What is the treatment for hyperkalemia in the Emergency Room (ER) setting?

From the Guidelines

The treatment for hyperkalemia in the ER setting involves a stepwise approach based on severity and ECG changes, with immediate stabilization of cardiac membranes using IV calcium gluconate, followed by shifting potassium intracellularly using IV insulin and glucose, and nebulized albuterol, as recommended by the most recent study 1.

Key Treatment Steps

• For severe hyperkalemia (potassium >6.5 mmol/L) or with ECG changes, immediate stabilization of cardiac membranes is achieved with IV calcium gluconate (10%, 10-30 mL) over 2-5 minutes, as noted in the study 1.
• Shifting potassium intracellularly using IV insulin (regular insulin 10 units) with glucose (25-50g of D50W) to prevent hypoglycemia, and nebulized albuterol (10-20 mg) is the next step, as outlined in the study 1.
• Sodium bicarbonate (50 mEq IV over 5 minutes) may be used in patients with metabolic acidosis, as mentioned in the study 1.
• For definitive removal of potassium, options include loop diuretics (furosemide 40-80 mg IV), sodium polystyrene sulfonate (15-30g orally or rectally), patiromer (8.4-25.2g orally), or hemodialysis for refractory cases, as discussed in the study 1.

Mechanisms of Action

• Calcium antagonizes cardiac membrane excitability without affecting potassium levels, as explained in the study 1.
• Insulin drives potassium into cells via Na-K-ATPase activation, as noted in the study 1.
• Removal strategies eliminate excess potassium from the body, as discussed in the study 1.

Clinical Considerations

• The specific treatment combination depends on the clinical scenario, potassium level, and presence of ECG abnormalities, as emphasized in the study 1.
• Continuous cardiac monitoring is essential throughout treatment, as recommended in the study 1.

From the FDA Drug Label

Sodium polystyrene sulfonate is indicated for the treatment of hyperkalemia. Limitation of Use: Sodium Polystyrene Sulfonate should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action The average total daily adult dose of Sodium Polystyrene Sulfonate is 15 g to 60 g, administered as a 15 g dose (four level teaspoons), one to four times daily.

The treatment for hyperkalemia in the Emergency Room (ER) setting is not sodium polystyrene sulfonate due to its delayed onset of action.

• Key points:
  • Sodium polystyrene sulfonate is not recommended for emergency treatment of life-threatening hyperkalemia.
  • It has a delayed onset of action, making it less suitable for emergency situations. 2

From the Research

Treatment Overview

• Hyperkalemia is a common electrolyte disorder that can result in morbidity and mortality if not managed appropriately 3.
• The treatment of hyperkalemia in the Emergency Room (ER) setting includes measures to stabilize cardiac membranes, shift potassium from extracellular to intracellular stores, and promote potassium excretion 3, 4.

Stabilization of Cardiac Membranes

• 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.
• Calcium gluconate is used to help stabilize the cardiac membranes and prevent life-threatening arrhythmias 5.

Shifting Potassium from Extracellular to Intracellular Stores

• Beta-agonists, such as albuterol, and intravenous insulin should be given to help shift potassium into cells 3, 6.
• Insulin and glucose are frequently used to manage patients with hyperkalemia, but hypoglycemia after insulin use is a frequent complication 7.
• Strategies to reduce the risk of hypoglycemia with insulin therapy include using lower doses of insulin, administering dextrose 50 g instead of 25 g, or administering dextrose as a prolonged infusion instead of a rapid intravenous bolus 7.

Promotion of Potassium Excretion

• Dialysis is the most efficient means to enable removal of excess potassium 3.
• Loop and thiazide diuretics can also be useful in promoting potassium excretion 3.
• New medications to promote gastrointestinal potassium excretion, such as patiromer and sodium zirconium cyclosilicate, hold promise 3, 4.
• Sodium polystyrene sulfonate is not efficacious in the treatment of hyperkalemia 3, 4.