The below abstracts show that beta 2 adrenergic agonists are effective at treating hyperkalemia. They do so by "shifting" K into the cells.
--0.5 mg of IV albuterol reduces K by about 1.2 mEq/L.
-- A 20 mg neb (most are 2.5 mg) lowers it by about 1.0 mEq/L.
--A 10 mg neb lowers it by about 0.6 mEq/L.
I give 0.25 mg of IM terbutaline to an adult, but only if it is critical, and add nebulized albuterol also. I've never given it IV, as I'm a bit reluctant to risk the cardiac irritability.
1
TI
Treatment of hyperkalaemia in renal failure: salbutamol v. insulin.
AU
Lens XM, Montoliu J, Cases A, Campistol JM, Revert L
SO
Nephrol Dial Transplant. 1989;4(3):228.
Three groups of patients with acute or chronic renal failure (GFR
less than 5 ml/min) and hyperkalaemia (K+ greater than or equal to 6
mEq/l), similar in age, serum creatinine and pretreatment K+. Group A (n
= 24) received salbutamol 0.5 mg i.v. in 15 min, group B (n = 10)
received glucose 40 g i.v. plus 10 units insulin i.v. in 15 min, and
group C (n = 10) received salbutamol 0.5 mg i.v., glucose 40 g i.v. and
insulin 10 units i.v. over a 15-min period. Serum potassium was measured
at 30, 60, 180 and 360 min after administration of treatment. All
treatments reduced serum potassium, maximal at 30 or 60 min, and ranging
from -0.5 +/- 0.1 to -1.5 +/- 0.2 mEq/l; patients in group C exhibited a
significantly greater decrement in serum potassium, when compared to
group B at 60 (-1.5 +/- 0.2 vs -1 +/- 0.1 mEq/l, respectively; P less
than 0.01) and 180 min (-1.2 +/- 0.2 vs -0.7 +/- 0.1 mEq/l,
respectively; P less than 0.05). There were no significant differences
between groups A and C. Patients from group C had moderate tachycardia
and more prolonged hyperglycaemia than those from group B, but all
treatments were well tolerated.
AD
Nephrology Service, Hospital Clínic, University of Barcelona, Catalonia, Spain.
PMID
2
TI
The management of hyperkalaemia in the emergency department.
AU
Ahee P, Crowe AV
SO
J Accid Emerg Med. 2000;17(3):188.
Life threatening hyperkalaemia (>7.0 mmol/l) is commonly
associated with acute renal failure. Moderate hyperkalaemia (6.1-6.9
mmol/l) is also common and well tolerated in patients with chronic renal
failure. Renal failure is the most common cause of hyperkalaemia
although other causes to consider include drugs (potassium sparing
diuretics, angiotensin converting enzyme inhibitors), hyperglycaemia,
rhabdomyolysis and adrenal insufficiency. Hyperkalaemia affects the
cardiac conducting tissue and can cause serious arrhythmias including
ventricular fibrillation and asystolic arrest. Therefore it is important
to treat hyperkalaemia promptly in the emergency department. This paper
evaluates the therapeutic options available for treatment of
hyperkalaemia.
AD
Department of Accident and Emergency Medicine, City Hospital, Birmingham.
PMID
TI
Albuterol and insulin for treatment of hyperkalemia in hemodialysis patients.
AU
Allon M, Copkney C
SO
Kidney Int. 1990;38(5):869.
We evaluated in maintenance hemodialysis patients the potassium
lowering effects of intravenous insulin with glucose, nebulized
albuterol, and a regimen combining both modalities. There was a similar
decrease in plasma potassium following either insulin with glucose (0.65
+/- 0.09 mmol/liter) or albuterol (0.66 +/- 0.12 mmol/liter), and a
substantially greater fall with the combined regimen (1.21 +/- 0.19
mmol/liter, P less than 0.02 vs. either drug alone). Baseline plasma
glucose concentrations were similar (about 4.8 mmol/liter) prior to all
three treatments. Following insulin with glucose, plasma glucose
increased transiently. but then fell to 2.8 +/- 0.3 mmol/liter at one
hour, with concentrations below 3 mmol/liter in 9 of 12 patients. None
of the patients had symptoms of hypoglycemia. Plasma glucose increased
to 6.8 +/- 0.5 mmol/liter with albuterol. After the combined drug
regimen plasma glucose rose transiently and was back to baseline (4.7
+/- 0.7 mmol/liter) at one hour. Treatment with insulin or albuterol
produced trivial increases in heart rate, whereas the combined drug
regimen was associated with a significant rise (15.1 +/- 6.0 min-1).
These observations suggest that albuterol and insulin with glucose are
equally efficacious in lowering plasma potassium in uremic patients, and
that the hypokalemic effects of the two drugs is additive. The
hypoglycemic effect of insulin is attenuated by coadministration
albuterol. Combined therapy with insulin, glucose and albuterol
isefficacious and safe for the acute treatment of hyperkalemia in
hemodialysis patients.
AD
University of Oklahoma Health Sciences Center, Oklahoma City.
PMID
4
TI
Hyperkalemia in end-stage renal disease: mechanisms and management.
AU
Allon M
SO
J Am Soc Nephrol. 1995;6(4):1134.
Clinical investigations in the past few years have enhanced the
understanding of the mechanisms of hyperkalemia in patients with ESRD.
The results of these studies have led to modifications in the acute
treatment and prevention of hyperkalemia in this patient population.
They have confirmed the efficacy of intravenous insulin, while raising
doubts about the utility of intravenous bicarbonate, for the acute
treatment of hyperkalemia. Moreover, the beta-adrenergic agonist
albuterol has been shown to be a useful adjunct to insulin for acutely
lowering plasma potassium. Finally, there has been enhanced recognition
of nondietary factors that can predispose to hyperkalemia in patients
with ESRD, including prolonged fasting and the use of nonselective
beta-adrenergic blockers. These new insights may improve the clinical
management of hyperkalemia in patients with renal failure.
AD
PMID
TI
Effect of various therapeutic approaches on plasma potassium and major regulating factors in terminal renal failure.
AU
Blumberg A, Weidmann P, Shaw S, Gnädinger M
SO
Am J Med. 1988;85(4):507.
PURPOSE:
The development of life-threatening hyperkalemia poses a risk for
patients with chronic preterminal renal failure. Various therapeutic
options have been suggested for hyperkalemic emergencies in these
patients; to date, however, no study has evaluated the relative
efficacies of these measures in the presence of renal failure. Our goal
was to examine the acute effects of a variety of therapeutic approaches,
as well as those of hemodialysis, on plasma potassium levels in a
hemodialysis population.
PATIENTS AND METHODS:
Ten patients with terminal renal failure undergoing maintenance
hemodialysis were enrolled in the study. Blood gas parameters and plasma
sodium, potassium, glucose, osmolality, renin, aldosterone,
epinephrine, norepinephrine, dopamine, and insulin were measured before,
during, and after 60-minute infusions of bicarbonate, epinephrine, and
insulin in glucose, and before, during, and after performance of regular
hemodialysis for one hour.
RESULTS:
Hypertonic as well as isotonic intravenous bicarbonate (2 to 4
mmol/minute) induced a marked rise in plasma bicarbonate and pH, but
failed to lower the plasma potassium level (5.66 versus5.83 mmol/liter
before and after). Epinephrine, 0.05 microgram/kg/minute administered
intravenously, decreased plasma potassium only slightly from 5.57 to
5.25 mmol/liter, and five patients showed no decline. On the other hand,
insulin in glucose, 5 mU/kg/minute intravenously, effectively lowered
plasma potassium levels from 5.62 to 4.70 mmol/liter, and hemodialysis
induced the most rapid decline from 5.63 to 4.29 mmol/liter. Plasma
aldosterone was elevated before treatment; it correlated with plasma
potassium and dropped during intravenous bicarbonate administration or
hemodialysis. Pretreatment plasma renin activity, insulin, epinephrine,
norepinephrine, and dopamine levels were generally normal.
CONCLUSION:
We conclude that in patients with terminal renal failure
undergoing maintenance hemodialysis, intravenous bicarbonate is
ineffective in lowering plasma potassium rapidly, and epinephrine is
effective in only half the patients, whereas insulin in glucose is a
fast and reliable form of therapy for hyperkalemic emergencies. Plasma
aldosterone levels are appropriate in relationship to plasma potassium
levels, and levels of other potassium-influencing hormones are generally
normal.
AD
Department of Medicine, Kantonsspital, Aarau, Switzerland.
PMID
6
TI
Hypokalemic effects of intravenous infusion or
nebulization of salbutamol in patients with chronic renal failure:
comparative study.
AU
Liou HH, Chiang SS, Wu SC, Huang TP, Campese VM, Smogorzewski M, Yang WC
SO
Am J Kidney Dis. 1994;23(2):266.
To examine and compare the efficacy and safety of different
routes of administration of salbutamol in treating hyperkalemia, 15
patients with chronic renal failure (blood urea nitrogen>80 mg/dL,
serum creatinine>8.0 mg/dL) were enrolled to sequentially receive
either intravenous infusion (0.5 mg) or nebulization (10 mg) of
salbutamol. Five of these patients (33.3%) did not respond to the
intravenous salbutamol and were excluded from the study. Both treatments
significantly decreased plasma potassium in 10 patients and the
decrease was sustained for at least 3 hours. After infusion, the maximal
reduction in plasma potassium levels was 0.92 +/- 0.10 mEq/L and
occurred after 30 minutes. On the other hand, the maximal reduction in
plasma potassium after nebulization (0.85 +/- 0.13 mEq/L) was similar to
that after infusion, but it occurred after 90 minutes. Insulin and
blood glucose increased, whereas blood pH, PCO2, sodium, osmolality, and
blood pressure did not change after either treatment. Heart rate
increased significantly after both treatments, but less after
nebulization than after infusion. It is concluded that both infusion and
nebulization are simple, effective, and safe therapeutic modalities for
the treatment of hyperkalemia in patients with chronic renal failure.
Infusion should be used in patients requiring a rapid decrease in plasma
potassium; nebulization, on the other hand, should be used in patients
with coronary artery diseases.
AD
Department of Medicine, Veterans General Hospital-Taipei, Taiwan, ROC.
PMID
7
TI
Subcutaneous terbutaline use in CKD to reduce potassium concentrations.
AU
Sowinski KM, Cronin D, Mueller BA, Kraus MA
SO
Am J Kidney Dis. 2005;45(6):1040.
BACKGROUND:
Acute hyperkalemia is a frequent and potentially life-threatening
medical problem in patients on maintenance hemodialysis therapy.
beta-Adrenergic receptor (betaAR) stimulation causes potassium cellular
influx and a decline in plasma potassium concentrations. Therefore,
betaAR agonists are used in the treatment of patients with hyperkalemia.
The goal of this study is to evaluate the utility of weight-based
subcutaneous terbutaline dosing to reduce plasma potassium
concentrations in a group of subjects with chronic kidney disease (CKD)
requiring hemodialysis.
METHODS:
Fourteen subjects with CKD receiving long-term hemodialysis were
administered terbutaline, 7 microg/kg, subcutaneously. Heart rate
measurements and blood samples for potassium concentration
determinations were made serially for 420 minutes. Effects of
terbutaline on heart rate and potassium responses were determined in
each subject.
RESULTS:
Terbutaline significantly reduced plasma potassium concentrations
and significantly increased heart rates during the time course of the study (P less than 0.001). Mean reduction in peak
potassium concentration (−1.31 ± 0.5 [SD] mEq/L) and increase in peak
heart rate (25.8 ± 10.5 beats/min) were significantly different from
baseline (P less than 0.001, baseline versus peak for both responses). No subject reported significant adverse effects. Conclusion:
Administration of subcutaneous terbutaline obviates the need for
intravenous access and should be considered as an alternative to
nebulized or inhaled β-agonists to treat acute hyperkalemia in patients with CKD. As with the use of any β-adrenergic agonist, close cardiovascular monitoring is necessary to avoid or minimize toxicity during therapy.
CONCLUSION: Administration of subcutaneous terbutaline obviates the need for intravenous access and should be considered as an alternative to nebulized or inhaled beta-agonists to treat acute hyperkalemia in patients with CKD. As with the use of any beta-adrenergic agonist, close cardiovascular monitoring is necessary to avoid or minimize toxicity during therapy.
CONCLUSION: Administration of subcutaneous terbutaline obviates the need for intravenous access and should be considered as an alternative to nebulized or inhaled beta-agonists to treat acute hyperkalemia in patients with CKD. As with the use of any beta-adrenergic agonist, close cardiovascular monitoring is necessary to avoid or minimize toxicity during therapy.
AD
Department of Pharmacy Practice, School of
Pharmacy and Pharmaceutical Sciences, Purdue University, Indianapolis,
IN 46202-2879, USA. ksowinsk@iupui.edu
PMID
Very cool case!
ReplyDeleteThanks, El!
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