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 using calcium gluconate for severe or symptomatic cases, followed by potassium-lowering therapies including insulin with glucose and beta-agonists, and ultimately addressing the underlying cause. 1

Initial Assessment and Classification

• Severity classification:

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

• ECG evaluation: Look for:

  • Peaked T waves
  • Widened QRS complexes
  • Prolonged PR interval 1

Caution: ECG findings can be highly variable and not as sensitive as laboratory tests in predicting hyperkalemia or its complications 2. Never delay treatment in severe hyperkalemia while waiting for ECG changes.

Acute Management Algorithm

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

• Calcium gluconate: 10% solution, 15-30 mL IV
  • Onset: 1-3 minutes
  • Duration: 30-60 minutes
  • May repeat if no effect seen within 5-10 minutes 2, 1

2. Shift Potassium Intracellularly

• Insulin with glucose: 10 units regular insulin IV with 50 mL of 25% dextrose

  • Onset: 15-30 minutes
  • Duration: 1-2 hours 1

• Inhaled beta-agonists: 10-20 mg nebulized over 15 minutes

  • Onset: 15-30 minutes
  • Duration: 2-4 hours 1
  • Can be used alone or to augment insulin effect 3

• Sodium bicarbonate: 50 mEq IV over 5 minutes

  • Consider only in patients with concurrent metabolic acidosis
  • Limited efficacy when used alone 1, 4

3. Remove Potassium from Body

• Loop diuretics: 40-80 mg IV (for patients with adequate renal function)

  • Onset: 30-60 minutes
  • Duration: 2-4 hours 1

• Potassium binders:

  • Newer agents (first-line per American College of Cardiology):

    • Patiromer
    • Sodium zirconium cyclosilicate 1

  • Sodium polystyrene sulfonate:

    • Not for emergency treatment due to delayed onset 5
    • Reserved for subacute treatment 6

• Hemodialysis:

  • Most effective for severe hyperkalemia
  • Indicated when other measures fail or in severe renal failure 2, 1

Chronic Hyperkalemia Management

1. Medication review and adjustment:

   • Consider dose reduction of medications that cause hyperkalemia:
     • RAAS inhibitors (ACE inhibitors, ARBs, MRAs)
     • Potassium-sparing diuretics
     • NSAIDs
     • Beta-blockers
     • Calcineurin inhibitors 1

2. Maintain beneficial medications when possible:

   • European Heart Journal recommends maintaining RAAS inhibitors when K+ is >5.0–<6.5 mEq/L while initiating potassium-lowering agents 1
   • Consider potassium binders rather than discontinuation of beneficial RAAS inhibitors 1

3. Dietary modifications:

   • Restrict high-potassium foods (bananas, oranges, potatoes, tomatoes)
   • Avoid salt substitutes containing potassium chloride 1

4. Regular monitoring:

   • Check potassium levels within 1 week of treatment initiation
   • More frequent monitoring for high-risk patients (CKD, heart failure, diabetes) 1

Important Considerations and Pitfalls

• Watch for rebound hyperkalemia 2-4 hours after treatments that shift potassium intracellularly 1

• Pseudo-hyperkalemia: Consider repeating measurement if suspected due to hemolysis during blood collection 1

• Underlying causes: Always identify and address underlying causes of hyperkalemia, including:

  • Renal impairment
  • Medication effects
  • Acidosis
  • Adrenal insufficiency 7

• Sodium polystyrene sulfonate limitations: Not for emergency treatment due to delayed onset of action 5

• Dialysis consideration: Should be instituted early in patients with severe hyperkalemia and significant renal impairment 2

By following this structured approach to hyperkalemia management, clinicians can effectively address this potentially life-threatening electrolyte disorder while maintaining beneficial medications when possible.