Calcium bicarbonate vs Calcium gluconate, which is better for hyperkalemia?

[seasurfer]

Which one is better? Thanks.

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[AbbyNormal]

In my experience use CaCl because it contains about 3 times more elemental calcium than an equal volume of calcium gluconate. The dose is CaCl (10%): 250-500 mg/dose slow IV

Don't forget the bicarb

 

[jdh71]

Better? Neither is really "better". What does that word mean anyway? Better at what? Stabilizing myocardocyte membranes? Then neither is better, not really. The question becomes do I have a central line? If no, then use the gluconate. If yes, use whatever on hand.

 

[Speculatrix]

In my experience use CaCl because it contains about 3 times more elemental calcium than an equal volume of calcium gluconate. The dose is CaCl (10%): 250-500 mg/dose slow IV

Don't forget the bicarb

Calcium Chloride? I would not give CaCl without a central line- major risk for thrombophlebitis and venous infiltration in peripheral IV (which I saw... actually with KCl). Really bad for limbs. In a peripheral, I would do calcium gluconate. Since you have to give bicarb anyway, and you don't want to give them together because they precipitate, I would imagine you could give calcium peripherally and bicarb centrally (or vice versa).

I've never actually seen Calcium Bicarbonate being used at the hospital... is it just some theoretical solution that exists?

For the original situation, I would do 1 amp (1g/10mL) Calcium Gluconate IV push, esp if it were a code... which is probably what the 'emergent situations' for board purposes are.

 

[gutonc]

As mentioned, neither is "better." Calcium is Calcium. In practice, gluconate is easier to give so is nearly always the one that gets used.

This always aggravated me about exam/pimp questions relating to the treatment of hyperK. In reality, you will write for Calcium, D50+Insulin, IVF, Bicarb and kayexalate all at the same time. The order in which it gets given will depend entirely on your order entry system, pharmacy, floor Pyxis stock and nurses (fortunately Calcium Gluconate is usually in the crash cart). Nitpicking over which should be first is just intellectual wanking.

 

[Speculatrix]

As mentioned, neither is "better." Calcium is Calcium. In practice, gluconate is easier to give so is nearly always the one that gets used.

This always aggravated me about exam/pimp questions relating to the treatment of hyperK. In reality, you will write for Calcium, D50+Insulin, IVF, Bicarb and kayexalate all at the same time. The order in which it gets given will depend entirely on your order entry system, pharmacy, floor Pyxis stock and nurses (fortunately Calcium Gluconate is usually in the crash cart). Nitpicking over which should be first is just intellectual wanking.

Well, I think the order should matter in terms of the Calcium and the Bicarb, because if given at the same time they can cause a precipitate. But anyway, how often do you find adding albuterol to that recipe? I see it added only in review books, but I'm not sure we're running around with ventolin inhalers while doing all this.

 

[AbbyNormal]

Well, I think the order should matter in terms of the Calcium and the Bicarb, because if given at the same time they can cause a precipitate. But anyway, how often do you find adding albuterol to that recipe? I see it added only in review books, but I'm not sure we're running around with ventolin inhalers while doing all this.

Yes I thought it was rather obvious to not give calcium and bicarb simultaneously unless you want chalk.

Sodium Bicarbonate drives K into cells approximately 5 min. Ca exerts its effect in 1-2 min Neither actually reduces K+ but it gives you time for the things that do like dialysis or kayexalate.

Thus I would give calcium first followed by bicarb. Maybe some insulin and D50. I can't recall ever seeing albuterol used.

 

[jdh71]

Well, I think the order should matter in terms of the Calcium and the Bicarb, because if given at the same time they can cause a precipitate. But anyway, how often do you find adding albuterol to that recipe? I see it added only in review books, but I'm not sure we're running around with ventolin inhalers while doing all this.

These are IV pushes. You know that right? You don't push two substances at once.

Albuterol (or even alternatively terbutaline) can be used, but it's used in such high doses patients really, really ****ing hate it - bad. I use it in the ESRD patients while I'm waiting for a dialysis nurse to get her pretty little ass into the hospital for symptomatic hyperK. These guys regularly walk around with K's like 5.5 to 6, so no need to get act super aggressive unless there are EKG changes or Ks >6.5. I do suggest something akin to panic, but much more measured and reasonable for arrhythmias in these patients and THOSE patients definitely get the Albuterol as well. When these patients code 2* to arrythmia 2* to hyperK, you just don't get them back.

 

[PirateHotel]

Is it risky to give high doses of albuterol considering the tachycardic effect?

 

[jdh71]

Is it risky to give high doses of albuterol considering the tachycardic effect?

It's a judgement call.

If the patient is already tachy, then you may avoid it. Giving people albuterol in NSR, usually does get them that tachy, maybe up to the 110s, which, while techincally fast, is not exactly a deadly rhythm. However, if you've got an ESRD guy, presenting with a K of 7.4, peaked t-waves big enough to drive a truck through, and intermittent NSVT on tele, and the dialysis people are still at least 30 minutes from plugging this guy in . . . I'd probably use it, along with all of your other normal hyperK quick fixes, even if tachy, as long as not too tachy, as a continuous neb until they got dialysis going for a awhile.

Medicine is an art. Any doc that can be replaced by a computer algorithm . . . should be.

 

[futureres]

It's a judgement call.
Medicine is an art. Any doc that can be replaced by a computer algorithm ... should be.

Best medicine quote EVER.

 

[dragonfly99]

We don't use the albuterol very much because it's not really that effective. If you're at the point where you have to use albuterol, then like jdh said, you're usually at the point where you don't give a crap about a little tachycardia. It's not like it will make the heart rate 200...

What I do if someone really has ECG changes and/or arrhythmias is give them a calcium gluconate push stat...that buys you a little time. It really does work fast.

After that, do the bicarb, insulin/glucose. Albuterol if you want, but I don't think it works that great...certainly not great like the calcium. After that you remove the potassium...dialysis and/or kayexalate. And don't be a weeny about the kayexalate...give them a crapload of it.

 

[PirateHotel]

Thanks for the great replies. In summary, consider salbutamol as a last ditch temporizing measure but there are much more effective options used prior to it. Also, the risk of symptomatic hyperK far outweighs the small risk of a salbutamol induced tachyarrhythmia.

 

[Speculatrix]

We don't use the albuterol very much because it's not really that effective. If you're at the point where you have to use albuterol, then like jdh said, you're usually at the point where you don't give a crap about a little tachycardia. It's not like it will make the heart rate 200...

Is albuterol readily available intravenously? Is that the form you give, or would you just write an order for some nebs or whatever? On a side note, the Target $4 list only has albuterol tabs PO. Of what possible use is this?? The only thing I can think of is exercise-induced asthma 20-30 minutes prior to exercise, since it would take too long to be a rescue medication for an acute attack in asthma/copd.

Te-hee, salbutamol, someone must be British!

 

[jdh71]

Is albuterol readily available intravenously? Is that the form you give, or would you just write an order for some nebs or whatever? On a side note, the Target $4 list only has albuterol tabs PO. Of what possible use is this?? The only thing I can think of is exercise-induced asthma 20-30 minutes prior to exercise, since it would take too long to be a rescue medication for an acute attack in asthma/copd.

Te-hee, salbutamol, someone must be British!

you use continuous nebs

 

[AuroraK]

Honestly, at the point at which you are relying on albuterol to correct someone's hyperK, youre rearranging deck chairs on a sinking ship. Calcium, Sodium Bicarb, insulin/glucose to buy you time, and Kayexelate, Lasix (and if needed dialysis) to get rid of the K.

 

[LukeWhite]

I'm always a little troubled by the folkloric didactics that accompany the management of critical conditions. Perhaps it's because nobody's going to argue with the senior physician ordering X,Y,Z STAT! or ask for an explanation of the pharmacology.

Anyway, the treatment of hyperkalemia is one of those conditions with lots of quantified data that nobody knows. Here's an oldish but good and widely-cited article that puts some numbers behind our PGY oral tradition:

http://jasn.asnjournals.org/cgi/reprint/6/4/1134

There's another good article I'll try to find that quantifies the effect of kayexelate. Though the theory of kayexelate is good, it turns out that the sodium-potassum gradient is only favorable for potassium exchange in the terminal sigmoid, at which point the kayexelate is already on its way out. In practice, most any cathartic, binding resin or no, will have roughly the same hypokalemic effect.

 

[drfunktacular]

I'm always a little troubled by the folkloric didactics that accompany the management of critical conditions. Perhaps it's because nobody's going to argue with the senior physician ordering X,Y,Z STAT! or ask for an explanation of the pharmacology.

Anyway, the treatment of hyperkalemia is one of those conditions with lots of quantified data that nobody knows. Here's an oldish but good and widely-cited article that puts some numbers behind our PGY oral tradition:

http://jasn.asnjournals.org/cgi/reprint/6/4/1134

There's another good article I'll try to find that quantifies the effect of kayexelate. Though the theory of kayexelate is good, it turns out that the sodium-potassum gradient is only favorable for potassium exchange in the terminal sigmoid, at which point the kayexelate is already on its way out. In practice, most any cathartic, binding resin or no, will have roughly the same hypokalemic effect.

Coincidentally, we had a lecture today about hyperkalemia...

Our renal attending basically said that kayexelate is fairly risky re: bowel necrosis, and should NEVER be given without lactulose or sorbitol (which was news to many of us, myself included). In addition, he also made the point that there's no clear evidence that it works any better than the cathartic alone. He was more in favor of giving someone 100 of lasix if they are making urine and replacing UOP cc for cc with NS if necessary for volume status.

 

[Hernandez]

Albuterol if you want, but I don't think it works that great...

I've seen more than a few asthmatics who were sucking down their HFA albuterol with Ks less well than 3.0, the last one had a k of 2.6 with no diuretic use, granted I think he used his HFA 30+ in the last half hour. 4 back to back albuterol treatments are easy to give, and in reality if you look at the data, it only increases the heart rate on average 4-8 bpm.