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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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Available at:
https://ukkidney.org/sites/renal.org/files/RENAL%20ASSOCIATION%20HYPERKALAEMIA%20GUIDELINE%202020.pdf
https://t.me/med1917
Chapter48
Hyperkalaemia
Guideline: UK Kidney Association (Treatment of acute hyperkalaemia in
adults):
https://ukkidney.org/sites/renal.org/files/RENAL%20ASSOCIATION%20HYPERKALAEMIA%20GUIDELINE%202020.pdf
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Hyperkalaemia is potentially a life-threatening emergency. Common underlying causes includeacuteorchronicrenalimpairment,inappropriatepotassiumsupplementation,and drugsideeffects.Inseverecases,urgenttreatmentisrequiredtopreventarrhythmias.
Diagnosis
History/diagnosticcriteria
The severity of hyperkalaemiacan be categorized according to serum potassium levels and thepresence of ECGchanges(Table48.1). In an emergency, a quick estimation of serum potassium can be achieved with blood gas testing, but a laboratory specimen shouldalwaysbesentforconfirmation.
Patients with hyperkalaemia may be asymptomatic, or the following symptoms and
signsmaybepresent:
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Arrhythmias Muscularweakness Paraesthesiae Chestpain Palpitations Syncope Breathlessness.
Table48.1Severityofhyperkalaemiaaccordingtoserumpotassiumlevel
Mild 5.5–5.9mmol/L
Moderate 6.0–6.4mmol/L
Severe ≥6.5mmol/L
Predisposingfactors
CKD Dialysispatients;non-compliance,missedorinadequatedialysissessions AKI Nephrotoxic medications (ACE inhibitor, e.g. ramipril; ARBs, e.g. losartan; NSAIDs, e.g. ibuprofen) Cardiacfailure Diabetesmellitus(useofACEinhibitors,diabeticketoacidosis) Liverdisease(useofaldosteroneantagonists,hepatorenalfailure) Adrenalinsufficiency.
Examination
SystematicallyexaminethepatientusinganABCDEapproach(Table48.2).
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Table48.2Hyperkalaemiaexaminationfindings
B
Pulmonaryoedema(secondarytorenaldisease) HyperventilationandKussmaul’sbreathing(secondarytoacidosis)
C
Irregularpulse Thirdheartsound RaisedJVP
E
Pittingoedema ArteriovenousfistulaorotherevidenceofCKD,suchastransplantscarringorballotablekidneys Stigmataofchronicliverdisease
Investigations
ECG:allpatientswithmoderateorseverehyperkalaemiashouldhavea12-leadECG(Fig.48.1).
TheECGmaybenormal,eveninseverehyperkalaemia.
Bloods:
Stratifyseveritybyserumpotassiumconcentration(seeTable48.1) U&E,LFT,creatinekinase,boneprofile,andmagnesium;VBGforacid–baseassessment.
Fig.48.1TypicalECGchangesinhyperkalaemia.(a)Anormalcomplex.(b)AbsenceofPwaves,tenting ofT waves. (c) Broadening ofthe QRScomplex. (d) Sine wave appearance. These changes typically followaprogressivepatternastheseverityofhyperkalaemiaincreases.
Pseudohypokalaemia
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Sample haemolysis and long processing times can cause falsely high potassium results. To prevent this,takebloodfrom largeveins,avoidsmall needlesandextendedtourniquettime, andprocessthesamplepromptly A highplateletorcellcountmayalsocausepseudohyperkalaemia.Repeatthe bloodsusing a lithium-heparintube(plasmasample)tocheck.Aplasmavalue≥0.4mmol/Llowerthanserum suggeststhediagnosis.
Callforhelp?
Anyclinicalconcernsshouldbeescalatedimmediatelytoseniormedicalstaffaspatients mayrequirereferraltohighdependencycare.
Management
MildhyperkalaemiawithoutECGchanges:step5only Inallothercases:treaturgentlystartingfromstep1.
Acutemanagement
Step1:protecttheheartifthereareECGchangesofhyperkalaemia
10mL10%calciumchlorideIVover5–10minutesOR 30mL10%calciumgluconateIVover5–10minutes.
IVcalciumsaltsantagonizecardiacmembraneexcitabilityandprotectagainstarrhythmias. Thedosecanberepeatedafter5–10minutesifchangespersist.Thedurationofactionis 30–60minutes.
It is important that patientshave ongoing cardiac monitoring during the calcium injectionto monitorforarrhythmias.
Step2:shiftpotassiumintocells
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10unitsIVshort-actinginsulin(e.g.Actrapid®)ineither:
50mL50%dextroseOR
125mL20%glucose Giveover15–30minutesviaalargevein Check CBG prior to the treatment. If <7mmol/L start an infusion of 10% dextrose at a rate of 50mL/hourfor5hours.MonitorforhypoglycaemiabytestingCBGat0,15,30,60,120minutes, andthenmonitorforupto12hourspostinfusion. In severe cases,a 10–20mgsalbutamol nebulizer maybeconsideredas anadditional treatment. Thistherapyiseffectivewithin30–60minutesandlastsfor4–6hours.
Insulin-dextrose is maximally effective within 45–180 minutes. A repeat potassium level shouldthereforebecheckedbetween60and180minutesafterthedrugsaregiven.Areduction ofapproximately1.0mmol/Lisexpected.
Step3:removepotassiumfromthebody
Considertheneedforacation-exchangeresinsuchascalciumresonium15gorallyor30grectally (donotuseinseverecasesduetoslowonsetofaction) Refractorycasesmayrequirehaemofiltrationordialysis,whichmayalsobeconsideredduringa cardiacarrestsuspectedtobeduetohyperkalaemia.
Treatmentafterstabilization
Step4:monitorserumpotassiumlevels
Aftertheeffect oftreatment has subsided, hyperkalaemia mayrecur.Itisthereforeadvisableto monitorserumpotassiumlevelsregularly Patientswithseverehyperkalaemia,orhyperkalaemiaaccompaniedbyECGchangesshouldhave (atleast)three-leadcardiacmonitoringandconsiderationoftransfertoahigherdependencyunit.
Step5:preventrecurrence
Reviewpotentialcausativeagentsandmonitorrenalfunctioninpatientsbeingtreatedwithdrugs thatcancausehyperkalaemia Requestadieticianreview.
Specialconsiderations
Renalpatients
Ifthepatientisreceivingregulardialysis,hasadvancedCKD,orsevereAKI(especiallyif
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oligo-/anuric),urgentlyinformthelocalrenalteam(orintensivecare,dependingonlocal availability)incaseemergencydialysisisrequired.
If thepatientis receiving sodiumbicarbonateaspartoftheir renalmanagement,do notgive sodiumbicarbonatethroughthesame IVlineascalciumduetotheriskofinsolublecalcium saltsforminginthebloodstream.
Furtherreading
1. UK Kidney Association (2020). Emergency management of hyperkalaemia in adults (algorithm, appendix 6). Available at:
https://ukkidney.org/sites/renal.org/files/RENAL%20ASSOCIATION%20HYPERKALAEMIA%20GUIDELINE%202020.pdf
https://t.me/med1917
49
50
51
52
53
54
55
56
Part8
Neurology
Acuteencephalitis
Epilepsy
Headache
Meningitis
Metastaticspinalcordcompression
Neuropathicpain
Parkinson’sdisease
Strokeandtransientischaemicattack
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Chapter49
Acuteencephalitis
Guideline:AssociationofBritishNeurologists,BritishInfectionAssociation
(Management of suspected viral encephalitis in adults):
https://www.journalofinfection.com/article/S0163-4453(11)00563-9/pdf
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Acuteencephalitisreferstoinflammationofthebrainparenchyma.
Causesinclude:
Infectious:viral,bacterial,fungal,parasitic Post-infectiouse.g.acutedisseminatedencephalomyelitis(ADEM) Antibodymediatede.g.byvoltage-gatedpotassiumchannel(VGKC)antibodies.
HSVisthemostcommonlydiagnosedcauseofencephalitisandthispresumeddiagnosis should be treated in the immediate management of suspected infectious encephalitis. Untreated, HSV encephalitis mortality is >70%, but this reduces to 20–30% with IV aciclovirtreatment.
Diagnosis
History
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Febrileorflu-likeillness(oftenprodromal) Headache Altered/bizarrebehaviour Changeincognition Changeinpersonality ↓GCSscore Seizures Focalneurology.
Importantpointstoelicitinhistory
HistoryofImmunocompromise/HIVstatus Travelandvaccinationhistory Bitesandanimalcontact Unwellcontacts Collateralhistoryifpatientiscognitivelyimpairedorhasa↓GCSscore.
Examination
Examine the patient using an ABCDE approach (Table 49.1). A mini mental state examinationorotherformofcognitiveassessmentisalsoimportant.
Table49.1Acuteencephalitisexaminationfindings
A/B/C
Signsofsepticshock,e.g.tachycardia,hypotension
D
Meningism,e.g.neckstiffness,positiveKernig’ssign,positiveBrudzinski’ssign(seeChapter52) Focalneurology(oftenuppermotorneuron) ↓GCSscore Pyrexia
E
Papilloedema Bites Rashes Needletrackmarks
Investigations
Bedside
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