How do you treat hyperkalemia?

Treatment of Hyperkalemia

The treatment of hyperkalemia requires a stepwise approach based on severity, with immediate administration of calcium gluconate 10% solution (15-30 mL IV) for cardiac membrane stabilization in hemodynamically unstable patients, followed by insulin with glucose (10 units regular insulin IV with 50 mL of 25% dextrose) to shift potassium intracellularly. 1

Assessment and Classification

Hyperkalemia severity guides treatment approach:

• Mild: 5.5-6.4 mmol/L - Peaked/tented T waves, nonspecific ST changes
• Moderate: 6.5-8.0 mmol/L - PR prolongation, flattened P waves, QRS widening
• Severe: >8.0 mmol/L - Bradycardia, junctional rhythm, sine wave pattern
• Life-threatening: >10.0 mmol/L - Ventricular fibrillation, asystole, PEA 1

Emergency Treatment Algorithm

1. Cardiac Membrane Stabilization (for ECG changes or K+ >6.5 mmol/L)

• Calcium gluconate 10%: 15-30 mL IV over 2-5 minutes
  • Onset: 1-3 minutes
  • Duration: 30-60 minutes
  • Note: Calcium chloride (10 mL) is preferred in cardiac arrest 1, 2
  • Caution: Limited efficacy for non-rhythm ECG disorders 2

2. Intracellular Potassium Shift

• Insulin with glucose: 10 units regular insulin IV with 50 mL of 25% dextrose

  • Onset: 15-30 minutes
  • Duration: 1-2 hours
  • Monitor glucose levels to prevent hypoglycemia 1, 3

• Inhaled beta-agonists: 10-20 mg nebulized over 15 minutes

  • Onset: 15-30 minutes
  • Duration: 2-4 hours
  • Can be used alone or in combination with insulin/glucose 1, 4

• Sodium bicarbonate: 50 mEq IV over 5 minutes (if metabolic acidosis present)

  • Onset: 15-30 minutes
  • Duration: 1-2 hours
  • Less effective when used alone 1, 4

3. Potassium Removal

• Hemodialysis: Most efficient method for severe or refractory hyperkalemia 3, 4

• Loop diuretics: Furosemide IV (if adequate renal function) 4, 5

• Potassium binders:

  Binder	Onset	Site of Action	Notes
  Sodium Polystyrene Sulfonate (SPS)	Variable; hours	Colon	Not for emergency use; GI injury risk 1, 6
  Patiromer	7 hours	Colon	No sodium content; binds magnesium 1, 7
  Sodium Zirconium Cyclosilicate (SZC)	1 hour	Small/large intestines	Higher selectivity; contains sodium 1, 7

Important Considerations

• Continuous monitoring: Serial ECGs and potassium levels are essential during treatment 1

• Medication review: Identify and adjust medications that may contribute to hyperkalemia (ACE inhibitors, ARBs, NSAIDs, potassium-sparing diuretics) 1

• Avoid premature discontinuation of beneficial medications like ACE inhibitors/ARBs when possible; consider potassium binders to maintain RAAS blockade 1

• Dietary modifications: Limit potassium intake (<40 mg/kg/day); educate patients about high-potassium foods to avoid 1

Pitfalls and Caveats

• ECG changes may be absent or atypical despite dangerous potassium levels; don't rely solely on ECG for treatment decisions 4

• Sodium polystyrene sulfonate should not be used for emergency treatment due to delayed onset of action 6, 3

• Calcium administration is primarily for membrane stabilization and does not lower serum potassium levels 2, 5

• Regular reassessment of potassium levels is crucial as temporary measures (insulin/glucose, beta-agonists) have limited duration of action 1

• Identify and address underlying causes to prevent recurrence (renal dysfunction, medication effects, acidosis, tissue breakdown) 4