How to manage hyperkalemia (elevated potassium level) prior to shoulder surgery?

From the Guidelines

Managing hyperkalemia before shoulder surgery requires prompt intervention to reduce potassium levels to a safe range, typically below 5.5 mEq/L, and the most effective approach is to administer oral sodium polystyrene sulfonate (Kayexalate) 15-30g mixed with sorbitol, or patiromer (Veltassa) 8.4g once daily, as recommended by the most recent and highest quality study 1.

For a patient with a potassium level of 5.3 two days prior to shoulder surgery, the following steps can be taken:

• Discontinue any potassium-sparing medications, ACE inhibitors, ARBs, and NSAIDs if possible, as they can contribute to hyperkalemia 1
• Administer oral sodium polystyrene sulfonate (Kayexalate) 15-30g mixed with sorbitol, or patiromer (Veltassa) 8.4g once daily to help lower potassium levels 1
• Monitor potassium levels closely and recheck 1-2 hours after treatment to ensure levels are decreasing
• Inform the anesthesiologist about the patient's hyperkalemia history, as hyperkalemia can increase the risk of arrhythmias and cardiac arrest during anesthesia, particularly when combined with succinylcholine, a depolarizing muscle relaxant often used during intubation 1

It's also important to note that loop diuretics like furosemide 40-80mg IV can enhance potassium excretion in patients with adequate renal function, and intravenous calcium gluconate 10mL of 10% solution may be administered to stabilize cardiac membranes if ECG changes are present 1. However, the most recent and highest quality study 1 recommends the use of oral sodium polystyrene sulfonate (Kayexalate) or patiromer (Veltassa) as the first line of treatment for mild to moderate hyperkalemia.

Some key points to consider when managing hyperkalemia include:

• The risk of hyperkalemia is higher in patients with cardiovascular disease and chronic kidney disease 1
• The incidence of hyperkalemia can be as high as 50% in unselected population of patients receiving RAASi 1
• Quality improvement programmes are needed to improve rates of laboratory monitoring for patients initiated on MRA therapy, particularly in high-risk patients 1

From the FDA Drug Label

Sodium polystyrene sulfonate is a potassium binder indicated for the treatment of hyperkalemia Limitation of Use: Sodium polystyrene sulfonate should not be used an emergency treatment for life threatening hyperkalemia because of its delayed onset of action.

For a potassium level of 5.3, which is considered mild hyperkalemia, management prior to shoulder surgery may involve the use of potassium binders such as sodium polystyrene sulfonate 2. However, it is essential to note that this medication has a delayed onset of action and should not be used as an emergency treatment for life-threatening hyperkalemia.

• The decision to use sodium polystyrene sulfonate should be made on a case-by-case basis, considering the severity of hyperkalemia and the timing of the surgery.
• It is crucial to monitor potassium levels closely and adjust treatment as needed to ensure patient safety prior to surgery.

From the Research

Management of Hyperkalemia Prior to Shoulder Surgery

To manage a potassium level of 5.3 two days prior to shoulder surgery, several options can be considered:

• Medications:
  • Patiromer: a potassium binder that can help reduce potassium levels 3, 4, 5
  • Sodium polystyrene sulfonate (SPS): a cation-exchange resin that can help reduce potassium levels, although its use is limited due to potential adverse effects 3, 4, 6, 7
  • Sodium zirconium cyclosilicate (SZC): a potassium binder that can help reduce potassium levels, although its use may be limited due to potential adverse effects 4, 7
• Other treatments:
  • Glucose and insulin: can help reduce potassium levels by driving potassium into cells 6, 7
  • Bicarbonate: may be useful in patients with metabolic acidosis or intact kidney function 7
  • Calcium gluconate: can help stabilize cardiac membranes and reduce the risk of arrhythmias 6
  • Beta-2 agonists: can help reduce potassium levels by driving potassium into cells 6
  • Hyperventilation: can help reduce potassium levels by driving potassium into cells 6
  • Dialysis: may be necessary in severe cases of hyperkalemia 6, 7

Considerations for Treatment

When choosing a treatment for hyperkalemia, several factors should be considered:

• Severity of hyperkalemia: more severe cases may require more aggressive treatment
• Underlying medical conditions: certain conditions, such as chronic kidney disease, may affect the choice of treatment
• Potential adverse effects: each treatment has potential adverse effects that should be considered
• Patient's overall health: the patient's overall health and medical history should be taken into account when choosing a treatment

Monitoring and Follow-up

It is essential to monitor the patient's potassium levels and overall health closely after initiating treatment:

• Regular blood tests: to monitor potassium levels and adjust treatment as needed
• Clinical evaluation: to assess the patient's overall health and adjust treatment as needed
• Follow-up appointments: to monitor the patient's condition and adjust treatment as needed 5