Hyper-K Treatment REVEAL-ED

Written by Clay Smith

Spoon Feed
Medical therapy for hyperkalemia is highly variable and dropped the level by about 1mmol/L in 4 hours. Dialysis dropped it about 2.2mmol/L in 4 hours.

Why does this matter?
Hyperkalemia is a potentially fatal electrolyte abnormality. We need to be expert in treating it. This is a look at how it was done across multiple EDs and how effective it was in lowering potassium. Or you could skip this and listen to Dr. Rob Orman’s ERcast on hyper-K.

Hyperkalemia treatment REVEAL-ED
This was a multicenter prospective study to determine the treatment patterns in actual practice for hyperkalemia. They found that insulin/glucose was given in 64%. Hypoglycemia occurred in 6%; 17% if K >7mmol/L. Medical therapy dropped potassium from 6.3 to 5.3 in the first 4 hours. Only hemodialysis dropped it to normal in 4 hours (dropped 2.2mmol/L). There was tremendous practice variation, with 43 different medical treatment combinations observed. Other than insulin/glucose, treatments included: “calcium (55%), inhaled b2-agonists (33%), oral sodium polystyrene sulfate (31%), IV bicarbonate (29%), dialysis (24%), and i.v. diuretics (5%).” ECG changes were only seen in about one quarter of patients. However, with a potassium >7 mmol/L, 45% of ECGs had either peaked T waves or wide QRS. The study was funded by AstraZeneca, which makes a drug to treat hyperkalemia; several authors had received funding from ZS Pharma (part of AstraZeneca) or AstraZeneca. Their drug, patiromer, is not mentioned, as it had just received FDA approval at the start of this study. However, this study provided valuable intelligence in how and where to best use their drug, which explains their interest in funding it.

Another Spoonful
Rob Orman’s ERcast has a free audio episode on hyperkalemia that is absolutely fantastic.

Source
Real World Evidence for Treatment of Hyperkalemia in the Emergency Department (REVEAL-ED): A Multicenter, Prospective, Observational Study. J Emerg Med. 2018 Dec;55(6):741-750. doi: 10.1016/j.jemermed.2018.09.007. Epub 2018 Nov 1.

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