# Hyperkalemia and Albuterol



## 18G

I was doing some overdue research today on hyperkalemia and learned a lot of information on the effects of albuterol in lowering potassium concentration. I found it very interesting that a medication commonly used to treat respiratory illnesses was very effective in treating an electrolyte disorder. I've only recently started hearing of albuterol being used for this so I assume the research is fairly new? I noticed in the draft DC EMS protocols, albuterol is an indicated treatment for hyperkalemia.

In case some aren't aware of how albuterol works in hyperkalemia I'll share an overview of what I was able to gather today... (others please correct if I give any misinformation and please share additional information on the topic).

The mechanism for which albuterol works in lowering potassium concentration is it stimulates release of glucose which in turn elevates the insulin level thus driving the potassium into the cells. Increased insulin activity also stimulates the Na/K+ pump also causing an increase in the driving of potassium into the cells.

One research study cited albuterol as having the same efficacy as insulin + glucose. The combined treatments have an even greater effect in lowering potassium level. No significant effects were noted with the high doses of albuterol administered. Albuterol was noted as causing a decrease in potassium by almost one mEq (0.63-0.98mEq) which is about the same as insulin + glucose administration.

The dose of albuterol for treating hyperkalemia is 10-20mg.

One question I have is will albuterol work in lowering potassium concentration in Type I diabetics? If the patient cannot increase insulin levels in response to the increased glucose level caused by the albuterol, how will the potassium be driven into the cells and the Na/K+ pump be stimulated? I tried researching this but came up empty.

I look forward to hearing comments and feedback.


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## alphatrauma

My question would be:

How does one definitively/accurately diagnose the underlying reason for hyperkalemia (or the presence of it period) in the field?




18G said:


> If the patient cannot increase insulin levels in response to the increased glucose level caused by the albuterol, how will the potassium be driven into the cells and the Na/K+ pump be stimulated?




Excellent question! A patient in DKA could present a problem. Of course you could give fluids but what if you are dealing with someone in ESRD. Then there is the potential for cardiac arrhythmias. Hyperkalemia can be somewhat insidious, so I would question the efficacy of including Albuterol in prehospital proticols.

I'd definitely be interested in learning more... heck, not so long ago they were giving Monoxidil to hypertensive patients


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## TomB

alphatrauma said:


> My question would be:
> 
> How does one definitively/accurately diagnose the underlying reason for hyperkalemia (or the presence of it period) in the field?



The classic presentation is the renal dialysis patient who has missed an appointment and presents with general weakness, shortness of breath, or paresthesia. Often with life threatening hyperkalemia the P-waves will flatten or disappear, the QRS complex will be very wide (often > 200 ms), and the S and T-waves will merge together in the so-called "sine wave" or "Z-fold" pattern.

Our protocol calls for nebulized albuterol, but more importantly, calcium gluconate to stabilize the transmembrane potential. Other optional meds include sodium bicarbonate, but far-and-away the most imortant medication for life threatening hyperkalemia is calcium gluconate or calcium chloride.

Tom


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## VentMedic

TomB said:


> Our protocol calls for nebulized albuterol,
> Tom


 

How much albuterol? What concentration? What nebulizer? 

Hypokalemia is a side effect of albuterol administration so protocols must be written very specific and accurate data must be recorded or the other side effect of rapid high dose albuterol will bite you hard.

It has to be given rapidly and at a high dose for it to be effective. 

For more information about albuterol and hyperkalemia, look up Salbutamol in literature from other countries since they can give it by nebulizer and IV to get the desired affects (or side effects).



TomB said:


> weakness, shortness of breath, or paresthesia.


That describes a lot of dialysis patients. As well, many do run with a higher than normal K+ on dialysis day. Since they may also have many other conditions that would also warrant consideration and careful assessment, one must not assume it is the hyperkalemia that is causing the problems. As well giving high dose albuterol to someone who is dehydrated or who has various cardiac conditions may be as life threatening as the hyperkalemia. 

We will also always have a lab value (iSTAT) to back up an ECG when on transport or in the hospital. 

If you also can not give a concentrated dose of albuterol with the proper nebulizer, sodium bicarbonate, calcium gluconate or calcium chloride should be the primary options.


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## 18G

The dose of albuterol used in the study I read was 10-20mg with effects of reduced potassium seen in 30min - http://www.ncbi.nlm.nih.gov/pubmed/2919849

I was reading the draft DC EMS protocols that go into effect in March and they include albuterol for hyperkalemia at the standard 2.5mg dose.


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## TomB

We don't treat for suspected hyperkalemia unless we have a suspicious history and clinical correlation, including a 12-lead ECG with nonspecific intraventricular conduction defect. It would be great to have a lab value to back up the treatment, but several ED physicians I've spoken to caution about waiting for labs to treat life threatening hyperkalemia, especially when the ECG is grossly abnormal.

Tom


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## boingo

We will tx the same as you Tom, there is little reason to wait for laboratory confirmation when life theatening hyperkalemia is suspected.  We tx with CaCl or gluconate, NaHCO3 and nebulized albuterol.  I have a bunch of great EKG's from past cases, someday I'll figure a way to scan them and post them for all, one was a wide complex tach that I'm sure you would love!


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## 18G

I have also been taught as well to not delay treatment of severe hyperkalemia. If the patient has a suggestive history and indicative EKG changes then better to treat than wait for them to code.


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## TomB

Sounds like a great case, boingo! 

Tom


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## VentMedic

18G said:


> I was reading the draft DC EMS protocols that go into effect in March and they include albuterol for hyperkalemia at the standard 2.5mg dose.


 
:lol::lol::lol::lol::lol::lol::lol::lol: 

Need I say anymore on that one?

The problem is few have the correct albuterol concentration or the equipment to deliver it at the rate and amount needed.

Too many think their little acorn neb is  a "continuous nebulizer" and will attempt to put 10 mg of Albuterol in it by way of 4 3 cc unit doses. Thus, they might as well do nothing since they have now decreased the efficiency of an already inefficient system of delivering albuterol.


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## VentMedic

TomB said:


> but several ED physicians I've spoken to caution about waiting for labs to treat life threatening hyperkalemia, especially when the ECG is grossly abnormal.
> 
> Tom


 
Excellent advice.   

It is very rare we give high dose albuterol to people who are elderly or may have cardiac disease.  Even for asthmatics we have to consider age and cardiac side effects when running 10 - 20 mg/hour of albuterol.  For hyperkalemia that dose needs to go into the patient in less than half that time. 

I believe the Canadians have trialed the equivalent dose in MDI form for a more efficient method but at this time their sample size is very small again due to the risks.


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## TomB

VentMedic said:


> Excellent advice.
> 
> It is very rare we give high dose albuterol to people who are elderly or may have cardiac disease.  Even for asthmatics we have to consider age and cardiac side effects when running 10 - 20 mg/hour of albuterol.  For hyperkalemia that dose needs to go into the patient in less than half that time.
> 
> I believe the Canadians have trialed the equivalent dose in MDI form for a more efficient method but at this time their sample size is very small again due to the risks.




What would you suggest be done in the prehospital setting assuming that all we carry are standard run-of-the-mill nebulizers? It seems to me that with suspected life threatening hyperkalemia, the risk/benefit analysis warrants the adminstration of albuterol, even to elderly patients with cardiac history, but it's certainly not my goal to harm anyone. As it stands right now, we'd probably just give the standard dose of nebulized albuterol while obtaining IV access, and then IV calcium gluconate. Sodium bicarbonate? Controversial, but some of the ED docs still order it.

Tom


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## VentMedic

TomB said:


> What would you suggest be done in the prehospital setting assuming that all we carry are standard run-of-the-mill nebulizers? It seems to me that with suspected life threatening hyperkalemia, the risk/benefit analysis warrants the adminstration of albuterol, even to elderly patients with cardiac history, but it's certainly not my goal to harm anyone. As it stands right now, we'd probably just give the standard dose of nebulized albuterol while obtaining IV access, and then IV calcium gluconate. Sodium bicarbonate? Controversial, but some of the ED docs still order it.
> 
> Tom


 
If it is just a standard dose (2.5 mg over 10 minutes) there is probably not much to worry about as it will just be a feel good treatment for the Paramedic to make them think they are doing something.  Wasting too much time on that neb and delaying the IV can however be a problem.


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## TomB

VentMedic said:


> If it is just a standard dose (2.5 mg over 10 minutes) there is probably not much to worry about as it will just be a feel good treatment for the Paramedic to make them think they are doing something.  Wasting too much time on that neb and delaying the IV can however be a problem.



Is it possible to give a therapeutic dose of albuterol for hyperkalemia with a standard nebulizer?

Tom


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## VentMedic

TomB said:


> Is it possible to give a therapeutic dose of albuterol for hyperkalemia with a standard nebulizer?
> 
> Tom


 
Is it possible to give a therapeutic dose of anything by a standard nebulizer?

The standard nebulizer only delivers between 10 - 30% of the medication.  There are now many nebs on the market for the patients requiring a more serious treatment or where every drop counts.

If you have the 5 mg/ml of 0.5% Albuterol, with a could mls of NS, you can get a decent shift in plasma K+.


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## boingo

Thats exactly what we use, strictly for hyperkalemia management.  The multi dose vials are not to be used for routine bronchodilator therapy, the concern is with contamination.


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## daedalus

Are we talking IVP or nebulized? In our class scenarios we gave sodium bicarb and calcium chloride for ^K+ and albuterol was second line.


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## boingo

Nebulized.  I like to get the neb going while getting IV access, preferably 2.  There is definately debate over the efficacy of NaHCO3, however we still use it.  CaCl is the drug of choice, and the NaHCO3 is given preferably through a different IV site.


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## VentMedic

daedalus said:


> Are we talking IVP or nebulized? In our class scenarios we gave sodium bicarb and calcium chloride for ^K+ and albuterol was second line.


 
IV is used in Canada and Europe.  Look up *salbutamol.*


Good article
http://www.aafp.org/afp/2006/0115/p283.html


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## VentMedic

boingo said:


> Thats exactly what we use, strictly for hyperkalemia management. The multi dose vials are not to be used for routine bronchodilator therapy, the concern is with contamination.


 

You can get single packages of 2.5 mg/o.5 ml. These are also great if you can score the asthmatics for a dose and add one or two to the acorn neb for a higher dose without overloading the nebulizer and decreasing its efficiency to deliver the correct particle size. This is what we also use when the pharmacy forgets to order "Duoneb" or whatever generic brand of Albuterol/Atrovent happens to be on sale that week. 

http://www.nephronpharm.com/albuterol_5.aspx


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## austinmedic2004

We are only treating the hyperkalemia if it is the suspected cause of cardiac arrest, ie the arrested renal dialysis patient. Our first line is Calcium gluconate 1-2 Gms IV/IO (membrane stabilization), 1 mEq/kg NaHCO3 IV/IO and 10 mg Albuterol via inline neb or 10 mg Albuterol direct ET instillation after intubation (extracellular to intracellular K+ shift).


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