What are the next steps for a patient with severe hyperkalemia who has already been treated with insulin, calcium gluconate, and Lokelma (sodium zirconium cyclosilicate)?

Management of Severe Hyperkalemia After Initial Treatments

For a patient with persistent severe hyperkalemia (K+ of 7 mEq/L) despite treatment with insulin, calcium gluconate, and Lokelma, urgent hemodialysis is the next critical intervention to rapidly remove potassium from the body and prevent life-threatening cardiac complications. 1

Immediate Next Steps

1. Assess for ECG changes:

   • Look for progression from peaked T waves to flattened P waves, prolonged PR interval, widened QRS complex, or sine-wave pattern which indicates imminent cardiac arrest
   • If ECG changes are present, administer additional calcium chloride (10%): 5-10 mL (500-1000 mg) IV over 2-5 minutes or calcium gluconate (10%): 15-30 mL IV over 2-5 minutes 1

2. Additional temporizing measures while preparing for dialysis:

   • Sodium bicarbonate: 50 mEq IV over 5 minutes to shift potassium intracellularly 1
   • Nebulized albuterol: 10-20 mg nebulized over 15 minutes (can augment insulin effect) 1
   • Repeat insulin/glucose: Consider additional dose of insulin (10 units) with glucose (50 mL of D50) if previous dose was given >2 hours ago 1
   • Furosemide: 40-80 mg IV to promote potassium excretion if patient has adequate renal function 1, 2

3. Arrange for urgent hemodialysis:

   • Most effective method for potassium removal in severe, refractory hyperkalemia
   • Can remove 25-50 mEq of potassium per session
   • Indicated when hyperkalemia is severe and unresponsive to medical management 1

Monitoring and Additional Considerations

• Continuous cardiac monitoring is essential until potassium levels normalize
• Check serum potassium levels every 2-4 hours until stable
• Monitor for hypoglycemia if insulin was administered
• Review and discontinue medications that may worsen hyperkalemia (ACE inhibitors, ARBs, potassium-sparing diuretics, NSAIDs)
• Assess for and treat underlying causes:
  • Acute kidney injury
  • Metabolic acidosis
  • Tissue breakdown (rhabdomyolysis, tumor lysis syndrome)
  • Medication effects
  • Adrenal insufficiency

Important Caveats

• Temporary effects: Remember that insulin/glucose, albuterol, and sodium bicarbonate only temporarily shift potassium into cells and do not remove it from the body 1
• Rebound hyperkalemia: Monitor for recurrence as effects of temporizing measures wear off
• Lokelma limitations: While sodium zirconium cyclosilicate (Lokelma) can bind potassium in the GI tract, its onset of action is not immediate and may be insufficient for severe hyperkalemia 1
• Avoid Kayexalate with sorbitol: Traditional sodium polystyrene sulfonate with sorbitol has been associated with intestinal necrosis and is no longer preferred for acute management 1
• Furosemide effectiveness: Only effective if patient has adequate renal function; ineffective in anuric renal failure 2

Persistent severe hyperkalemia despite initial treatments represents a true medical emergency requiring rapid, decisive action to prevent cardiac arrest. Hemodialysis remains the definitive treatment when medical management fails to adequately reduce potassium levels.