What is the composition of a hyperkalemia cocktail?

Hyperkalemia Cocktail Composition

The standard hyperkalemia cocktail consists of calcium gluconate 10% solution (15-30 mL IV), insulin (10 units regular insulin IV) with glucose (50 mL of 25% dextrose), and may include sodium bicarbonate (50 mEq IV) and inhaled beta-agonists (10-20 mg nebulized). 1

Components of Hyperkalemia Cocktail and Their Functions

Immediate Membrane Stabilization

• Calcium Gluconate: 10% solution, 15-30 mL IV
  • Onset: 1-3 minutes
  • Duration: 30-60 minutes
  • Function: Stabilizes cardiac cell membranes to prevent arrhythmias
  • Does not lower potassium levels but protects against cardiac effects 1

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
  • Function: Drives potassium into cells
  • Monitor for hypoglycemia (common side effect) 1

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

  • Onset: 15-30 minutes
  • Duration: 2-4 hours
  • Function: Stimulates Na-K-ATPase pump, shifting potassium into cells
  • Can be used alone or in combination with insulin/glucose for additive effect 1

• Sodium Bicarbonate: 50 mEq IV over 5 minutes

  • Onset: 15-30 minutes
  • Duration: 1-2 hours
  • Function: Increases pH, promoting potassium shift into cells
  • Less effective when used alone; better as part of combination therapy 1, 2

Administration Considerations

Research shows that continuous infusion of a solution containing fixed concentrations of calcium gluconate, insulin, dextrose, and sodium acetate (HyperK-Cocktail) can be effective and safe for managing hyperkalemia 3. This approach demonstrated a mean decrease in serum potassium of 1.0,1.7,2.1, and 2.1 mmol/L at 1,2,4, and 8 hours, respectively 3.

Potassium Removal Strategies (Additional Steps)

After initiating the hyperkalemia cocktail, consider:

• Diuretics: IV furosemide if renal function permits 1
• Potassium Binders:
  • Patiromer (Veltassa): 8.4g once daily, onset within 7 hours
  • Sodium zirconium cyclosilicate (SZC): Faster onset (1 hour)
  • Sodium polystyrene sulfonate (SPS): Variable onset, several hours 1, 4
• Dialysis: Consider for severe cases, especially with renal failure or when other measures are ineffective 4

Monitoring During Treatment

• Continuous cardiac monitoring for patients with moderate to severe hyperkalemia
• Serial ECGs to monitor for progression or resolution of changes
• Regular potassium level checks during treatment
• Blood glucose monitoring when using insulin 1

Common Pitfalls and Caveats

1. Calcium administration: Avoid in patients taking digoxin as it may potentiate digoxin toxicity
2. Insulin/glucose: Monitor for hypoglycemia, especially in diabetic patients
3. Sodium bicarbonate: Limited efficacy as monotherapy; use cautiously in patients with volume overload
4. SPS: Associated with serious gastrointestinal adverse effects including colonic necrosis 4
5. Absent ECG changes: Do not exclude the need for immediate intervention in severe hyperkalemia 2

Treatment Algorithm Based on Severity

Severe Hyperkalemia (K+ >6.0 mmol/L or ECG changes)

1. Administer calcium gluconate immediately
2. Follow with insulin/glucose ± nebulized beta-agonists
3. Consider sodium bicarbonate if metabolic acidosis present
4. Initiate potassium removal with diuretics, binders, or dialysis

Moderate Hyperkalemia (K+ 5.5-6.0 mmol/L without ECG changes)

1. Insulin/glucose ± nebulized beta-agonists
2. Potassium binders
3. Address underlying causes

The combination of insulin with glucose and albuterol by nebulizer is favored as first-line therapy for acute management, as it provides rapid and effective potassium lowering 2, 4.