From the Guidelines
The immediate treatment for hyperkalemia should prioritize stabilizing cardiac membranes with calcium gluconate 10% (10 mL IV over 2-3 minutes) for severe hyperkalemia (potassium >6.5 mmol/L) or with ECG changes, as recommended by the most recent and highest quality study 1. This approach is crucial for preventing arrhythmias, although it does not lower potassium levels. To shift potassium into cells, administering insulin (10 units regular insulin IV) with glucose (25-50g IV) to prevent hypoglycemia, and considering albuterol nebulization (10-20 mg) are effective strategies, as supported by 1. Sodium bicarbonate (50 mEq IV over 5 minutes) may also be beneficial in acidotic patients, as noted in 1. For potassium removal, options include sodium polystyrene sulfonate (15-30g orally or rectally), or preferably newer agents like patiromer (8.4-16.8g orally) or sodium zirconium cyclosilicate (10g orally), with loop diuretics like furosemide (40-80mg IV) enhancing renal potassium excretion in patients with adequate kidney function, as discussed in 1 and 1. Hemodialysis remains the most effective method for life-threatening hyperkalemia unresponsive to medical therapy. Key considerations in managing hyperkalemia include:
- Continuous cardiac monitoring during treatment
- Identifying and addressing the underlying cause of hyperkalemia to prevent recurrence
- Monitoring kidney function and adjusting treatment accordingly
- Considering the use of K+ lowering agents in patients with hyperkalemia on RAASi therapy, as recommended by 1. Overall, the management of hyperkalemia requires a multifaceted approach that prioritizes both the immediate stabilization of cardiac membranes and the longer-term removal of excess potassium, guided by the most recent and highest quality evidence 1.
From the Research
Immediate Treatment for Hyperkalemia
The immediate treatment for hyperkalemia involves several measures to stabilize cardiac membranes, shift potassium from extracellular to intracellular stores, and promote potassium excretion.
- The first step is to administer calcium gluconate 10% (10 mL intravenously) to stabilize cardiac membranes, unless the patient is in cardiac arrest, in which case 10 mL calcium chloride is warranted 2.
- Beta-agonists and intravenous insulin should be given, with some experts recommending the use of synthetic short-acting insulins rather than regular insulin 2.
- Dextrose should also be administered, as indicated by initial and serial serum glucose measurements 2.
- Dialysis is the most efficient means to enable removal of excess potassium 2.
- Loop and thiazide diuretics can also be useful in promoting potassium excretion 2.
Pharmacotherapies for Hyperkalemia
Several pharmacotherapies are available to treat hyperkalemia, including:
- Glucose and insulin
- Bicarbonate
- Calcium gluconate
- Beta-2 agonists
- Hyperventilation
- Dialysis 3
- Sodium polystyrene sulfonate (SPS)
- Sodium zirconium cyclosilicate (SZC)
- Patiromer 3
Emergency Interventions for Hyperkalaemia
Emergency interventions for hyperkalaemia include:
- Inhaled beta-agonists
- Nebulised beta-agonists
- Intravenous (IV) insulin-and-glucose
- Dialysis 4
- IV bicarbonate (although results are equivocal)
- K-absorbing resin (not effective by four hours) 4
Practical Considerations
It is essential to note that the treatment of hyperkalemia requires a comprehensive approach, including:
- Identifying and addressing underlying causes and pathophysiologic mechanisms
- Uncovering overt or covert medications that may have led to the development of hyperkalemia
- Obtaining detailed dietary and medical history of hyperkalemic patients 5
- Being aware of the unique benefits and contraindications of different medications used to treat hyperkalemia 3