What is the treatment for a patient with hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia requires immediate intervention with calcium gluconate for cardiac membrane stabilization, followed by insulin with glucose to shift potassium intracellularly, and ultimately removal of excess potassium from the body through dialysis or potassium binders. 1

Classification and Assessment

• Definition: Hyperkalemia is defined as serum potassium >5.0 mmol/L

• Severity classification:

  • Mild: 5.0-5.5 mmol/L
  • Moderate: 5.6-6.5 mmol/L
  • Severe: >6.5 mmol/L 1

• ECG changes correlate with increasing potassium levels:

  Potassium Level	ECG Changes
  5.5-6.5 mmol/L	Peaked/tented T waves (early sign)
  6.5-7.5 mmol/L	Prolonged PR interval, flattened P waves
  7.0-8.0 mmol/L	Widened QRS, deep S waves
  >10 mmol/L	Sinusoidal pattern, VF, asystole, or PEA

Treatment Algorithm

1. Cardiac Membrane Stabilization (Immediate)

• Administer IV calcium gluconate 10% solution (15-30 mL) 1
  • Onset: 1-3 minutes
  • Duration: 30-60 minutes
  • Particularly important for patients with ECG changes 2
  • For cardiac arrest, use calcium chloride instead 3

2. Intracellular Potassium Shift (15-30 minutes)

• Administer 10 units regular insulin IV with 50 mL of 25% dextrose 1, 4

  • Onset: 15-30 minutes
  • Duration: 1-2 hours
  • Alternative: 20 units insulin infused over 60 minutes for severe hyperkalemia (>6.5 mmol/L) 4
  • Provide sufficient glucose (50g with 10 units insulin, 60g with 20 units insulin) 4
  • Monitor blood glucose frequently to prevent hypoglycemia 4, 5

• Consider adjunctive therapy:

  • Inhaled beta-agonists (10-20 mg nebulized over 15 minutes) 1
  • Sodium bicarbonate (50 mEq IV over 5 minutes) if metabolic acidosis present 1

3. Potassium Elimination

• Hemodialysis: Most rapid and effective method for eliminating potassium 1

  • First-line for severe or refractory hyperkalemia
  • Essential for patients with renal failure

• Potassium binders:

  • Newer agents (patiromer or sodium zirconium cyclosilicate) preferred over sodium polystyrene sulfonate (SPS) 1, 3
  • SPS should not be used for emergency treatment due to delayed onset 6
  • SPS dosing: 15-60g daily in divided doses 6

• Loop diuretics: Promote renal potassium excretion in patients with adequate renal function 1

Important Caveats

1. Sodium polystyrene sulfonate limitations:

   • Not for emergency treatment of life-threatening hyperkalemia 6
   • Risk of intestinal necrosis, especially with sorbitol 6
   • Administer at least 3 hours before or after other medications 6
   • Contraindicated in obstructive bowel disease 6

2. Monitoring requirements:

   • Continuous ECG monitoring during treatment
   • Serial potassium measurements
   • Frequent blood glucose monitoring (risk of hypoglycemia ~20%) 4

3. Risk factors for hyperkalemia to address:

   • Medications: RAAS inhibitors, NSAIDs, beta-blockers, potassium-sparing diuretics
   • Renal dysfunction
   • Diabetes mellitus
   • Heart failure 1

Prevention of Recurrent Hyperkalemia

• Review and adjust medications that contribute to hyperkalemia 1
• Dietary potassium restriction (<40 mg/kg/day) 1
• Avoid potassium-containing salt substitutes 1
• Consider chronic potassium binders for long-term management 1
• Ensure adequate dialysis prescription if applicable 1