Real World Evidence for Treatment of Hyperkalemia in the Emergency Department (REVEAL–ED): A Multicenter, Prospective, Observational Study

• Published in: The Journal of emergency medicine 2018-12, Vol.55 (6), p.741-750
• Main Authors: Peacock, W. Frank, Rafique, Zubaid, Clark, Carol L., Singer, Adam J., Turner, Stewart, Miller, Joseph, Char, Douglas, Lagina, Anthony, Smith, Lane M., Blomkalns, Andra L., Caterino, Jeffrey M., Kosiborod, Mikhail
• Format: Article
• Language: English
• Subjects: Aged; emergency department; Emergency Service, Hospital; Evidence-Based Medicine; Female; Humans; hyperkalemia; Hyperkalemia - therapy; Male; Middle Aged; observational study; potassium levels; Prospective Studies; Time-to-Treatment; Treatment Outcome; treatment patterns; United States
• ISSN: 0736-4679; 2352-5029
• DOI: 10.1016/j.jemermed.2018.09.007

Contemporary emergency department (ED) standard-of-care treatment of hyperkalemia is poorly described. Our aim was to determine the treatment patterns of hyperkalemia management in the ED. This multicenter, prospective, observational study evaluated patients aged ≥ 18 years with hyperkalemia (potassium [K+] level ≥ 5.5 mmol/L) in the ED from October 25, 2015 to March 30, 2016. K+-lowering therapies and K+ were documented at 0.5, 1, 2, and 4 h after initial ED treatment. The primary end point was change in K+ over 4 h. Overall, 203 patients were enrolled at 14 U.S.-based sites. The initial median K+ was 6.3 (interquartile range [IQR] 5.7–6.8) mmol/L and median time to treatment was 2.7 (IQR 1.9–3.5) h post-ED arrival. Insulin/glucose (n = 130; 64%) was frequently used to treat hyperkalemia; overall, 43 different treatment combinations were employed within the first 4 h. Within 4 h, the median K+ for patients treated with medications alone decreased from 6.3 (IQR, 5.8–6.8) mmol/L to 5.3 (4.8–5.7) mmol/L, while that for patients treated with dialysis decreased from 6.2 (IQR 6.0–6.6) mmol/L to 3.8 (IQR 3.6–4.2) mmol/L. Hypoglycemia occurred in 6% of patients overall and in 17% of patients with K+ > 7.0 mmol/L. Hyperkalemia-related electrocardiogram changes were observed in 23% of all patients; 45% of patients with K+ > 7.0 mmol/L had peaked T waves or widened QRS. Overall, 79% were hospitalized; 3 patients died. Hyperkalemia practice patterns vary considerably and, although treatment effectively lowered K+, only dialysis normalized median K+ within 4 h.