From the Guidelines
Management of hyperkalemia involves a stepwise approach based on severity and symptoms, with the most recent and highest quality study recommending a combination of calcium gluconate, insulin, and potassium-binding agents for treatment. For mild hyperkalemia (5.0-5.9 mEq/L), discontinue potassium-containing medications and supplements, and restrict dietary potassium 1. For moderate to severe hyperkalemia (≥6.0 mEq/L) or when ECG changes are present, immediate intervention is necessary.
Key Treatment Steps:
- First, administer calcium gluconate 10% (10 mL IV over 2-3 minutes) to stabilize cardiac membranes and prevent arrhythmias, as recommended by the Mayo Clinic Proceedings study in 2021 1.
- Next, shift potassium intracellularly using insulin (10 units regular insulin IV with 25g dextrose to prevent hypoglycemia) and/or nebulized albuterol (10-20 mg) 1.
- Sodium bicarbonate (50 mEq IV over 5 minutes) may be used in patients with metabolic acidosis, as suggested by the European Heart Journal study in 2018 1.
Definitive Removal of Potassium:
- Administer sodium polystyrene sulfonate (15-30g orally or rectally), patiromer (8.4-16.8g orally), or sodium zirconium cyclosilicate (10g orally) for definitive removal of potassium, as recommended by the Mayo Clinic Proceedings study in 2021 1.
- In severe cases or when other measures fail, hemodialysis provides rapid and effective potassium removal, as noted in the European Journal of Heart Failure study in 2018 1.
Ongoing Monitoring and Adjustment:
- Throughout treatment, continuous cardiac monitoring is essential, and serial potassium measurements should guide therapy adjustments, as emphasized by the European Heart Journal study in 2018 1.
- Addressing the underlying cause of hyperkalemia is crucial for preventing recurrence, as highlighted by the Mayo Clinic Proceedings study in 2021 1.
From the Research
Management of Hyperkalemia
The management of hyperkalemia involves several strategies to reduce serum potassium levels and prevent fatal complications. Some of the key management approaches include:
- Elimination of reversible causes, such as diet and medications 2
- Rapidly acting therapies to shift potassium into cells and block cardiac membrane effects, such as calcium gluconate, insulin, and beta-2 agonists 3, 2, 4, 5
- Measures to facilitate removal of potassium from the body, including saline diuresis, oral binding resins, and hemodialysis 2, 5
Treatment Options
Treatment options for hyperkalemia depend on the severity of the condition and the presence of electrocardiogram (ECG) changes. Some of the treatment options include:
- Calcium gluconate to stabilize cardiomyocyte membranes 2, 4, 5
- Insulin injection to stimulate intracellular uptake of potassium 3, 2, 4, 5
- Beta-2 agonists to augment the effects of insulin and glucose 2, 5
- Sodium polystyrene sulfonate (SPS) and other oral binding resins for subacute treatment 3, 4
- Hemodialysis for severe cases that are refractory to medical treatment 2, 5
Considerations for Patient Management
When managing patients with hyperkalemia, it is essential to consider the underlying causes of the condition, such as kidney disease, hyperglycemia, and medication use 3, 2, 4, 5, 6. Clinicians must also be aware of the potential benefits and contraindications of different medications used to treat hyperkalemia, including SPS, sodium zirconium cyclosilicate (SZC), and patiromer 3. Additionally, changes to prescribing systems and institutional protocols can improve patient safety for this frequently encountered electrolyte disorder 5.