How to manage hyperkalemia?

Management of Severe Hyperkalemia (6.78 mEq/L)

Severe hyperkalemia with a potassium level of 6.78 mEq/L requires immediate intervention with IV calcium for cardiac membrane stabilization, followed by insulin/glucose and albuterol for intracellular potassium shifting, and potassium elimination strategies. 1

Immediate Management (First 30 Minutes)

1. Cardiac Membrane Stabilization

   • Administer calcium gluconate 10%: 15-30 mL IV over 2-5 minutes OR calcium chloride 10%: 5-10 mL IV 1
   • Onset: 1-3 minutes; Duration: 30-60 minutes
   • Repeat dose if no effect observed within 5-10 minutes
   • Monitor ECG continuously

2. Intracellular Potassium Shifting

   • Administer 10 units regular insulin IV with 50 mL of 50% dextrose 1
     • Onset: 15-30 minutes; Duration: 4-6 hours
   • Nebulized albuterol (salbutamol): 10-20 mg over 15 minutes 1
     • Onset: 30 minutes; Duration: 2-4 hours
   • Consider sodium bicarbonate 50 mEq IV over 5 minutes if metabolic acidosis is present 1

Potassium Elimination (Next 1-4 Hours)

1. Diuresis (if adequate renal function)

   • Furosemide 40-80 mg IV 1

2. Potassium Binders

   • Sodium zirconium cyclosilicate (SZC): 10g TID for 48 hours initially OR
   • Patiromer: 8.4g daily, titrated as needed 1

3. Hemodialysis

   • Consider urgent hemodialysis if:
     • Hyperkalemia is resistant to medical therapy
     • Patient has oliguria or end-stage renal disease
     • Severe symptoms persist 2, 1

Monitoring and Follow-up

1. Continuous ECG monitoring to assess for:

   • Peaked T waves
   • PR interval prolongation
   • QRS widening
   • Sine wave pattern (ominous sign)

2. Serial potassium measurements:

   • Recheck potassium level 1-2 hours after initial treatment
   • Target serum potassium in the 4.0-5.0 mmol/L range 1
   • Reassess potassium within 1 week after resolution 2

3. Monitor for complications:

   • Hypoglycemia (from insulin treatment)
   • Hypocalcemia
   • Volume overload (especially in heart failure patients)

Addressing Underlying Causes

1. Medication Review

   • Evaluate and modify medications that may cause hyperkalemia:
     • RAAS inhibitors (ACEIs, ARBs)
     • Potassium-sparing diuretics
     • NSAIDs
     • Beta-blockers
     • Trimethoprim-sulfamethoxazole
     • Heparin 1, 3

2. Dietary Modifications

   • Limit potassium intake to 50-70 mmol (1,950-2,730 mg) daily 1
   • Avoid high-potassium foods: bananas, oranges, potatoes, tomatoes, legumes, yogurt, chocolate 1
   • Consider presoaking root vegetables to lower potassium content by 50-75% 1

Special Considerations

1. RAAS Inhibitor Management

   • Consider continuing RAAS inhibitors with close monitoring when potassium levels are between 5.0-6.5 mEq/L after initial stabilization 1
   • Discontinuation is associated with worse cardiovascular outcomes 2, 1
   • If discontinued during acute hyperkalemia, consider reinitiation after resolution 2

2. Hyperglycemia Management

   • In diabetic patients, treat hyperglycemia aggressively as it can contribute to hyperkalemia 4
   • Insulin treatment for hyperglycemia may help correct hyperkalemia simultaneously

3. Fluid Management

   • Initial fluid resuscitation with isotonic saline (0.9% NaCl) at 15-20 mL/kg/hr during the first hour 1
   • More careful fluid management in heart failure patients to prevent volume overload 1

Pitfalls and Caveats

1. Beware of rebound hyperkalemia after temporary shifting treatments wear off
2. Monitor for hypoglycemia when administering insulin/glucose
3. Avoid rapid correction of associated hyponatremia if present
4. ECG changes may not correlate perfectly with potassium levels, especially in chronic hyperkalemia
5. Pseudohyperkalemia should be ruled out before aggressive treatment (hemolysis, thrombocytosis, leukocytosis)
6. Calcium administration is contraindicated in patients taking digoxin (increased risk of digoxin toxicity)