What is the management for an 80-year-old female with pancreatic cancer history, hyperkalemia, renal impairment, and ECG abnormalities on antipsychotic medication?

Management of Hyperkalemia in an 80-Year-Old Female with Pancreatic Cancer History

The patient requires immediate treatment for hyperkalemia (potassium 6 mmol/L) with ECG changes including sinus bradycardia and conduction abnormalities, which constitutes a medical emergency requiring prompt intervention. 1

Initial Assessment and Immediate Management

• Hyperkalemia with potassium of 6 mmol/L along with ECG changes (sinus bradycardia, left intraventricular block, delayed pericardial wave progression) requires urgent treatment to prevent life-threatening cardiac arrhythmias 1
• Administer intravenous calcium gluconate immediately to stabilize cardiac membranes and reduce risk of arrhythmias, which acts within 1-3 minutes 1
• Initiate insulin (with glucose) therapy to promote intracellular shift of potassium, which takes effect within 30 minutes 1
• Consider inhaled beta-agonists as additional measure to promote intracellular potassium shift 1

Specific Interventions for Acute Management

• Administer 10 mL of 10% calcium gluconate IV over 2-3 minutes with cardiac monitoring; may repeat dose if no effect observed within 5-10 minutes 1
• Give 10 units of regular insulin IV with 25% dextrose (50 mL) to prevent hypoglycemia 1
• Sodium bicarbonate administration may be beneficial, especially if metabolic acidosis is present 1
• Loop diuretics should be considered to enhance potassium excretion if renal function permits (patient has EGFR of 62) 1

Medication Review and Adjustment

• Discontinue or reduce the antipsychotic medication (Albin/Zabi) as it may be contributing to hyperkalemia 1, 2
• Review all medications that may contribute to hyperkalemia, including any hidden sources of potassium such as salt substitutes or supplements 1
• Assess for drug interactions that might be exacerbating the hyperkalemia 2

Ongoing Management

• Once stabilized, initiate potassium-binding agent therapy such as patiromer (Veltassa) for ongoing management of hyperkalemia 3
• Start with recommended dosing of patiromer based on potassium level: for K+ >6.0 mmol/L, consider starting at 16.8 g daily 3
• Monitor serum potassium levels closely - recheck within 2-3 days after initiating treatment and again at 7 days 1
• Implement dietary potassium restriction with nutritional counseling 1

Special Considerations for This Patient

• The patient's history of pancreatic cancer with surgical intervention and parathyroidectomy requires special attention as these conditions can affect electrolyte balance 4
• The patient's mild renal impairment (EGFR 62) increases risk of hyperkalemia and requires dose adjustments of medications 1
• The elevated liver enzymes, triglycerides, and uric acid suggest metabolic derangements that may be contributing to the hyperkalemia 5
• Consider hemodialysis if hyperkalemia is refractory to medical management, especially given the patient's complex medical history and renal impairment 1

Monitoring and Follow-up

• Perform serial ECGs to monitor for resolution of conduction abnormalities 1
• Check potassium levels daily until stabilized, then weekly for 1 month, then monthly 1
• Monitor renal function closely with regular creatinine and EGFR measurements 1
• Assess for symptoms of hyperkalemia including muscle weakness, paralysis, and cardiac symptoms 5

Long-term Management

• For chronic management, continue potassium binder therapy if needed to maintain normal potassium levels 1, 3
• Regular monitoring of electrolytes, particularly in the context of the patient's multiple comorbidities 1
• Reassess the need for medications that may contribute to hyperkalemia and consider alternatives when possible 6
• Provide education on dietary potassium restriction and medication adherence 1