What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia should follow a stepwise approach based on severity, with immediate calcium administration for cardiac membrane stabilization in severe cases, followed by insulin with glucose and beta-agonists to shift potassium intracellularly, and ultimately potassium removal strategies including diuretics, potassium binders, or dialysis. 1

Classification of Hyperkalemia

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

Assessment of Severity

• Check for ECG changes: peaked T waves, flattened/absent P waves, prolonged PR interval, widened QRS complex 1
• Note: ECG findings can be variable and not always sensitive in predicting hyperkalemia complications 1
• Assess for symptoms: muscle weakness, paresthesia, depressed deep tendon reflexes, respiratory difficulties 1

Treatment Algorithm

1. Severe Hyperkalemia (>6.0 mEq/L) or with ECG Changes

Immediate interventions:

• Cardiac membrane stabilization (acts within 1-3 minutes):

  • 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
  • If no effect observed within 5-10 minutes, another dose may be given 1

• Shift potassium into cells (acts within 30 minutes):

  • Insulin with glucose: 10 units regular insulin with 25g glucose (50 mL of D50) IV over 15-30 minutes 1
  • Nebulized beta-agonist: 10-20 mg albuterol nebulized over 15 minutes 1
  • Sodium bicarbonate: 50 mEq IV over 5 minutes (primarily if metabolic acidosis present) 1

2. Remove Potassium from Body

• Diuretics: Furosemide 40-80 mg IV to increase renal K+ excretion 1
• Potassium binders:
  • Sodium polystyrene sulfonate (Kayexalate): 15-50g with sorbitol orally or rectally 1
  • Note: Not for emergency treatment due to delayed onset of action 2
  • Newer K+ binders: patiromer sorbitex calcium or sodium zirconium cyclosilicate 1
• Dialysis: For severe, refractory hyperkalemia, especially in renal failure 1

3. Chronic Hyperkalemia Management

• Review and adjust medications that can cause hyperkalemia (RAASi, NSAIDs, beta-blockers, etc.) 1
• Use loop or thiazide diuretics to enhance potassium excretion 1
• Consider newer potassium binders for long-term management 1
• Avoid excessive dietary potassium intake 3

Special Considerations

• Cardiac arrest due to hyperkalemia: Follow standard ACLS protocols plus the above adjuvant therapies 1
• Renal failure patients: More likely to develop severe hyperkalemia; may require dialysis 1
• Patients on RAASi therapy: Monitor potassium levels 7-10 days after starting or increasing doses 1
• Rebound hyperkalemia: Can occur 1-4 hours after insulin/beta-agonist treatment; monitor accordingly 1

Common Pitfalls to Avoid

1. Relying solely on ECG changes: Absence of ECG changes does not exclude severe hyperkalemia 4, 5
2. Delayed treatment: Severe hyperkalemia is potentially lethal and requires immediate intervention 1
3. Using sodium polystyrene sulfonate for emergency treatment: It has a delayed onset of action 2
4. Failure to identify and address underlying causes: Renal failure and medications are common causes 1, 4
5. Inadequate monitoring: After initial treatment, continue monitoring for rebound hyperkalemia 1

The management approach should be tailored based on the severity of hyperkalemia, presence of symptoms, ECG changes, and underlying causes, with the primary goal of preventing life-threatening cardiac arrhythmias and neuromuscular dysfunction.