What is the treatment for hyperkalemia?

Treatment of Hyperkalemia with K+ 6.6

Hyperkalemia with a potassium level of 6.6 mmol/L is a medical emergency requiring immediate treatment with calcium gluconate to stabilize cardiac membranes, followed by insulin with glucose and beta-agonists to shift potassium intracellularly, and measures to remove potassium from the body. 1

Immediate Management (First 30-60 minutes)

1. Cardiac Membrane Stabilization:

   • Administer 10% calcium gluconate, 15-30 mL IV over 5 minutes
   • Onset: 1-3 minutes; Duration: 30-60 minutes
   • Note: This does not lower potassium but protects against cardiac arrhythmias 1

2. Intracellular Potassium Shifting:

   • Administer 10 units regular insulin IV with 50 mL of 25% dextrose
   • Onset: 15-30 minutes; Duration: 1-2 hours
   • Consider nebulized beta-agonists (10-20 mg over 15 minutes)
   • Onset: 15-30 minutes; Duration: 2-4 hours 1

3. Additional Acute Measures:

   • Sodium bicarbonate: 50 mEq IV over 5 minutes (especially if acidotic)
   • Onset: 15-30 minutes; Duration: 1-2 hours
   • Loop diuretics: 40-80 mg IV (if renal function adequate)
   • Onset: 30-60 minutes; Duration: 2-4 hours 1

Potassium Removal (Next 1-4 hours)

1. Hemodialysis:

   • Most reliable method for severe hyperkalemia (K+ > 6.5 mmol/L)
   • Indicated when medical therapy fails or in patients with renal failure 2

2. Potassium Binders:

   • Sodium polystyrene sulfonate (SPS) - not for emergency treatment due to delayed onset of action 3
   • Consider newer agents like sodium zirconium cyclosilicate (SZC) or patiromer for ongoing management 4

ECG Monitoring

Monitor for these ECG changes which correlate with potassium levels:

• 5.5-6.5 mmol/L: Peaked/tented T waves, nonspecific ST segment abnormalities
• 6.5-7.5 mmol/L: Prolonged PR interval, flattened or absent P wave
• 7.0-8.0 mmol/L: Widened QRS, deep S waves, fusion of S and T waves

• 10 mmol/L: Sinusoidal wave pattern, ventricular fibrillation, asystole 1

Follow-up Management

1. Identify and Address Underlying Causes:

   • Medication review: Stop or adjust medications that increase potassium (NSAIDs, RAASi)
   • According to European Society of Cardiology guidelines, RAASi therapy should be discontinued when K+ > 6.0 mmol/L 5

2. Monitoring:

   • Recheck potassium and renal function within 2-3 days after intervention
   • Continue monitoring weekly until stable, then monthly for 3 months 1

3. Long-term Management:

   • For chronic or recurrent hyperkalemia, an approved K+-lowering agent may be initiated when K+ levels are >5.0 mmol/L 5
   • Consider cautious reintroduction of RAASi at lower doses with close monitoring if clinically indicated 5

Pitfalls and Caveats

1. Sodium polystyrene sulfonate (SPS) limitations:

   • Not for emergency treatment of life-threatening hyperkalemia due to delayed onset 3
   • Chronic use of SPS, especially with sorbitol, should be avoided due to risk of bowel necrosis 5

2. Medication interactions:

   • Avoid triple combination of ACE inhibitor, ARB, and aldosterone antagonist to minimize hyperkalemia risk 1
   • Be cautious with sodium bicarbonate in fluid-overloaded patients 1

3. Treatment limitations:

   • Diuretics alone are ineffective in anuric patients 1
   • Watch for rebound hyperkalemia as temporary measures wear off 6

4. Special populations:

   • In heart failure patients, RAASi therapy should be carefully reintroduced as soon as possible after stabilization of potassium levels 5
   • Patients with CKD require more frequent monitoring when on potassium-affecting medications 1