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Three Part Question

In [adults (>16 years) presenting to the emergency department with hyperkalaemia] is [nebulised salbutamol more effective than intravenous salbutamol] at [lowering serum K+ levels]?

Clinical Scenario

A 50- year old woman is referred to the Emergency Department by her GP with a serum potassium level of 6.4 mmol/L. A repeat blood test confirms hyperkalaemia, with a serum potassium of 6.8 mmol/L. After giving a cardiac membrane stabiliser and IV insulin and glucose her serum potassium is still high. You are about to prescribe IV salbutamol, then remember someone telling you they always prescribe nebulised salbutamol in hyperkalaemic. You wonder which of the two is more effective.

Search Strategy

Cochrane Library for Systematic Reviews: May 2011
MEDLINE using the OVID interface: 2003 to June 2011 week 2
EMBASE: 2003 to 2011 week 24
Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus: 1937 to 26th June 2011
COCHRANE: hyperkalaemia, hyperkalemia, hyperkal*, hyperpotass*, potassium and hyperpotassaemia.

MEDLINE:[exp Potassium/ OR exp Hyperkalemia/ OR hyperkalaemia.mp/ OR high potassium.mp/ OR hyperkal$.mp/ OR hyperpotass$.mp] AND [Salbutamol.mp/ OR exp Albuterol/ OR Adrenergic beta-agonist.mp/ OR exp Adrenergic beta-Agonists/ OR Ventolin.mp.] Limit to (english language and humans and yr="2003 -Current")

EMBASE:[exp Potassium/ OR exp Hyperkalemia/ OR hyperkalaemia.mp/ OR high potassium.mp/ OR hyperkal$.mp/ OR hyperpotass$.mp] AND [exp salbutamol/ or Salbutamol.mp./ OR albuterol. mp / OR Adrenergic beta-agonist.mp/ OR exp beta adrenergic receptor stimulating agent/ OR Ventolin.mp.] Limit to (english language and humans and yr="2003 -Current")

CINAHL: [Hyperkalaemia/ OR Hyperkalemia/ OR Potassium/ OR High Potassium/ OR Hyperkal*/ OR Hyperpotass*]AND [salbutamol/ OR albuterol/ OR ventolin/ OR adrenergic beta-agonist/ OR beta adrenergic receptor stimulating agent] Limit to (english language and humans)

Search Outcome

COCHRANE: 51 papers found, one of which was relevant. Review dated to 2003.
MEDLINE: 6 papers found, 1 of which was relevant.
EMBASE: 9 papers found, one of which was relevant.
CINAHL: 2 papers found, 1 of which was relevant.
The one relevant paper identified from this search was the Cochrane review.
After de-duplication 1 relevant paper was identified.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Mahoney BA, Smith WA, Lo D, Tsoi K, Tonelli M, Clase C 2005 Canada.	1 randomised cross-over study.	Systematic review. 1a	Serum potassium concentration.	No statistical significance observed. CI [ 0.0 , 0.0] for all time points 0 - 30 minutes. For both groups a second dose at 120mins further reduced levels.

Comment(s)

There is no clinical evidence comparing the use of nebulised salbutamol with intravenous salbutamol in the emergency management of hyperkalaemia in adults.

Clinical Bottom Line

As there is no clinical evidence available, local guidelines and advice should be followed.

References

1. Mahoney BA, Smith WA, Lo D, Tsoi K, Tonelli M, Clase C Emergency interventions for hyperkalaemia Cochrane Database of Systematic Reviews. 2005, Issue 2