Management of hyperkalemia involves treatment of elevated serum potassium levels in patients in the neonatal intensive care unit (NICU), particularly those dependent on parenteral fluids.
Initially, neonates should be in good fluid and electrolyte balance and thus have normal serum potassium concentrations. Exceptions can and do occur rarely but need to be recognized in a timely fashion.
Maternal history suggestive of abnormal fluid and electrolyte status
Renal diseases with abnormal electrolytes
Malnutrition or very abnormal diet
Physical findings suggestive of abnormal electrolyte balance
Ascites, abdominal/flank masses
The usual neonate, even the very premature patient, does not need serum electrolytes measured immediately after birth. Initially, a neonate’s electrolytes and creatinine should reflect the mother’s status. Patients with a history or physical findings like those mentioned in the discussion of clinical findings may need an electrolyte panel early in life. Note that in the face of normal placental and maternal renal function, a totally anephric neonate may have normal (ie, maternal) serum creatinine and potassium levels at birth.
Serum electrolytes should be followed closely in all low birth weight (LBW) and sick patients in the NICU. Serum potassium levels in neonates tend to be somewhat higher than in older children and adults and not uncommonly will be in the range of 5 to 6 mEq/L. However, levels greater than 6.5 should be watched closely, and those greater than 7 are associated with poor outcomes.
Hyperkalemia results in specific recognizable changes in the electrocardiogram (ECG) in the following progression:
Tall, peaked T waves
Prolonged P-R interval
Bradycardia with abnormal QRS axis
Differential Diagnosis/Diagnostic Algorithm
Hyperkalemia in the neonate can be thought of in 4 categories:
Nonoliguric hyperkalemia (NOHK) occurs in the first few days of life in very low birth weight infants in the presence of normal urine output. It is caused by the transfer of potassium from the very high intracellular concentration (∼150 mEq/L) to the relatively low concentration in extracellular fluids. Factors that contribute to this potassium flux include
Immaturity of the energy-dependant Na+-K+ ion pump, which may be worsened by perinatal hypoxia or hypoglycemia
Acidosis resulting in increased H+-K+ exchange across cellular membranes
Epidemiologic findings associated with NOHK, including
(1) Birth weight less than 1000 g
(2) Fetal distress
(3) Metabolic acidosis
(4) Hyperglycemia (caused by osmolality and low insulin)
(5) Polyuric renal failure
(6) No antenatal steroid treatment
Tissue breakdown (eg, hemolysis, necrosis) is a minor contributor1 to NOHK. Indeed, severe hemolytic disease of the newborn does not commonly result in life-threatening hyperkalemia. Rare situations exist in which tissue breakdown may result in hyperkalemia:
(1) Tumorlysis (eg, congenital leukemia)
(2) Rhabdomyolysis from trauma, commonly concomitant with oliguria
(3) Rapid massive ...
Log In to View More
If you don't have a subscription, please view our individual subscription options below to find out how you can gain access to this content.
Want remote access to your institution's subscription?
Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.
If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.
AccessPediatrics Full Site: One-Year Subscription
Connect to the full suite of AccessPediatrics content and resources including 20+ textbooks such as Rudolph’s Pediatrics and The Pediatric Practice series, high-quality procedural videos, images, and animations, interactive board review, an integrated pediatric drug database, and more.
Pay Per View: Timed Access to all of AccessPediatrics
24 Hour Subscription $34.95
48 Hour Subscription $54.95
Pop-up div Successfully Displayed
This div only appears when the trigger link is hovered over.
Otherwise it is hidden from view.