Tuesday, August 31, 2010

Giving Albuterol to decrease potassium.



Lately we at my humble hospital have been getting more and more orders for albuterol nebulizer treatments to decrease a elevated potassium level in a patient. This has made me curious as to why this works and if it really is a viable reason to give albuterol and a elevated potassium situation so I did some digging and here are some facts I found:


- Potassium is both an electrolyt and a mineral. It helps keep the water and electrolyte balance of the body. Potassium is also important in how nerves and muscles work.
- The normal level of potassium is 3.5-5.0 mEq/L
- Albuterol works to create smooth muscle relaxation through the beta-2 receptor site but one of it's other effects, is to reduce extracellular potassium concentrations by pushing the potassium into the cells. This action is quite handy, in a pinch, but do not rely on it because the action is too slow in it's onset to be of emergent help.
- Doses of 15 mg albuterol via nebulizer, hyperkalemic patients on hemodialysis experienced a 0.9 mEq/L decrease in plasma potassium which was sustained for 6 hours. Albuterol may stimulate sodium-potassium ATPase, resulting in an intracellular shift of potassium.
- Albuterol works to lower potassium concentrations by stimulating the release of insulin. This release of insulin shifts the potassium into the cells thus lowering the potassium level.
- Albuterol also stimulates the Na/k+ pump causing potassium to be shifted into the cells.
- A study compared the efficacy of 1) insulin + glucose. 2) albuterol and 3) both regimens combined when used to lower potassium concentrations. The study found that albuterol was just as effective and quick at lowering potassium concentration as insulin + glucose. The study also found that the two treatments administered together worked even better in reducing potassium level. Albuterol reduced the potassium level by up to almost 1mEq (0.62 - 0.98mEq).
- Using a large amount of albuterol in a patent not in hyperkalemia may cause the patient to become hypokalemic.
- The dose for albuterol when administered in hyperkalemia is 10-20mg.
- It is mentioned in ACLS for Experienced Providers (2003) p.162.
  • For moderate elevation of potassium (6 to 7 mEq/L):
  • Initiate a temporary intracellular shift of potassium using the following agents:
  • * Sodium bicarbonate: 50 mEq IV or up to 1 mEq/kg over 5 minutes
  • * Glucose/insulin: Mix 10 U regular insulin and 25 g (50 mL of D50) glucose, and give IV over 10 to 15 minutes
  • * Nebulized Albuterol: 5 to 20 mg over 15 min.

Well after doing some research on the subject to me it does look like a viable treatment to assist in the treatment of Hyperkalemia in patients, but from what I have been noticing is that the Doctors are not ordering this properly to even make a dent. We here at my hospital get orders for just a regular nebulized albuterol treatment of 2.5mg which is nowhere near the recommended 10-20mg to even cause a dent in the potassium levels.

To be curious about why your doing something is a good thing and the internet is a plethera of information to be found in our profession. If you have questions, research it.

Keep driving on RT's.

18 comments:

Rick Frea said...

I started writing a post about this a while ago, and also came to the same conclusion that you did: that ventolin can lower potassium, but doctors don't order a high enough dose to make it worth your time and effort.

Here are some further readings I've found:
low potassium

Rick Frea said...

Here's a couple more related links:

Xoponex just as effective as Albuterol in lowering potassium.

serum potassium

Djanvk said...

Thanks for the links Rick, I'll check them out.

Glenna said...

The docs at my hospital write for the 20mg dose fairly often and it works well. We were concerned about the side effects at first but only people extremely sensitive albuterol show more than a slight elevation of heart rate so that's good. The effects are temporary but it's a nice bandaid while they fix the rest of the metabolic problems that usually go along with it so we've found the tx to be worthwhile.

Anonymous said...

Thanks for sharing this link, but unfortunately it seems to be offline... Does anybody have a mirror or another source? Please answer to my post if you do!

I would appreciate if a staff member here at respiratorytherapydriven.blogspot.com could post it.

Thanks,
Charlie

Djanvk said...

I see what your saying about the link only the abstract comes up, somehow I had the full article when I was looking up information on the subject, I'll see if I can find another link.

Kannan said...

Good post.

robert said...

Thanks for that info. Here in Victoria, British Columbia, RT's very seldom give albuterol for hyperkalemia. As other RT's have commented, the requested dose is almost always 2.5 -5.0 mg. Hardly worth the effort.

RT Deo said...

I found your post because I was looking for the appropriate dose of albuterol to administer for hyperkalemia. In other links, I found the same dosage recommendation. I passed the information to the nurse caring for a patient we have that is experiencing some hyperkalemia in the am. The physcian ordered 2.5mg albuterol. I will pass this information to my counterparts so we can be a more effective team. I also was a combat medic on active duty and then was retrained as an RT in the reserves.

Patti said...

I'm a retired critical care RN now working with equine nutrition and found this post interesting as I'm looking at ways to prevent hyperkalemia in horses with HYPP. HYPP - HYperkalemic Periodic Paralysis is a genetic disease in Quarter Horses (and related stock breeds which have been interbred with affected lines). I'm exploring the use of PO albuterol - while nebulizers are used with horses with COPD its not a real practical solution in the average barn.
If anyone comes across anything they think might be relevant, I'd really appreciate if you'd post a comment.
Thanks!
Patti Woodbury Kuvik
Vail AZ

Snotsucker said...

I am curious why IV or oral albuterol is not used for this purpose. In the case of hyperkalemia you are using a side effect of the drug that you would want to work systemically instead of locally; as with a inhaled delivery. Any thoughts?

Anonymous said...

@SNOTSUCKER SEE THIS ARTICLE
Arch Dis Child. 1994 Feb;70(2):126-8.
Treatment of hyperkalaemia using intravenous and nebulised salbutamol.
McClure RJ, Prasad VK, Brocklebank JT.
SourceAcademic Unit of Paediatrics and Child Health, St James's University Hospital, Leeds.

Anonymous said...

I'm just a 4th yr medical student who randomly came across this while looking for something else.

We don't typically give more than 2.5-5 mg of albuterol because the side effects aren't typically worth it (frankly, almost every doctor I know would rather not treat a potassium of 6-7 than give albuterol, and would probably just do IV fluids instead). Think of the side effects of albuterol: tachycardia secondary to peripheral vasodilation, palpitations, hypoglycemia, tremor, sweats, agitation, and even crazy stuff in extreme cases like pulm edema, tachyarrhythmia, etc... also don't forget the epidemiology - how old is your typical patient who presents to you with hyperK? I think it's safe to say that they are generally older people. Therefore, expect the aforementioned side effects to be amplified by quite a bit. How many older people have undiagnosed a-fib or heart problems? You can literally kill them.

Why give b2 agonists when you can easily give them IV D5 (in moderate hyperK). In severe cases, you can give calcium gluconate (or calcium chloride). You can augment all this with bicarb if you wana go nuts, although I'm seeing bicarb getting used less.

by the way, you are wrong in saying that the action of albuterol in lowering potassium is slow. You can see the effects of it within 30 minutes in some cases. There are many many many articles on this. Here's one for example:
http://www.ncbi.nlm.nih.gov/pubmed/3827459

Anyways, as I mentioned, I am just a medical student. Many times my butt has been saved by an RT, so I have the highest regard for you guys.

Anonymous said...

I'm just a 4th yr medical student who randomly came across this while looking for something else.

We don't typically give more than 2.5-5 mg of albuterol because the side effects aren't typically worth it. Think tachycardia secondary to peripheral vasodilation, palpitations, hypoglycemia, tremor, sweats, agitation, and even crazy stuff in extreme cases like pulm edema, tachyarrhythmia, etc... also don't forget the epidemiology - how old is your typical patient who presents to you with hyperK? I think it's safe to say that they are generally older people. Therefore, expect the aforementioned side effects to be amplified by quite a bit. How many older people have undiagnosed a-fib or heart problems? You can literally kill them.

Why give b2 agonists when you can easily give them IV D5 (in moderate hyperK). In severe cases, you can give calcium gluconate (or calcium chloride). You can augment all this with bicarb if you wana go nuts, although I'm seeing bicarb getting used less.

by the way, you are wrong in saying that the action of albuterol in lowering potassium is slow. You can see the effects of it within 30 minutes in some cases. There are many many many articles on this. Here's one for example:
http://www.ncbi.nlm.nih.gov/pubmed/3827459

Anyways, as I mentioned, I am just a medical student. Many times my butt has been saved by an RT, so I have the highest regard to you guys.

Anonymous said...

my apologies - there seems to be something wrong with my connection (or me!) that my comment posted twice.

Karen Wright said...

I'm a mother of a child with an ion channelopathy. Doctors believe it is either hyperkalemic Periodic paralysis or hypoKPP. They haven't been able to catch an episode quickly enough to determine it. However, when he recently had severe asthma symptoms, and was treated with albuterol (2.5mg every 2-4 hours), he started having his muscle weakness. This post makes SO much sense now. I'm going to mention it to his neuro when we see him next.
Thank you!

Cora said...

Good post

rrtdave said...

New study in 2016 for management and prevention of hyperkalemia in adults. Can be found on "Up to Date" web site.

New guidelines for Hyperkalemia

Treatment and prevention of hyperkalemia in adults
September 29, 2016

David B Mount, MD
Richard H Sterns, MD
John P Forman, MD, MSc



Albuterol, which is relatively selective for the beta-2-adrenergic receptors, can be given as 10 to 20 mg in 4 mL of saline by nebulization over 10 minutes (which is 4 to 8 times the dose used for bronchodilation).


10 MG = 2 ml or 4 droppers of 0.5ml Albuterol solution mixed with 4 ml of NACL
20 MG = 4 ml or 8 droppers of 0.5ml Albuterol solution mixed with 4 ml of NACL

Dave MSRT, RRT-NPS