From the Guidelines
The urgent care management of hyperkalemia involves a stepwise approach based on severity, with the most recent and highest quality study 1 guiding the treatment protocol. For severe hyperkalemia (potassium >6.5 mmol/L or with ECG changes), immediately administer calcium gluconate 10% (10 mL IV over 2-3 minutes) to stabilize cardiac membranes and prevent arrhythmias, as recommended by 1. This does not lower potassium levels but protects the heart while other treatments take effect. Next, shift potassium into cells using insulin (10 units regular insulin IV) with glucose (25-50g IV) to prevent hypoglycemia, and consider albuterol nebulization (10-20 mg), as suggested by 1 and 1. To eliminate potassium from the body, give 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), as recommended by 1 and 1. Loop diuretics like furosemide (40-80mg IV) can help if kidney function is adequate, as stated in 1 and 1. For life-threatening hyperkalemia with significant ECG changes or cardiac instability, urgent hemodialysis may be necessary, as indicated by 1 and 1. Throughout treatment, continuous cardiac monitoring is essential, and serial potassium measurements should be performed to assess response, as emphasized by 1 and 1. The underlying cause of hyperkalemia should be identified and addressed, which may include medication review, assessment of kidney function, and evaluation for adrenal insufficiency or tissue breakdown, as recommended by 1 and 1.
Some key points to consider in the management of hyperkalemia include:
- The severity of hyperkalemia and the presence of ECG changes or cardiac instability guide the urgency and intensity of treatment, as noted in 1 and 1.
- A combination of treatments may be necessary to effectively manage hyperkalemia, as suggested by 1, 1, and 1.
- Newer agents like patiromer and sodium zirconium cyclosilicate offer alternative options for potassium elimination, as recommended by 1 and 1.
- Continuous monitoring and serial potassium measurements are crucial to assess response to treatment and adjust the management plan as needed, as emphasized by 1 and 1.
Overall, the management of hyperkalemia requires a comprehensive and individualized approach, taking into account the severity of the condition, the presence of underlying medical conditions, and the patient's response to treatment, as recommended by 1, 1, and 1.
From the FDA Drug Label
Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia (1). Limitation of Use: Sodium Polystyrene Sulfonate Powder, for Suspension should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action (1)
The urgent care management for hyperkalemia should not include Sodium Polystyrene Sulfonate Powder, for Suspension as an emergency treatment due to its delayed onset of action.
- Key points:
From the Research
Urgent Care Management for Hyperkalemia
The management of hyperkalemia in an urgent care setting involves several key steps to prevent fatal cardiac arrhythmias and muscle paralysis.
- Early recognition of moderate to severe hyperkalemia is vital, with potassium levels above 6.5 mEq/L or EKG changes considered a medical emergency 3.
- Treatment should be initiated with calcium gluconate to stabilize cardiomyocyte membranes, followed by insulin injection, and beta-agonists administration 3, 4.
- Measures to facilitate removal of potassium from the body include saline diuresis, oral binding resins, and hemodialysis, with hemodialysis being the most reliable method for potassium removal 3.
Treatment Options
Several treatment options are available for hyperkalemia, including:
- Calcium gluconate 10% dosed 10 mL intravenously for membrane stabilization, unless the patient is in cardiac arrest, in which case 10 mL calcium chloride is warranted 4.
- Beta-agonists and intravenous insulin, with some experts recommending the use of synthetic short-acting insulins rather than regular insulin 4.
- Dextrose administration, as indicated by initial and serial serum glucose measurements 4.
- Dialysis, which is the most efficient means to enable removal of excess potassium 4.
- Loop and thiazide diuretics, which can also be useful in promoting potassium excretion 4.
New Medications
New medications, such as patiromer and sodium zirconium cyclosilicate, have shown promise in promoting gastrointestinal potassium excretion and may be useful in the management of hyperkalemia 4, 5, 6.
- These medications have increased selectivity for potassium and work primarily in the gastrointestinal tract 5.
- Clinicians should be aware of the unique benefits and contraindications of these medications when managing patients with hyperkalemia 5.
Effectiveness of Calcium Gluconate
The effectiveness of calcium gluconate in the treatment of hyperkalemia has been studied, with one study finding that IV Ca-gluconate therapy was effective in main rhythm ECG disorders due to hyperkalemia, but not in nonrhythm ECG disorders 7.
- The study found that nine of the 79 main rhythm disorders due to hyperkalemia improved with calcium gluconate treatment, and this change was statistically significant 7.