How do you treat hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia requires a stepwise approach starting with calcium gluconate for cardiac membrane stabilization, followed by insulin with glucose for intracellular potassium redistribution, and ultimately potassium removal from the body through diuretics, potassium binders, or hemodialysis. 1

Initial Assessment and Classification

• Verify hyperkalemia with a second sample to rule out pseudohyperkalemia from hemolysis during phlebotomy 1
• Classify severity:
  • Mild: >5.0 to <5.5 mmol/L
  • Moderate: 5.5 to 6.0 mmol/L
  • Severe: >6.0 mmol/L 1
• Evaluate for precipitating factors, including medications (ACE inhibitors, ARBs, potassium-sparing diuretics, NSAIDs), tissue destruction, and renal dysfunction 1

Emergency Treatment Algorithm

Step 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
  • Protects the heart but does not lower potassium levels 1, 2

Step 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, 3
• Inhaled beta-agonists: 10-20 mg nebulized over 15 minutes
  • Onset: 15-30 minutes
  • Duration: 2-4 hours 1, 4
• Sodium bicarbonate: 50 mEq IV over 5 minutes (if metabolic acidosis present)
  • Onset: 15-30 minutes
  • Duration: 1-2 hours 1
  • Note: Less effective when used alone 3

Step 3: Remove Potassium from Body

• Loop diuretics: 40-80 mg IV (if adequate renal function)
  • Onset: 30-60 minutes
  • Duration: 2-4 hours 1
• Potassium binders:
  • Sodium polystyrene sulfonate: 1 g/kg orally or rectally (avoid rectal route in neutropenic patients)
    • Note: Takes hours to work, not effective within 4 hours 1, 5
  • Newer agents (patiromer or sodium zirconium cyclosilicate) for long-term management 1
• Hemodialysis: Most effective method for severe or refractory hyperkalemia 1, 3

Indications for Dialysis

• Severe hyperkalemia (>6.5 mEq/L) resistant to medical therapy
• Significant ECG changes or symptoms despite initial treatment
• Oliguric or anuric renal failure
• End-stage renal disease 1

Monitoring and Follow-up

• Repeat serum potassium within 1-2 hours after initial treatment
• Continue ECG monitoring for changes
• Avoid administering sodium bicarbonate and calcium through the same IV line (risk of precipitation)
• Monitor serum potassium within 1 week of treatment initiation, more frequently in high-risk patients 1

Treatment Combinations and Efficacy

• The combination of nebulized beta-agonists with IV insulin-and-glucose is more effective than either treatment alone 5
• For severe hyperkalemia, consider using multiple agents simultaneously 3

Common Pitfalls and Caveats

• Failing to verify hyperkalemia with a repeat sample can lead to inappropriate treatment
• Overlooking pseudohyperkalemia from hemolysis or poor phlebotomy technique
• Risk of overtreatment leading to hypokalemia
• Rebound hyperkalemia can occur after temporary shifting treatments wear off
• Sodium polystyrene sulfonate takes several hours to work and should not be relied upon for acute management 1, 2, 6
• Calcium administration is critical in severe hyperkalemia with ECG changes, even though it doesn't lower potassium levels 6