Is Calcium compulsory in Hyperkalaemia 'Cocktail Regimen'?

Symptoms occur when Serum Potassium > 6.0 to 6.5 meq/LNeurologic Changes Weakness

• Paresthesias

• Areflexia

• Ascending paralysis

• Respiratory failure

Cardiovascular Changes

• Bradycardia to Asystole or Ventricular Fibrillation

• AV prolonged transmission to complete Heart Block

Treatment Algorithm:

Rationale of Calcium Use

1.     Antagonizes Hyperkalemia cardiac, neurologic effects

a.     Further calcium beyond first 1-2 dose are ineffective for additional myocardial stabilization unlessHypocalcemia

2.     Effect occurs in 1-3 minutes and lasts for 30-60 minutes

a.     Anticipate EKG improvement within 3 minutes

3.     Caution in Digoxin Toxicity (may worsen)

a.     Use slower infusion (over 20-30 minutes)

b.     Consider Calcium Gluconate 10 ml in 100 ml of D5 infused over 20-30 minutes

c.     Consider Magnesium as alternative to Calcium

4.     Calcium Chloride (1.4 mEq/ml)

a.     Dose: 5 ml over 10 minutes

b.     May repeat second dose in 5 minutes if EKG not improved

c.     Preferred historically for shock or cardiac instability (especially if central access)

                i.     However Calcium Gluconate likely has same efficacy with better peripheral IV safety

               ii.     See Intravenous Calcium for differences between calcium preparations

5.     Calcium Gluconate 10% (0.4 mEq/ml)

a.     Preferred agent if only peripheral IV available (Decreased venous sclerosis with infusion)

b.     Initial dose: 10 ml over 2-5 minutes (10 minutes is lower risk if time allows)

c.     Second dose after 5 minutes if EKG not improved

References:

1. Hyperkalaemia Management. http://www.fpnotebook.com/Renal/Potassium/HyprklmMngmnt.htm
2. http://www.aafp.org/afp/2006/0115/p283.html