Management of Fluid and Electrolyte problems in Children


Hyperkalaemia - Treatment

There is no agreement on treatment threshold but generally high K+ levels, presence of ECG changes and the risk of increasing K+ levels, especially in the setting of diminished excretion (renal failure) require vigorous treatment.

  • Treat underlying cause.
  • General Management
    • Give attention to Airway, Breathing and Circulation.
    • Continuous ECG monitoring (and oxygen saturation, BP and urine output).
    • Get IV access
  • Stop potassium intake and drugs which cause hyperkalaemia
  • Protect the cardiac membrane if acute ECG changes
    • Give 0.5-1ml/kg (maximum 20m) of 10% calcium gluconate over 5-10 minutes undiluted (does not lower serum [K]). An ECG improvement should be seen within the first few minutes and if not can re-dose after 5-10 minutes.
  • Shift potassium from the blood into the cell
    • Give nebulized Salbutamol (2.5mg <2 years of age and 5mg >2 years age), repeat 1-2 hourly as necessary. Onset of action is seen within thirty minutes and maximum effect between 60-90 minutes. It is not recommended as a single agent.
    • If patient acidotic give sodium bicarbonate 1-2mmol/kg intravenously over 30 minutes (1mmol = 1ml of 8.4% of sodium bicarbonate, dilute1:5 in 5% dextrose).
    • Glucose insulin infusion – Infuse 5-10mls/kg/hr (0.5-1g/kg/hr) of 10% dextrose with insulin at 0.05 units/kg/hr. Maintain blood glucose at 10-15mmol/l by adjusting the infusion rate in 0.05ml/kg/hr steps. Measure blood sugar frequently (15 minutes after commencing or increasing dose and then every thirty minutes until stable).
  • Remove potassium from the body
    • Furosemide 2mg/kg intravenously where appropriate, ensuring the patient is intravascularly well filled.
    • Calcium Resonium – It takes 4 hours for full effect. By rectum 125-250mg/kg (maximum 15g) six hourly; repeat if expelled within thirty minutes. By mouth 125-250 mg/kg (maximum 15g) six hourly. Risk of sodium retention and hypervolaemia if used in large doses.
    • Dialysis is the most effective treatment and should be initiated if there is no response to the other measures.

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