From the Guidelines
Treatment for hyperkalemia should prioritize lowering potassium levels quickly and safely, with the most recent and highest quality study recommending a combination of calcium gluconate, insulin, and loop diuretics for moderate to severe cases 1.
Key Considerations
- For mild hyperkalemia (potassium 5.5-6.0 mEq/L), dietary potassium restriction and discontinuation of potassium-sparing medications may be sufficient.
- For moderate to severe hyperkalemia (potassium >6.0 mEq/L), more aggressive interventions are needed, including:
- Calcium gluconate 10% (10 mL IV over 2-3 minutes) to stabilize cardiac membranes if ECG changes are present.
- Insulin (10 units regular insulin IV) with glucose (25g dextrose) to drive potassium into cells within 15-30 minutes, lasting 4-6 hours.
- Albuterol nebulizer (10-20 mg) to shift potassium intracellularly.
- Sodium bicarbonate (50 mEq IV over 5 minutes) may help in acidotic patients.
Potassium Removal
- Sodium polystyrene sulfonate (15-30g orally or 30-50g rectally) exchanges sodium for potassium in the gut.
- Loop diuretics like furosemide (40-80mg IV) increase renal potassium excretion in patients with adequate kidney function.
- Hemodialysis remains the most effective method for severe or refractory hyperkalemia, especially in patients with kidney failure.
Monitoring and Prevention
- Continuous cardiac monitoring is essential during treatment.
- The underlying cause of hyperkalemia should be identified and addressed to prevent recurrence.
- Monitoring serum K+ should be individualized, with increased frequency of monitoring considered for patients with chronic kidney disease, diabetes, heart failure, or a history of hyperkalemia, and for those receiving RAASi therapy 1.
From the FDA Drug Label
1 INDICATIONS AND USAGE Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia.
Treatment for hyperkalemia includes the use of Sodium Polystyrene Sulfonate Powder, for Suspension.
- However, it is noted that this treatment should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 2.
From the Research
Treatment Options for Hyperkalemia
- Membrane stabilization: Calcium gluconate 10% dosed 10 mL intravenously should be provided for membrane stabilization, unless the patient is in cardiac arrest, in which case 10 mL calcium chloride is warranted 3
- Shifting potassium from extracellular to intracellular stores: Beta-agonists and intravenous insulin should be given, and some experts recommend the use of synthetic short-acting insulins rather than regular insulin 3
- Promoting potassium excretion: Dialysis is the most efficient means to enable removal of excess K+, and loop and thiazide diuretics can also be useful 3
- New medications: Patiromer and sodium zirconium cyclosilicate hold promise for promoting gastrointestinal K+ excretion 3
Effectiveness of Calcium Gluconate
- A study found that IV Ca-gluconate therapy was effective in main rhythm ECG disorders due to hyperkalemia, but not in nonrhythm ECG disorders due to hyperkalemia 4
- The study analyzed 243 ECG pathology related to hyperkalemia and found that 9 out of 79 main rhythm disorders improved with calcium gluconate treatment 4
Common Misconceptions and Recommendations
- There are no consensus guidelines on the treatment of hyperkalemia or even a standard definition 5
- A review of current available literature and discussion of practical points on several modalities of hyperkalemia treatment can aid emergency physicians in making safe and efficacious choices for the treatment of acute hyperkalemia 5