumberDocument Name ................
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