BIOGRAPHY Dr Halstead is a Medical Registrar at Hawke's Bay Hospital. He is an advanced trainee (currently on interrupted training) in General and Acute Care Medicine. ABSTRACT Audit of the medical management of severe hyperkalaemia at Hawke’s Bay Hospital Dr Michael Halstead1 Background: Hyperkalaemia is a common and potentially life-threatening condition, and initial management is often with medical therapy aimed at cardiac membrane stabilization and intracellular potassium redistribution. Emergency management is usually based on institutional guidelines. The aim of this study was to examine current practice in the medical management of severe hyperkalaemia at Hawke’s Bay Hospital. Methods: A retrospective audit of the management of severe hyperkalaemia (serum potassium ≥ 6.5 mmol/L) was performed. Episodes of severe hyperkalaemia were identified from laboratory data. Demographics, clinical characteristics, and management were recorded for 50 consecutive episodes during the period March-December 2015 in adult patients with initial medical management in the Emergency Department or inpatient wards. Results: There was poor adherence to the hospital’s protocol, which advises membrane stabilization and intracellular redistribution of potassium only if there are QRS and T wave changes on the electrocardiogram (ECG). Overall, 18% of episodes were treated according to protocol. There was no significant difference in treatment given to those with or without protocol ECG changes, and most episodes were treated with calcium gluconate and insulin regardless of ECG changes. Eleven combinations of one or more of calcium gluconate, insulin, salbutamol, and resonium were used. Hypoglycaemia (blood glucose < 4 mmol/L) occurred in 17% of the episodes treated with insulin, and occurred at a mean of 92 minutes after treatment. Patients on dialysis had a higher risk of hypoglycaemia (odds ratio 12, 95% confidence interval 1.9-78, p=0.009). Conclusion: The local protocol is not being used consistently to guide treatment of hyperkalaemia, with treatment usually being started at lower thresholds than stipulated. Hypoglycaemia is an important complication of insulin treatment. Recommended changes to the protocol include lower thresholds for treatment and closer monitoring for hypoglycaemia. |