From the Guidelines
Refractory hyperkalemia should be managed with a multi-modal approach, prioritizing urgent hemodialysis when potassium exceeds 6.5 mEq/L with ECG changes or when other measures fail, as it is the most effective intervention for severe cases. The management of refractory hyperkalemia requires a comprehensive approach, including the stabilization of cardiac membranes, shifting of potassium into cells, and removal of excess potassium from the body.
Initial Management
- Begin with intravenous calcium gluconate (1-2 ampules of 10% solution over 2-3 minutes) to stabilize cardiac membranes and prevent arrhythmias, as recommended by 1.
- Simultaneously administer insulin and glucose (10 units regular insulin with 25g dextrose IV) to shift potassium intracellularly, with effects lasting 4-6 hours, as suggested by 1.
- Add nebulized albuterol (10-20mg) for additional intracellular potassium shifting, as indicated by 1.
Ongoing Removal
- Sodium bicarbonate (150mEq in 1L D5W over 2-4 hours) may help in acidotic patients, as noted by 1.
- For ongoing removal, use sodium polystyrene sulfonate (15-30g orally or rectally every 4-6 hours) or newer potassium binders like patiromer (8.4-25.2g daily) or sodium zirconium cyclosilicate (10g three times daily initially), as recommended by 1.
Monitoring and Addressing Underlying Causes
- Throughout treatment, identify and address underlying causes such as medication effects, tissue breakdown, renal failure, or adrenal insufficiency, and monitor potassium levels frequently to guide ongoing management, as emphasized by 1.
- The most recent and highest quality study, 1, highlights the importance of a multi-modal approach in managing refractory hyperkalemia, and its recommendations should be prioritized in clinical practice.
From the Research
Definition and Prevalence of Refractory Hyperkalemia
- Refractory hyperkalemia is a life-threatening condition that occurs when the body's potassium levels become excessively high and do not respond to standard treatments 2, 3.
- Hyperkalemia is a common electrolyte abnormality that can lead to cardiac arrhythmia and death if left untreated 4.
Treatment Options for Refractory Hyperkalemia
- Medical management of acute hyperkalemia revolves around three strategies: stabilizing the myocardium, intracellular shifting of serum potassium, and enhancing elimination of total body potassium via urinary or fecal excretion 4.
- Insulin and glucose are frequently used to manage patients with hyperkalemia, but hypoglycemia is a common complication of this treatment 5.
- Albuterol and insulin with glucose have been shown to be effective in lowering plasma potassium in uremic patients, and their effects are additive 6.
- The combination of nebulised beta agonists with IV insulin-and-glucose may be more effective than either alone in treating hyperkalemia 2.
- Dialysis is effective in treating hyperkalemia, but pharmacological interventions are needed to prevent dialysis or avoid complications until dialysis is performed 3.
Pharmacological Interventions for Refractory Hyperkalemia
- Salbutamol administered via either nebulizer or metered-dose inhaler significantly reduces serum potassium compared with placebo 3.
- Intravenous insulin-and-glucose is effective in reducing serum potassium, and its combination with salbutamol may be more effective than either alone 2, 3.
- The effectiveness of potassium binding resins and IV calcium salts has not been tested in RCTs and requires further study before firm recommendations for clinical practice can be made 3.
- New oral potassium-binding agents, such as patiromer and sodium zirconium cyclosilicate, show promise in the management of hyperkalemia, but their role in the acute setting needs further investigation 4.