lactulose vs kayexalate for hyperkalemia

furosemide, 500 mg i.v. It is important to know that the peak effect of SPS takes about 4-6 hours, so if ECG changes are present, you will need to use IV calcium for membrane protection and albuterol/insulin+dextrose for transient K+ shift to the intracellular. Bactrim: the hyperkalemia induced by Bactrim is via an ENaC inhibitory effect exerted by the trimethoprim moiety. Magnesium depletion reduces intracellular potassium concentration due to impairment of the activity of cell-membrane NA+/K+-ATPase and causes renal potassium wasting. (2) Gennari FJ. I’m curious as to why paediatricians are wedded to NS especially in really sick septic kids with hyperK. The European Resuscitation Guidelines further classify hyperkalaemia as: 1. In primary care, samples cannot be takenclose to the point of analysis for rapid delivery without widespreadroutine use of point of care testing, which has its own difficulties.Laboratories could optimise carrying conditions and educate users: more systematic use of insulated specimen boxes in practices and temperature controlled transport systems in collection vansmay help. Measured K before and after.Results: Saline worked just as well as bolus. Drugs which cause translocation of K from the intracellular to the extracellular fluid: these include succinylcholine, isoflurane, minoxidil, and beta-blockers.2. Thought maybe there would becombined/synergistic effects of the two meds.Results: Bicarb alone didn’t change the potassium. Traditional management of hyperkalemia has involved using ampules of hypertonic 8.5% sodium bicarbonate (which has an osmolality of 2000 mOsm, about seven times higher than plasma). is the K+ excreted with the stool) The reason I ask is that we have a patient w/K+ 5.4. First option, if he doesn’t have ECG changes, is to try a loop diuretic at a high dose to see if he can respond to that and produce some kaliuresis. This combination should be avoided, especially in patients with compromised GI function (e.g. (3)  Zipes DP, et al. has been to combine intravenous furosemide and chlorothiazide, and this seems to be effective. ileus post-op). Recent evidence fuels growing concerns about use of sodium polystyrene sulfonate with sorbitol. Hyperkalaemiahas four broad causes: 1. Here … (6) Nicolis, GL, et al. Thus, 30 g of Kayexalate … Hyperkalemia, used to describe an elevated level of potassium in the blood, occurs when there is a disturbance in the balance between intake and elimination or a shift of potassium between the … Storage And Handling. More acute hyperkalemia management on this blog. Normal saline is proven to worsen hyperkalemia and should be avoided. Marked hypokalemic rhabdomyolysis with myoglobinuria due to diuretic treatment  Eur Neurol 1991; 31:396. There have beena few studies looking at combining bicarb + either of these othermethods, and it looks like the bicarb *probably* DOES have somesynergistic effect (it lowers the potassium more than just, say, albuterol alone). ileus post-op). If wide QRS:1 amp CaCl by slow push or if poor IV line, 2 amps CaGluc by slow infusion10 units insulin &2 amps D50 (50 G)Albuterol 5 mg nebulizedNaBicarb 150 meq in IV fluids, administer at a rate commensurate with volume status250 ml Normal SalineKayexalate 60 GIf volume overloaded, Lasix 40 mg ACEARBsNsaidsCOX2Potassium Sparing Diuretics, Hyperkalemia can be a life-threatening condition. Their paper titled, “Single-dose sodium polystyrene sulfonate for hyperkalemia in chronic kidney disease or end-stage renal disease” from 2019 used retrospective data of 114 CKD/ESRD patients with hyperkalemia. Both groups showed decreases in their potassium, ~1.6-1.8mmol/L (never seen this significant of a drop reproduced). Glucose may cause a further decrease in the serum potassium concentration, presumably caused by the enhanced insulin secretion stimulated by glucose, which results in the movement of potassium into cells. However, in the face of life-threatening hyperkalemia, it may be safer to err on the side of over-treatment followed by meticulous replacement of electrolytes and fluid as needed. This page includes the following topics and synonyms: Hyperkalemia due to Medications, Medication Causes of Elevated Serum Potassium, Drug-induced Hyperkalemia. It has now been clearly demonstrated that short-term bicarbonate infusion does not reduce plasma potassium concentration in patient with dialysis-dependent renal failure, implying that it does not cause potassium shift into cells (1). For example, at Genius General we once admitted a pleasant elderly man with chronic renal failure complicated by hyperkalemia causing bradycardia and shock. Kayexalate is used to treat high levels of potassium in the blood, also called hyperkalemia. The reason behind this approach is that a session of hemodialysis further delays the recovery from ATN/ischemia and significantly drops urine output afterwards (indirect evidence – no randomized trials available). Sodium polystyrene sulfonate (SPS; e.g., Kayexalate) has been used as an oral or rectal therapy for hyperkalemia … I’d love to know your thoughts on this. The reduction in serum potassium allows only a rough approximation of whole body losses. Precisely why hypertonic bicarbonate fails to work is unclear. Renal causes - eg, due to decreased excretion or drugs. Spurious results relating to temperature or storage can be moreproblematic. In the presence of hyperglycemia (blood glucose >360 mg/dL), insulin alone should be given, as additional glucose leads to hypertonicity that can aggravate hyperkalemia (1). Hyperkalemia revisited. Glucose-induced hyperkalemia in diabetic subjects  Arch Intern Med  1981;141:49. cardiac abnormalities are common when > 6.5, not a stepwise progression, can go from none to fatal dysrhythmia (J of Crit Care 2008;28:431). Hi there -- Quick question. A cation-exchange resin is a cross-linked polymer with negatively charged structural units. References: (1) Weisberg LS. NSAIDs: NSAIDs can lower renin secretion, which is normally mediated in part by locally-produced prostaglandins.6. For a hypovolemic patient without metabolic acidosis, lactated ringers is a reasonable fluid choice. Pentamidine induced hyperkalemia via a similar mechanism.7. 2. Pharmacology - Lactulose vs. Kayexalate nursing RN PN NCLEX. Isotonic bicarbonate may be effective for patients … My question to you is whether the points you make hold true in children? For bicarb, it was 8.4% in water, 4mmol/min, for 1 hour only. 2. Moderate - 6.0-6.4 mmol/L. Results: Divided groups retrospectively into “constant pH” and”changed pH” groups. * The use of IV calcium with concurrent digitalis toxicity is of concern because of the potential to exacerbate bradyarrhythmia and potentially cause arrest. Many articles from the70s/80s cite this one. Last year, Sterns et al. The good news is that abandoning Kayexalate allows us to focus on a more effective approach to hyperkalemia: renal potassium excretion (kaliuresis). potassium salts of penicillin), Trauma (especially crush injuries and ischaemia), Decreased glomerular filtration rate (eg, acute or end-stage chronic renal failure), Defect in tubular secretion (eg, renal tubular acidosis II and IV), Drugs (eg, NSAIDs, cyclosporine, potassium-sparing diuretics, ACE Inhibitors), Haemolysis (in laboratory tube) most common, Venepuncture technique (e.g. They also tried a isotonic bicarb infusion of 1.4%.Results: The K actually went UP after both bicarb infusions.They conclude that bicarb didn’t work, but in the past it’s workedover longer periods of time. A patient who is hypokalemic in the face of ACIDOSIS and is getting insulin to boot, may be another exception. References: (1) Sood MM, et al. (Some of them got calcium as well, others required “5-10 gramsof bicarb a day,” others got bicarb + blood transfusion. Checked K every hour. Salt substitutes (e.g. The also have contraction alkalosis, and because the K gets artificially very low, are getting aggressive (20 mmol/h) K replacement. KAYEXALATE is available as a cream to light brown, finely ground powder in jars of 1 pound … This is potentially related to hemodynamic changes associated with the dialytic procedure, even in the absence of volume removal (osmotic shift). Efficiency of a resin is dependent on several factors, including intrinsic properties of the resin (capacity and ion selectivity), [K+] and [Na+] extracellular concentrations and colonic transit time. As an alternative, lactulose could be used to stimulate the GI tract. Lactulose and Hyperkalemia - a phase IV clinical study of FDA data Summary: Hyperkalemia is found among people who take Lactulose, especially for people who are male, 60+ old, have been taking the drug for < 1 month. Finally, Kayexalate releases sodium ions after uptake of potassium, so there is a potential side effect of edema due to sodium retention … Anything with insulinor albuterol the combination worked, lowered them from 0.5-0.8,depending on the group. Of note, bicacrb + albuterol worked betterthan saline + albuterol (see Kim, 1997).Kim, 1997 Methods: Took 9 HD hyperK patients, gave them separate or combinedbicarb infusions (1/2 hour long) along with nebulized albuterol,checked K before and after. Also checked an EKG.Results: Average K was 6.0. Polystyrene sulfonate. Immediate translocation of potassium into cells is bestachieved by insulin and b-2 agonists.”, Martin et al. a K of 2.5 may be equivalent to a K of 1.5 in a patient with normal pH. Isotonic bicarbonate may be effective for patients with metabolic acidosis. K dropped at 4-6 hours, by 0.5-0.7, andthey believe that half of the drop is probably due to the huge sodiumload and increase in the extracellular fluid compartment.Allon, 1996Methods: Took 8 HD non-HyperK patients, put them through differentcombinations to lower their K (bicarb infusion, saline infusion,bicarb+insulin, saline+insulin, bicarb+albuterol, saline+albuterol).Results: Bicarb or saline infusions didn’t work. Can lead to rhabdomyolysis, GI losses, ampho B, Insulin, Rta, Diet, Burns, Alkalosis, Timentin and other pcns, Hypomagnesaemia, Steroids. )Fraley, 1977Methods: Took 14 hyperK patients, gave them bicarb infusions over 4-6hours. See here for full disclaimer. 2nd ed. Regardless of the cause, the ability to correct potassium deficiency is impaired when magnesium deficiency is present, particularly when the serum magnesium concentration is < 0.5 mmol/L. Drugs such as mannitol can therefore cause translocational hyperkalemia.5. Related to collection and storage of specimen: Patient clenched fist when sample was taken, Sample was shaken or squirted through needle into collection tube, Contamination with anticoagulant from another sample (potassium EDTA), Deterioration of specimen due to length of storage, Severe leucocytosis (which can also produce pseudohypokalaemia), Hereditary and acquired red cell disorders, Serum potassium is normally maintained between 3.5 -5.0 mmol/L, Hyperkalaemia is defined as a potassium level greater than 5.5 mmol/L. London, England: BMJ Publishing Group; 1997:254. If ECG changes are present, administration of IV calcium should normalize the ECG patterns. Going back to our patient: After a diuretic trial, I would recommend two doses of 30g of Kayexalate mixed with water PO with repeat labs in 8-12 hours. This has been documented to precipitate arrhythmias and neuromuscular paralysis (1,2). This medication comes … Some authors recommend slow infusion of calcium if ECG changes due to hyperkalemia, such as loss of P waves or QRS complex widening, are present. The serum potassium concentration can rise acutely by as much as 1-1.5 meq/L after an oral dose of 40-60 meq, and by 2.5-3.5 meq/L after 135-160 meq (6). This is not meant to imply that sodium bicarbonate should be withheld from the hyperkalemic patient with metabolic acidosis; rather, no short-term effect on the potassium concentration should be anticipated. Unfortunately this requires a large volume of fluid, and cannot be used in patients with volume overload. Kayexalate is indicated for the treatment of hyperkalemia. Bicarbonate also appears to be ineffective in patients without significant pre-existing metabolic acidosis. Decreased potassium release due to profound hypokalemia may diminish blood flow to muscles in response to exertion. The danger is giving potassium to a patient in ALKALOSIS where the observed hypokalemia is an effect of the pH. Bicarb is probably pretty worthless.Reviewing the literature, it seems like the insulin/D50, albuterol (? Renal insufficiency, adrenal or aldosterone insufficiency, diuretics or ACEI, Type IV RTA, Tumor lysis or Rhabdo, Hemolysis, GI Bleeds, Pen-VK, DKA, Beta Blockers, Digoxin Overdose, Sodium Bicarb 150 meq in 1 liter fluids run like IV fluids variable variable Insulin/Glucose 10 units Insulin/50 g D50 then add 20 units RI in 1 liter fluids with 2 amps D50 added run over 2 hours 30 min 4 to 6 hours Albuterol 10-20 mg over 15 min 15 min 15 to 90 min Furosemide 40 -80 mg c diuresis until end of diuresis Kayexylate 15-50 g (PO or PR) plus sorbitol. Bicarb For Hyperkalemia: Not What You Were Taught (from EMEDhome). KAYEXALATE is indicated for the treatment of hyperkalemia. Thanks. Five cases of extensive mucosal necrosis and transmural infarction of the colon have been reported after the use of sodium polystyrene sulfonate (Kayexalate) and sorbitol enemas to treat hyperkalemia in uremic patients [24]. 3. Theoretically, acetazolamide may be expected to be more kaliuretic than a thiazide diuretic. In a retrospective review, ECG changes were seen in 43% of patients with potassium values ranging from 6.0 – 6.8 mEq/L and in only 55% of patients with values > 6.8 mEq/L (1,2). Tex Heart Inst J. (5) Dominic, JA, et al. “Should not be used.”Weisberg, 2008: Definitely doesn’t work short-term, but might still beuseful for temporizing hyperK. This has been discussed in, The effects of pH on renal handling of potassium is reviewed by. He responded well, and ultimately required potassium and fluid repletion. (4) Shintani, S, et al. hyperkalemia before or always has hyperkalemia. 1998;158(8):917-924. Post was not sent - check your email addresses! He wished never to undergo dialysis and was not amenable to this therapy even temporarily. Nonetheless, in transplant recipients with delayed graft function, there is a tendency to try to avoid dialysis early after transplant. Magnesium repletion improves the coexistent potassium deficit (1,3). I think in theED we’re sometimes taught to just give them an amp or two of sodiumbicarb, but that appears to have NEVER been studied.All the studies have really looked at bicarb infusions over hours, andif there’s any change to be found, it’s maaaybe at the 6 hour mark(after 6 hours of bicarb infusion, in patients who are already gettingdialysis). Potassium repletion is most easily done orally. In general, a decrease in 0.5mEq/l [K+} would require at least 30g of Kayexalate. This Na + is theoretically exchangeable for 4 mEq of K +. As an alternative, lactulose could be used to stimulate the GI tract. In considering when hyperkalemia … Potassium levels of 6.1 mEq/L to 7.0 mEq/L are considered moderate hyperkalemia, while levels above 7 mEq/L are severe hyperkalemia. Small number of patients (n=22) but the results looked quite impressive, since a median dose of 40g was able to decrease the potassium level by 1mEq/L and additional doses led to further decrease in levels (median decrease of 1.8mEq/L). The insulin will further drop his serum K. Yes, I would give KCl in this setting. I love this post. in an editorial on JASN concluded that the use of SPS resins is largely unproven and potentially harmful, and should be considered only as a last resource. Pretty interesting stuff.Sincerely,Graham WalkerKim MedlejBurnell, 1956Looks like this is where a lot of it started. If it does not, a second dose can be administered (1). Hypokalemia  N Engl J Med 1998;339:451-458. (2) Acker CG, et al. We are the EMCrit Project, a team of independent medical bloggers and podcasters joined together by our common love of cutting-edge care, iconoclastic ramblings, and FOAM. When treating significant hypokalemia with IV potassium replacement, initial therapy should consist of potassium administered in glucose-free solutions. From what I understand there is also the thought that at this point the K has poisoned the Na channels so much that you are almost treating it like a Na-Channel blocker overdose. It's also used to treat portal-systemic encephalopathy, a complication of liver disease. The phase IV clinical study analyzes which people take Lactulose and have Hyperkalemia… There’s very little on their methodology, butthey have some pretty cool graphs that show an inverse relationshipbetween pH and serum potassium concentration.Schwarz, 1959Case series of hyperK patients who had EKG changes who got better withbicarb. I know before I read this literature I felt better because I’d given theperson kayexalate, or I’d given them bicarb, but really, the othermethods are much more likely to keep the patient alive on the floorfor 6 hours while they await their dialysis, without putting them intoflorid fluid overload.I’ve summarized the literature and we can send you the articles ifyou’re curious (but they’re old, so the PDFs are big and it’s about9MB). (One study that took patients and put themon a high or low dose bicarb infusion for an hour actually found ahigher potassium levels after the infusion.) When you're done listening to the podcast. Reviewing the bibliography of the single RCT identifies a preliminary report describing the use of kayexalate in 1961 s… Now, it gets into a little controversial territory. Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation, Filed Under: PULMCrit Tagged With: hyperkalemia. Hi, thanks for your comment — sorry I should have clarified this earlier. This combination should be avoided, especially in patients with compromised GI function (e.g. Ionization and hemodynamic effects of calcium chloride and calcium gluconate in the absence of hepatic function. This site represents the opinions of Crashing Patient LLC. “It has now been clearly demonstratedthat short-term bicarbonate infusion does not reduce PK in patientswith dialysis-dependent kidney failure, implying that it does notcause K shift into cells. Josh is the creator of PulmCrit.org. There is no evidence regarding the number or dose of diuretic which should be used. digitalis: digitalis inhibits the Na-K ATPase (which pumps 3 Na out of the cell and 2 K in); as such, it can result in hyperkalemia and a variety of cardiac arrhythmias. For a patient with life-threatening hyperkalemia, it is often reasonable to make a single attempt at kaliuresis prior to proceeding to dialysis or simultaneously to pursuing dialysis (e.g., while arranging transfer to a hospital with dialysis capabilities). (4) Kim HJ. The magnitude of the decrease is 0.5 – 1.0 mEq/L. 3. Here are a list of some of the common offenders, categorized loosely based on mechanism, though admittedly there is some overlap between categories:1. Neither Kayexalate nor hypertonic bicarbonate (i.e., ampules of 8.4% bicarbonate) are effective for emergent treatment of hyperkalemia. In my experience, sick kids with renal failure & hyperK get exclusively 0.9%saline & insulin/dextrose perhaps, but the suggestion of giving Hartmanns/LR is practically heresy. Image of bicarbonate ampule: http://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=c1ab9fff-c97b-4fca-b7a2-2378045bc799&type=display, Diagram of nephron: http://www.boomer.org/c/p2/Exam/Exam9905/Exam9905-1.html. Arch Intern Med. References: (1) Agarwal A, Wingo CS. Combined effect of bicarbonate and insulin with glucose in acute therapy of hyperkalemia in end-stage renal disease patients. Anesthesiology. The FDA approved oral sodium zirconium cyclosilicate (ZS-9), to be marketed as Lokelma, for the treatment of hyperkalemia. In the absence of evidence, selection of the number and dosage of diuretics must be based on clinical judgement. Is Kayexalate effective? Kayexalate works differently from other medicines because it passes into your intestines without being absorbed into your blood stream. Limitation of Use: Kayexalate should not be used as an emergency treatment for life-threatening hyperkalemia because of its … That really doesn’t appear to be the case. CONTRAINDICATIONS . This dogma was based upon studies using a prolonged (4-6 hours) infusion of bicarbonate (1,2). (3) Allon M, Shanklin N.  Effect of bicarbonate administration on plasma potassium in dialysis patients: interactions with insulin and albuterol  Am J Kidney Dis 1996;28:508-14. These patients may arrest at K levels of 5-6. and as their alkalosis is corrected may get there pretty darn quick. Serum K tends to rise. Sorry, your blog cannot share posts by email. I was able to download the first trial using SPS resins published in the NEJM in 1961! Anesthesiology 1987;66:465-70. It is used as a potassium binder in acute and chronic kidney disease for people with hyperkalemia … * Insulin administration decreases serum potassium levels within 15 minutes, with the effect peaking at approximately 60 minutes and lasting for 4 – 6 hours. Magnesium depletion often coexists with potassium depletion as a result of drugs (e.g., diuretics) or disease processes (e.g. See. Emergency Management and Commonly Encountered Outpatient Scenarios in Patients With Hyperkalemia Mayo Clin Proc 2007;82:1553-1561. Acidosis shifts K from the cell to the extracellular compartment. Further discussion of isotonic bicarbonate may be found on a prior post regarding, (3) I'm not aware of any direct evidence upon which to base this selection. Many case reports in the literature describe patients with severe hyperkalemia who present with a normal ECG (1). This is commonly obtained by adding 3 ampules of sodium bicarbonate (containing 50 mM/ampule) to a liter of D5W. So what are your options if you have a patient with a potassium of 6 about 72 hours after transplantation with low urine output? Is it seen as an evil practice for you ? She is receiving Kayexalate … That was quite shocking to me since I have used it many times and I always saw a decrease of serum potassium levels. will see flattened T waves and U waves on ekg, RTAs 1 and 2, worry if <2.5. (4) Parham WA, et al. Can you address specifically the use of NaBicarb push in the patient who has developed a wide complex bradycardia/sine wave morphology from their hyperkalemia? Lasix, not much literature on it) methods are the way to go. Of course in some situations such as chronic anuric renal failure, kaliuresis is unlikely to succeed, so it may be more sensible to proceed immediately to dialysis. According to the most recent AHA/ACC guidelines it is “reasonable” to maintain serum potassium > 4.0 meq/L in patients with an acute MI (3). In order to lower a high K+ level with Kayexalate, does there need to be a successful bowel movement (i.e. Other studies with bicarb infusions show no statisticallysignificant change, either. There is increasing recognition that sodium polystyrene sulfonate (Kayexalate) is ineffective for the immediate management of severe hyperkalemia (. Copyright 2009-. With Kayexalate exerting its effects primarily in the large intestine, this therapy is rendered ineffective in this patient. The resin can exchange bound Na + (Kayexalate) or Ca 2+ (calcium resonium) for cations including K +. Salbutamol alonedropped the K by 0.6, and salbutamol + bicarb dropped the K by 0.9.Kaplan, 1997Methods: Took 8 dogs, gave potassium infusion until they gotconduction disturbances, then backed down on the K, and gave eitherbicarb infusion (1.05% over 1 hour), bicarb bolus (8.4% over 5minutes, then saline), or “saline” therapy (hypertonic saline 8.4%bolus + normal saline). Picture above from Jackson Hole – insane ski destination…Bicarb Stuff From Graham:Quick summary: We’re all taught bicarb works within 30 minutes, byintracellular shift/exchange of potassium ions for hydrogen ions, yadayada yada. Your patient is the exact opposite example, and his hypokalemia should have been corrected. Diuretics, Cushing’s, Familial Periodic Paralysis, Hyperthyroidism. What about volume resuscitation of a patient with hyperkalemia who doesn't have metabolic acidosis? Kayexalate treats hyperkalemia … Nearly 40 years after Farber and colleagues4 associated skeletal muscle exercise with increases of potassium levels from 0.3 to.1.0 mmol/L, Don and colleagues5 showed that fist clenching produced ex vivo hyperkalemia … Inhibitors of renin-angiotensin-aldosterone axis: ACE-inhibitors, angiotensin receptor blockers.4. Infusion of a hypertonic or an isotonic bicarbonate solution for 60 mins has been shown to have no effect onPK in dialysis patients, despite a substantial increase in serumbicarbonate concentration.” “Sodium bicarbonate should not be withheldfrom the hyperkalemic patient with met- abolic acidosis; rather, thatno short-term effect on the PK should be anticipated.”Rachoin, 2010: “When treating hyperkalemic patients, hospitalists should use sodium bicarbonate to potentiate urinary elimination ofpotassium and should consider administering it either withacetazolamide or a loop diuretic, anticipating a lowering effect aftera few hours.26 It should be avoided in patients with volume overloadand anuria. Would love your thoughts, please comment. (3) Advanced Life Support GroupPaediatric Life Support: The Practical Approach. In retrospect, he likely would have responded to a less aggressive diuretic regimen. Kayexalate has marginal efficacy, is poorly tolerated, and has delayed onset of action; Kayexalate … Kayexalate was approved in by the U.S. Food & Drug Administration (FDA) in 1958 to treat hyperkalemia, or dangerously high levels (greater than 6.0 (mmol/L) of potassium. So then they do …Blumberg, 1992Methods: Took 12 hyperK (>5.8) patients on dialysis, gave a bicarb(8.4% in free water) infusion 4mmol/min x1 hour, then 1.4% bicarb inwater infusion 0.5mmol/min hours 2-6 and checked potassium levelsthroughout the time on dialysis. Acute hyperkalemia is a clinical emergency that requires immediate treatment with the agents discussed below (TABLE 1).IV Calcium: IV calcium is indicated when the serum potassium is >6.5 mEq/L regardless of whether ECG changes are present.6 Given their poor sensitivity and specificity, ECG changes should not be used as diagnostic criteria for treatment of hyperkalemia.7 The immediate goal of acute management in hyperkalemi… Furthermore, she had specific contraindications to Kayexalate use, such as being on opiates and having a history of colectomy due to ulcerative colitis. In this situation, calcium should be diluted in 250 mL of D5W and given over 30 minutes (4). Nephron  1996;72:476-82. American College of Cardiology/American Heart Association Task Force; European Society of Cardiology Committee for Practice Guidelines; European Heart Rhythm Association; Heart Rhythm Society  ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines Circulation  2006;114:1088-1132.