Hyperkalaemia in the neonate
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If you consider treatment for hyperkalaemia, discuss with the specialist on call.
Definition and diagnosis
- Hyperkalaemia is defined as a serum potassium concentration greater than 7 mmol/L1
- Hyperkalaemia is common when capillary blood samples are haemolysed. The first step should be to confirm high serum K+ with a non-haemolysed venous or arterial sample.
- ECG changes (peaked T waves, broad QRS complexes, and arrhythmias) indicate significant hyperkalaemia and require urgent treatment with calcium gluconate.2
- Hyperkalaemia in the NICU is most commonly associated with non-oligurigic hyperkalaemia in the first 72 hours of life of the very preterm infant. Immature function of the erythrocyte Na/K - ATPase is believed to be the reason for non-oliguric hyperkalaemia.
- Oliguric renal failure (e.g.: due to hypoxic event, drug error or renal tubular acidosis) or haemolysis are other causes for hyperkalaemia.3
- Hyperkalaemia is believed to be exacerbated by:
- metabolic acidosis, due to exchange of intracellular K+ with extracellular H+
- renal impairment and hypovolaemia
- Peaked T-waves
- Prolonged PR interval
- Broadened QRS complexes
- Disappearing of the P-wave
- Ventricular tachycardia and impaired AV conduction.
1. 10% Calcium Gluconate
|Dose:||0.5 mL/kg IV (0.1 mmoL/kg) over 10-30 min. The dose of calcium gluconate may be repeated.|
|Effect:||Stabilizes myocardial membrane potential, should be given if the infant is at risk of, or has ECG changes and/or arrhythmias.|
|Side effects:||Cardiac arrhythmias and seizures with severe hypercalcaemia.|
2. Stop IV K+
Remove K+ from IV (i.e.: replace TPN with 10% glucose with Na+)
3. IV Glucose and Insulin
|Dose:||Glucose: 8-16 mg/kg/min (e.g.: 2.5-5 ml/kg/hr 20% glucose (20 ml of 50% glucose and 30 ml of water in a 50 ml syringe)) in addition to maintenance fluid, aim for blood glucose concentration (BGC) > 12 mmol/l. When BGC >12 mmol/L, start insulin infusion (0.1-0.6 units/kg/hr).3,4|
|Effect:||Shift of ionized K+ from the extracellular to the intracellular space. K+ is transported over the membrane in combination with glucose.|
|Side effects:||Hypoglycaemia, hyperglycaemia|
|Dose:||Intravenous: 4 micrograms/kg over 10 min or
nebulized via ETT: 400 micrograms/dose (made up to a total of 4 ml
with normal saline) up to 2 hrly.3,5,6
N.B Be aware: salbutamol comes in two different preparations, for IV administration and as sterinebs: they are not interchangeable !
|Effect:||Salbutamol is a beta-adrenergic agonist and stimulates the membrane Na+/K+ - ATPase. Singh et al report a small randomized trial of nebulized salbutamol compared with saline for very preterm infants. Nebulized salbutamol reduced plasma K+ rapidly with no adverse effects noted.5|
|Side effects:||Tachycardia, hypertension, tremor, hypokalaemia, hyperglycaemia. Inhaled Salbutamol seems to be generally well tolerated. 5,6|
5. Sodium bicarbonate
Correction of an existing metabolic acidosis can be considered
|Dose:||Sodium bicarbonate dose (mL) = base deficit x 0.6 x weight (kg).|
|Effect:||May facilitate shift of K+ from the extracellular to the intracellular space.|
|Side effects:||Increased vascular volume, serum osmolarity,
serum sodium, hypercapnia and respiratory acidosis, hypocalcaemia,
oedema, congestive heart failure, hyperirritability,
Should be avoided in preterm infants
|Dose:||0.5 - 1 g/kg rectally|
|Effect:||Binds intestinal K+ and prevents intestinal absorption.|
|Side effects:||Intestinal perforation and constipation in
preterm infants.7 IV Salbutamol seems
more effective than resonium.6
7. Exchange transfusion or peritoneal dialysis
- Gruskay J, Costarino AT, Polin RA, Baumgart S. Nonoliguric hyperkalemia in the premature infant weighing less than 1000 grams. J Pediatr. 1988;113:381-6.
- Lista G, Bastrenta P, Castoldi F, Meneghin F, Zuccotti G. Severe bradycardia in an extremely low birth weight preterm infant with hyperkalaemia. Resuscitation [Internet]. European Resuscitation Council, American Heart Association, Inc., and International Liaison Committee on Resuscitation.; 2011;82:640-1.
- Vemgal P, Ohlsson A. Interventions for non-oliguric hyperkalaemia in preterm neonates. Cochrane database Syst Rev. 2012;5:CD005257.
- Hu PS, Su BH, Peng CT, Tsai CH. Glucose and insulin infusion versus kayexalate for the early treatment of non-oliguric hyperkalemia in very-low-birth-weight infants. Acta Paediatr Taiwan;40:314-8.
- Singh BS, Sadiq HF, Noguchi A, Keenan WJ. Efficacy of albuterol inhalation in treatment of hyperkalemia in premature neonates. J Pediatr. 2002 ;141:16-20.
- Yaseen H, Khalaf M, Dana A, Yaseen N, Darwich M. Salbutamol versus cation-exchange resin (kayexalate) for the treatment of nonoliguric hyperkalemia in preterm infants. Am J Perinatol. 2008;25:193-7.
- Setzer ES, Ahmed F, Goldberg RN, Hellman RL, Moscoso P, Ferrer PL, et al. Exchange transfusion using washed red blood cells reconstituted with fresh-frozen plasma for treatment of severe hyperkalemia in the neonate. J Pediatr. 1984;104:443-6.
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- Date last published: 01 August 2015
- Document type: Clinical Guideline
- Services responsible: Neonatology
- Owner: Newborn Services Clinical Practice Committee
- Editor: Sarah Bellhouse
- Review frequency: 2 years
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