Introduction and Aims: Hyperkalaemia is a potentially life-threatening electrolyte disorder that can occur in various clinical settings and is correctable with treatment. It can be classified into mild (5.5 - 5.9 mmol/L), moderate (6.0 - 6.4 mmol/L) and severe (≥ 6.5 mmol/L). Calcium gluconate should be reserved for patients with ECG changes and the recommended dose is 30 ml 10% calcium gluconate. The aim of this audit was to compare our performance against the joint guidelines from the UK Renal Association. In addition, we also looked at the prescription of insulin-glucose and calcium gluconate.
Methods: Amongst 1403 hospital admissions in September 2014, true hyperkalaemia was detected in 44 patients. Out of these, 37 patients were included in the analysis.
Results: Out of 37 cases; 25 were of mild (67.6%), 4 moderate (10.8%) and 8 of severe hyperkalaemia (21.6%). The mean age was 76.4 years (35 - 101) with an equal male to female ratio. Summary of the audit results can be found in the table below.
SO007 Table 1:
All patients in the severe and 2 in the moderate group received treatment. ECG changes occurred in 6 patients and repeat ECGs post treatment were done in 4 of them (66.7%). These ECGs were repeated 12, 14, 15 and 24 hours post treatment. 10 ml 10% Calcium gluconate was administered to 5 patients with ECG changes (83%) and to 4 patients with no ECG changes. In patients with severe hyperkalaemia, continuous ECG monitoring was only documented in 1 patient (12.5%) and resin was given to 1 patient (12.5%). Repeat measurement of potassium (K+) level within 2 hours of treatment initiation was only done in 5/8 patients (62.5%). Out of 10 patients receiving insulin-glucose treatment, only 3 patients (30%) had repeat blood glucose measurement within 1 hour of treatment completion. An insulin-glucose infusion rate of ‘’over 15-30 minutes’’ as per guideline was prescribed in 7/10 cases (70%). Although a local guideline was available, it was not easily accessible and has not been updated. Since March 2014, no update on the topic hyperkalaemia has been taught in Emergency Department's (ED) or in Emergency Assessment Unit's (EAU) weekly teaching.
Conclusions: Our audit highlighted important issues such as delays in repeating ECG after treatment completion, insufficient dosage of calcium gluconate (undertreatment) and inappropriate prescription of calcium gluconate for patients without ECG changes; these are most likely caused by lack of education in the subject. As evidenced by this audit, the most common mistake practised involves administration of a single dose of 10 ml 10% calcium gluconate followed by poor assessment of response. The guidelines recommend a dose of 30 ml 10% calcium gluconate since sequential dosage is often required and this should be highlighted during teaching. Improvements in documentation and simple measurements such as; repeat K+-level within 2 hours after treatment initiation, measuring blood glucose within an hour after treatment completion and repeating ECG post treatment, are necessary to monitor possible side effects such as hypoglycaemia and to assess adequate response to treatment. Measurements involving updating local guidelines, teaching sessions for doctors and nursing staff working in ED and EAU, as well as displaying posters of treatment algorithm have been organized. A re-audit will be done once all steps are in place.
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