Hyperkalemia and Albuterol

[ResTech]

I was doing some overdue research today on hyperkalemia and learned a lot of information on the effects of albuterol in lowering potassium concentration. I found it very interesting that a medication commonly used to treat respiratory illnesses was very effective in treating an electrolyte disorder. I've only recently started hearing of albuterol being used for this so I assume the research is fairly new? I noticed in the draft DC EMS protocols, albuterol is an indicated treatment for hyperkalemia.

In case some aren't aware of how albuterol works in hyperkalemia I'll share an overview of what I was able to gather today... (others please correct if I give any misinformation and please share additional information on the topic).

The mechanism for which albuterol works in lowering potassium concentration is it stimulates release of glucose which in turn elevates the insulin level thus driving the potassium into the cells. Increased insulin activity also stimulates the Na/K+ pump also causing an increase in the driving of potassium into the cells.

One research study cited albuterol as having the same efficacy as insulin + glucose. The combined treatments have an even greater effect in lowering potassium level. No significant effects were noted with the high doses of albuterol administered. Albuterol was noted as causing a decrease in potassium by almost one mEq (0.63-0.98mEq) which is about the same as insulin + glucose administration.

The dose of albuterol for treating hyperkalemia is 10-20mg.

One question I have is will albuterol work in lowering potassium concentration in Type I diabetics? If the patient cannot increase insulin levels in response to the increased glucose level caused by the albuterol, how will the potassium be driven into the cells and the Na/K+ pump be stimulated? I tried researching this but came up empty.

I look forward to hearing comments and feedback.

[12170]

This is especially important to remember with asthmatic kiddos who take a heck of a lot of albuterol compared to most adults to get through an attack. Some of these kids can be on hours and hours of continuous neb treatments of up to 30 mg of albuterol an hour. They can become quickly hypokalemic.

As far as treatment for hyperkalemia, it is becoming much more prevalent. Don’t see it much by it self but used in conjunction with other treatments such as kayexalate or insulin/glucose.

[medic230]

This is why we use Albuterol for Crush Injuries / Compartment Syndrome. The K+ that is normally in the cells leaks into the bloodstream during anerobic metabolism and causes a number of cardiac complications when introduced into the circulation as the compressive forces (Present in crush) are removed. This is one reason why we pre-medicate crush patients with Sodium Bicarb (Because of the lactic acid produced by anerobic metabloism) Albuterol, Insulin/Dextrose and Calcium prior to removing the source of the compressive force.

[phlem sucker]

In order for this to work you would have to use 10-20 mg of albuterol per hour for several hours . Even then the change in K+ levels is not that much. I have had doctors order it, but never have seen it work. I would look at other ways to lower K+ levels instead of albuterol.

[medic230]

Like Calcium Chloride and Insulin.

[ResTech]

I have never given albuterol for hyperkalemia personally, but from the multiple studies on albuterol and hyperkalemia and different resources on treating hyperkalemia, albuterol is said to begin to work within 30mins and with the same efficacy as insulin - http://www.ncbi.nlm.nih.gov/pubmed/2919849.

From the American Academy of Family Physicians - "Shifting potassium intracellularly is done using insulin or a beta2 agonist". "Inhaled beta2 agonists have a rapid onset of action. The effect of beta2 agonists is additive to that of insulin administration, and they can be taken together".

The whole article is a great read on hyperkalemia management - http://www.aafp.org/afp/2006/0115/p283.html.

Reducing total body potassium level is kind of a long process and doesn't happen immediately.

"Even then the change in K+ levels is not that much" - almost 1mEq from albuterol alone is clinically significant, right? Add insulin at the same time and your probably looking at almost 2mEq decrease in potassium which may be enough to get a patient out of the danger zone and stabilized while other treatments are able to be started and the underlying cause of the hyperkalemia can be managed.

[Mary Katherine Gallagher]

In an acute care setting albuterol is rarely used for hypokalemia management and pre-hospitally I don't know too many services that carry enough albuterol to treat hypokalemia effectively. You also need to watch for the tachycardia that a dose of albuterol that high can cause in a patient that already has the potential for cardiac instability. The effects of insulin and D50 (together) and calcium do not last long but will work long enough to stabilize the cardiac cells and prevent life threatening arrythmias . Kayexelate is really your best fix as it works by calcium binding to potassium in the GI tract and thereby getting rid of the pottasium with the calcium. This can be given orally or by enema. The enemas are no fun to give though. In extreme cases dialysis is used. I don't have time to get citations for this info. The person that took time to get citations, good job but watch out on the dates of your citations. The first citation is from the 1980s and although the second citation is from the 2000's the sources the authors used are a bit old. As far as the albuterol working for Type 1 diabetics I am not sure. I will ask the clinical toxicologist that runs the unit I work on at the hospital.