What interventions should be done for hyperkalemia (elevated potassium level)?

From the Guidelines

For a potassium level of 6, immediate interventions should include calcium gluconate 10% (10mL IV over 2-3 minutes) to stabilize cardiac membranes, insulin (10 units regular insulin IV) with glucose (25g IV) to shift potassium intracellularly, and nebulized albuterol (10-20mg) which also promotes intracellular potassium shift, as recommended by the most recent and highest quality study 1.

Treatment Overview

The goal of treating hyperkalemia is to protect the heart from the effects of high potassium levels, shift potassium into cells, and ultimately remove excess potassium from the body.

Immediate Interventions

• Stabilize myocardial cell membrane: Calcium gluconate 10% (10mL IV over 2-3 minutes) or calcium chloride can be used for this purpose, as noted in 1 and 1.
• Shift potassium into cells: Insulin (10 units regular insulin IV) with glucose (25g IV) and nebulized albuterol (10-20mg) are effective, as mentioned in 1 and 1.
• Sodium bicarbonate (50 mEq IV over 5 minutes) may be considered in patients with metabolic acidosis, as suggested by 1 and 1.

Ongoing Management

• Loop diuretics like furosemide 40-80mg IV can enhance potassium excretion in patients with adequate kidney function, as indicated in 1 and 1.
• Potassium binders such as sodium polystyrene sulfonate (Kayexalate) 15-30g or patiromer 8.4g can be used for ongoing management, as mentioned in 1.

Severe Cases

In severe cases unresponsive to medical therapy, hemodialysis provides definitive treatment by removing potassium from the body, as noted in 1 and 1.

General Considerations

Dietary potassium restriction and discontinuation of medications that increase potassium levels (ACE inhibitors, ARBs, potassium-sparing diuretics) are also crucial, as highlighted in 1. The choice of intervention should be tailored to the severity of hyperkalemia, the presence of ECG changes, and the patient's underlying kidney function and clinical presentation.

From the Research

Interventions for Hyperkalemia

For a potassium level of 6, several interventions can be done to manage 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 2.
• Cellular Shift: Beta-agonists and intravenous insulin should be given to shift potassium from extracellular to intracellular stores 2, 3, 4.
• Excretion: Dialysis is the most efficient means to enable removal of excess potassium 2. Loop and thiazide diuretics can also be useful 2.
• Gastrointestinal Ion Exchange: New medications to promote gastrointestinal potassium excretion, which include patiromer and sodium zirconium cyclosilicate, hold promise 2, 3, 4.
• Other Treatments: Sodium polystyrene sulfonate is not efficacious 2, while sodium bicarbonate can be used to correct acidosis and promote short-term shifts of potassium out of the plasma pool 3, 5.
• Monitoring: Electrocardiogram (ECG) monitoring is essential to detect any changes in cardiac rhythm due to hyperkalemia 6, 5.

Specific Treatment Options

The following treatment options can be considered:

• Intravenous Calcium Gluconate: Effective in reversing electrocardiographic changes and reducing the risk of arrhythmias, but does not lower serum potassium 6, 5.
• Intravenous Insulin and Glucose: Can lower serum potassium levels acutely 3, 4, 5.
• Nebulized Beta2 Agonists: Can also lower serum potassium levels acutely 3, 5.
• Dialysis: The most efficient means to enable removal of excess potassium 2.