What are the management steps for hyperkalemia?

Management of Hyperkalemia

The management of hyperkalemia requires a stepwise approach based on severity, with immediate stabilization of cardiac membranes for severe cases followed by potassium redistribution and elimination strategies. 1

Classification and Assessment

Hyperkalemia is classified based on serum potassium levels:

• Mild: 5.0-5.5 mEq/L
• Moderate: 5.5-6.0 mEq/L
• Severe: >6.0 mEq/L 1

Key assessment factors:

• ECG changes (peaked T waves, prolonged QRS complexes)
• Symptoms (muscle weakness, paresthesias)
• Rate of potassium rise
• Underlying conditions (CKD, heart failure, diabetes)

Caution: ECG findings can be highly variable and not as sensitive as laboratory tests for detecting hyperkalemia or predicting complications. 1

Acute Hyperkalemia Management Algorithm

1. Cardiac Membrane Stabilization (for severe hyperkalemia or ECG changes)

• IV calcium gluconate 10% (10 mL) or calcium chloride
  • Acts within 1-3 minutes
  • Protects against arrhythmias
  • May repeat after 5-10 minutes if no effect
  • Does not lower serum potassium 1

2. Intracellular Potassium Shift (30-60 minutes)

• IV insulin (10 units) with glucose (50 mL of 50% dextrose)
  • Prevents hypoglycemia
  • Effect lasts 4-6 hours
• Nebulized β2-agonists (salbutamol/albuterol 10-20 mg)
  • Can be used alone or with insulin
  • Effect lasts 2-4 hours
• IV sodium bicarbonate
  • Only in patients with concurrent metabolic acidosis
  • Limited efficacy when used alone 1, 2

Important: Shifting agents provide only temporary benefit (1-4 hours) and do not eliminate potassium from the body. Rebound hyperkalemia can occur after 2 hours. 1

3. Potassium Elimination

• Loop diuretics (IV furosemide)
  • For patients with adequate kidney function
  • Ineffective in oliguric patients
• Potassium binders
  • Sodium polystyrene sulfonate (SPS)
  • Newer agents: patiromer, sodium zirconium cyclosilicate
  • Note: SPS is not for emergency treatment of life-threatening hyperkalemia due to delayed onset 3
• Hemodialysis
  • Most effective for severe or refractory hyperkalemia
  • Indicated for patients with oliguria, anuria, or ESRD
  • Consider when other measures fail 1, 4

Chronic Hyperkalemia Management

1. Identify and address underlying causes:

   • Review medications (RAASi, NSAIDs, potassium-sparing diuretics)
   • Assess kidney function
   • Evaluate dietary potassium intake

2. Medication adjustments:

   • Loop or thiazide diuretics
   • Modification of RAASi dose (rather than discontinuation)
   • Remove other hyperkalemia-causing medications 1

3. Potassium binders for long-term management:

   • Consider newer K+ binders (patiromer, sodium zirconium cyclosilicate)
   • May allow optimization of RAASi therapy in patients with heart failure 1

4. Monitoring:

   • Check serum K+ 7-10 days after starting RAASi therapy or increasing doses
   • More frequent monitoring for high-risk patients (CKD, diabetes, heart failure) 1

Common Pitfalls and Caveats

1. Rebound hyperkalemia after temporary treatments (insulin/glucose, β-agonists)

   • Always initiate potassium elimination strategies concurrently 1

2. Overreliance on ECG changes

   • Absent or atypical ECG changes do not exclude the need for immediate intervention 2

3. Pseudohyperkalemia

   • Can result from hemolysis, repeated fist clenching, or poor phlebotomy techniques
   • Verify elevated levels before aggressive treatment 1

4. Discontinuation of beneficial medications

   • Avoid complete discontinuation of RAASi when possible
   • Consider dose reduction and concurrent use of potassium binders 1

5. Inadequate monitoring

   • Failure to reassess potassium levels after treatment
   • Insufficient follow-up in high-risk patients 4