【原】避雷～当快速输注甘露醇时注意高钾血症的发生可能

感谢梦梦提供ppt

高钾血症最严重的临床表现为肌无力或麻痹、心脏传导异常以及心律失常，其中心律失常包括窦性心动过缓、窦性停搏、缓慢型心室自主心律、室性心动过速、心室颤动及心搏停止。

甘露醇对血钾的双向调节作用

低剂量甘露醇（1g/kg）可以使血钾水平轻度降低，而快速输注高剂量的甘露醇（2g/kg）确实可以引起高钾血症。

解释这种现象的理论如下：

①甘露醇引起细胞外液扩容，HCO3-稀释，继发稀释性酸中毒是发生高钾血症的原因；

②另一种以强离子差理论解释，认为渗透性利尿剂作用与肾脏，使H+浓度升高，继发高钾血症；

③还有学者认为K+被动经K+通道移出细胞内是甘露醇引起高钾血症的原因。尽管甘露醇引发高钾血症的病例非常罕见，一旦发生常常为致命性。

根据是否存在高钾血症相关症状和体征、钾升高的严重程度以及高钾血症的病因，高钾血症的治疗紧迫性存在差异。关于治疗紧迫性，我们的处理方法如下

·高钾血症紧急情况−以下患者视为存在高钾血症紧急情况：有高钾血症的临床体征或症状(如，肌无力或麻痹、心脏传导异常以及心律失常)的患者；重度高钾血症(血清钾>6.5mEq/L)的患者；以及伴有持续性组织分解或钾吸收的中度高钾血症(血清钾>5.5mEq/L)合并显著肾功能受损的患者。

·需要及时治疗的患者−一些中度高钾血症患者尽管无高钾血症紧急情况，但仍需尽快(即，6-12小时之内)降低其钾离子水平。这类患者包括：在非常规透析时间就诊的血液透析患者，存在临界性肾功能和/或临界性尿量的患者，或者需要被最优化以接受手术的高钾血症患者。

·可缓慢降钾的患者−大部分高钾血症患者存在因CKD和/或使用抑制RAAS的药物而出现的血清钾慢性轻度(≤5.5mEq/L)或中度(5.5-6.5mEq/L)升高。这类患者并不需要尽快降低血清钾。

●存在高钾血症紧急情况的患者应接受如下处理

·静脉给予钙剂以拮抗高钾血症的细胞膜作用。

·静脉给予胰岛素(通常联合静脉用葡萄糖)以促使细胞外钾进入细胞内。

·迅速清除体内多余钾离子的治疗[即，肾功能未严重受损时使用袢利尿剂或噻嗪类利尿剂，或者肾功能严重受损时使用胃肠道阳离子交换剂和/或透析(优选血液透析)]。

·治疗高钾血症的可逆性病因，如纠正低血容量和停用会增加血清钾的药物[如，非甾体类抗炎药(NSAIDs)、RAAS抑制剂]。

·持续心脏监测和连续心电图检查。应在开始治疗后1-2小时检测血清钾浓度。此后的检测时间由血清钾浓度和患者对治疗的反应来决定。对于接受胰岛素的患者，无论是否使用葡萄糖，均应每小时检测1次葡萄糖，需持续最长达6小时，以监测是否存在低血糖。

●对于不存在高钾血症紧急情况的患者，治疗通常取决于降钾的紧迫程度如何

·若患者需要及时降低钾离子水平，通常可进行血液透析(若其存在重度肾功能不全)，还可联用胃肠道阳离子交换剂(优选锆环状硅酸盐或帕替柔莫)。对于肾功能正常或轻至中度受损的患者，纠正高钾血症的病因(如，药物、低血容量)结合盐水输注和袢利尿剂治疗通常足矣。这类患者有时会使用胃肠道阳离子交换剂。

·对于可缓慢且安全地降钾的患者，通常能采用逐渐降低血清钾的疗法进行治疗，如低钾饮食、袢利尿剂或噻嗪类利尿剂、或者减量或停用能升高血清钾的药物。随着帕替柔莫和锆环状硅酸盐的上市，预计胃肠道阳离子交换剂将会更频繁地用于这些患者，以长期控制血清钾。

●一些措施可帮助CKD患者预防高钾血症或防止其恶化，尤其是终末期肾病(ESRD)患者。除了低钾饮食以外，下述方案也对接受维持性血液透析的病情稳定患者有效

·避免空腹，空腹可增加钾离子向细胞外转移，这种情况至少部分归因于胰岛素分泌减少。

·对于中度高钾血症患者，若条件允许，应避免使用可使血清钾浓度升高的药物。这些药物包括RAAS抑制剂，如ACEI、ARB、直接肾素抑制剂、醛固酮受体拮抗剂，以及非选择性β受体阻滞剂(如，普萘洛尔和拉贝洛尔)。

·避免或停用其他减少钾离子排泄的药物(如，NSAIDs)。

·当适用时均应使用噻嗪类利尿剂或袢利尿剂。

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