الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Hyperkalemia is a common problem in ER that can range in severity from inconsequential to life-threatening. The treatment of hyperkalemia also varies widely and can include simply restricting dietary potassium, administrating oral, intravenous or inhaled medications and providing emergent dialysis for more extreme elevations. The AHA provided 2005 CPR guidelines that defined hyperkalemia as a serum K+ concentration higher than 5 mmol/ L. It was classified according to serum K+ level as; mild (5- 6 mmol/ L), moderate (6- 7 mmol/ L) and severe elevations (> 7 mmol/ L with toxic ECG changes).
More attention should be paid to the moderate elevation in serum K+ level between 6 - 7 mmol/ L as suddenly it may deteriorate to severe one, complicate with ECG changes, develop life threatening arrhythmias or push the patient to a sudden cardiac arrest. Early detection, accurate assessment, definitive classification, rapid management and short-term follow-up for susceptible patients; all are key points in obtaining better clinical outcomes in treatment of moderate hyperkalemic patients.
While hemodialysis is considered the definitive line of treatment for severe hyperkalemia and diagnosed cases of acute renal failure, still the moderate hyperkalemic patients with only impaired renal functions are not reported with such moderate laboratory values for urgent dialysis. Insulin, salbutamol and NaHCO3 are the three lines of treatment recommended by AHA 2005 CPR guidelines for this moderate level.
We concerned in our study with the moderate level (6- 7 mmol/ L). The aim of the study was to assess the response of serum K+ levels after initial lines of management of hyperkalemic patients. We assessed the efficacy of each line of treatment either separated or in a combination in the first twelve hours of patient presentation at ER. We selected all moderate hyperkalemic patients in our study with renal impairment (serum creatinine level 2-5 mg/dl) to ensure accurate comparison between the outcomes of different lines of treatment. We excluded patients on renal replacement therapy, patients with pH < 7.1 and patients with hyperkalemic ECG changes.
The study was conducted on fifty patients divided into 5 groups (G1, G2, G3, G4 and G5). Patients were randomly distributed provided that half of the patients in the whole sample and in each group were diabetics and the other half were not.
The ten patients of G1 were managed by IV infusion of 10 units of insulin AR over 2 hours, provided that 25 gm glucose in the form of 100 ml of glucose 25% were infused with in non-diabetic patients or in diabetic patients with blood glucose level below 250 mg/dl. Diabetic patients with glucose level above 250 mg/dl were given insulin infusion only. The ten patients of G2 were managed by 10 mg nebulized salbutamol over 2 hours where the nebulization settings were given divided into 4 doses of 2.5 mg (2.5 ml) per setting each half an hour, that were more safe to avoid any untolerated tachycardia. The ten patients of G3 were managed by NaHCO3 50 mmol IV over 5-15 minutes for 2 hours after ensuring that pH is > 7.5 and blood HCO3 level is > 28 mmol/L. The ten patients of G4 were managed by a triple cocktail of all previous lines.The ten patients of G5 were managed by giving IV Furosemide (Lasix) 10 mg/ 2 hours provided that BP was not below 110/70 mmhg.
The end target of treatment was to lower serum K+ level to < 6 mmol/L. The recommended treatment for each group was repeated every two hours until serum K+ level declined to < 6 mmol/L. Two DKA patients had been excluded from the sample as they had been randomly distributed in G2 and G3 where insulin infusion could not be given in our protocol of study. Another two diabetic patients were distributed instead of them.
Statistically, there were no significant differences between groups as regards means of age, initial serum K+ level, initial serum creatinine level, initial HR, initial pH and initial blood HCO3 level.
The results of this study showed that mean serum K+ level changes after 2 hours were ↓0.59, ↓0.42, ↓0.06, ↓0.69 and ↓0.01 mmol/ L in G1, G2, G3, G4 and G5 respectively. Mean serum K+ level changes after 4 hours were ↓1.07, ↓0.80, ↓0.16, ↓1.14 and ↓0.07 mmol/ L in G1, G2, G3, G4 and G5 respectively. At the end of the four hours; nine, nine and ten patients of G1, G2 and G4 respectively achieved the target point of treatment, while only one patient in G3 and none in G5 achieved the target point of treatment. After 12 hours, the changes of mean last obtained serum K+ levels from mean initial serum K+ levels were ↓1.21, ↓0.92, ↓0.39, ↓1.05 and ↓0.45 mmol/ L in G1, G2, G3, G4 and G5 respectively. At the end of the twelve hours; patients with serum K+ levels above 6 mmol/ L were one, one, seven, one and five patients in G1, G2, G3, G4 and G5 respectively.
After both 2 and 4 hours, there was a statistical decline change in mean serum K+ levels in G1 (IV insulin), G2 (nebulized salbutamol) and G4 (the triple cocktail) in comparison to G3 (NaHCO3) and G5 (furosemide).
However, after 12 hours, only G1 (IV insulin) had statistical significant decline in serum K+ level in comparison to G3 (NaHCO3) and G5 (furosemide). While G4 (the triple cocktail) had only statistical significant decline in serum K+ level in comparison to G3 (NaHCO3).
But only 3 of 10 patients of G2 (nebulized salbutamol) responded to treatment while 5 and 6 of 10 patients in G1 (IV insulin) and G4 (the triple cocktail) respectively responded to treatment after 2 hours.
This may imply that G1 (IV insulin) and G4 (the triple cocktail) were more effective than G2 (nebulized salbutamol).
Pharmacologically, the short duration of action of salbutamol is the possible explanation of this regression of the effects of both G2 and G4 at 12 hours in comparison with that at both 2 and 4 hours. Thus repeating the salbutamol dose is recommended every 6 hours at least guided with serum K+ level monitoring. Long acting Beta agonists are recommended to be tried in a lot of future studies to declare their therapeutic effects in hyperkalemia.
HRs of all groups were assessed and analyzed after the first two hours. The mean HR changes after two hours were ↑2.50, ↑12.90, ↑1.60, ↑13.40 and ↑3.60 b/ m in G1, G2, G3, G4 and G5 respectively. Statistically; the mean HR change after two hours was greater in G4 (the triple cocktail), then G2 (nebulized salbutamol), then G5 (furosemide), then G1 (IV insulin) and then G3 (NaHCO3). Both G2 and G4 showed significant differences in mean HR changes with all G1, G3 and G5. However, there was no significant difference between G2 and G4.
PHs of all groups were assessed and analyzed after the first two hours. The mean pH changes after two hours were ↑0.01, ↑0.02, ↑0.05, ↑0.06 and ↑0.01 in G1, G2, G3, G4 and G5 respectively. Statistically; the mean pH change after two hours was greater in G4 (the triple cocktail), then G3 (NaHCO3), then G2 (nebulized salbutamol) and then both G1 (IV insulin) and G5 (furosemide). Both G3 and G4 showed significant differences in mean pH changes with both G1 and G5. G4 alone showed significant difference in mean pH change with G2. However, there was no significant difference between G3 and G4.
HCO3 blood levels of all groups were assessed and analyzed after the first two hours. The mean HCO3 blood level changes after two hours were ↑0.17, ↑0.22, ↑2.06, ↑2.52 and ↓0.10 mmol/L in G1, G2, G3, G4 and G5 respectively. Statistically; the mean HCO3 blood level change after two hours was greater in G4 (the triple cocktail), then G3 (NaHCO3), then G2 (nebulized salbutamol), then G1 (IV insulin) and then G5 (furosemide). Both G3 and G4 showed significant differences in mean HCO3 blood level changes with all G1, G2 and G5. However, there was no significant difference between G3 and G4.
An additive comparison was done of mean serum K+ level changes after two hours between diabetic and non-diabetic patients in each group. There were no significant differences between diabetics and non-diabetics in all groups.
Another comparison was done in mean serum K+ level changes after twelve hours between diabetic and non-diabetic patients in each group. There were no significant differences between diabetics and non-diabetics in any of G1, G2, G3 and G5. Only there was significant difference between diabetics and non-diabetics in G4.
At last, the results of the study on the acute presentation of moderate hyperkalemic patients with renal impairment showed that IV insulin, nebulized salbutamol and the triple cocktail were more effective in lowering serum K+ level. Neither NaHCO3 alone nor furosemide alone showed any significant therapeutic effect in lowering serum K+ level.
The results of the study on the patients after twelve hours from the start of treatment according to the protocol showed that IV insulin alone had a more prolonged effect on serum K+ level than the triple cocktail.
The results of the study in the first two hours showed that the triple cocktail and the nebulized salbutamol had significant effects in increasing the heart rate, while the triple cocktail and NaHCO3 had significant effects in increasing both pH and blood HCO3 level.