What is the treatment for a patient with hyperkalemia (high potassium) and hypocalcemia (low calcium)?

Treatment for Hyperkalemia with Hypocalcemia

For patients with both hyperkalemia and hypocalcemia, administer intravenous calcium gluconate (10% solution, 15-30 mL IV) as the first-line treatment to stabilize cardiac membranes, followed by insulin with glucose to lower potassium levels, while simultaneously correcting the calcium deficit. 1

Initial Management of Hyperkalemia

Step 1: Cardiac Membrane Stabilization

• Administer 10% calcium gluconate, 15-30 mL IV over 5-10 minutes with ECG monitoring
  • Onset of action: 1-3 minutes
  • Duration: 30-60 minutes
  • Protects against cardiac arrhythmias while other treatments take effect 1
  • Particularly effective for main rhythm disorders due to hyperkalemia 2

Step 2: Intracellular Shift of Potassium

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

Step 3: Potassium Elimination

• Sodium polystyrene sulfonate (Kayexalate): 15-60g orally in divided doses
  • Adult dosage: 15g (four level teaspoons) 1-4 times daily
  • Suspend each dose in 3-4 mL of water or syrup per gram of resin 3
  • Administer with patient in upright position to prevent aspiration 3

Concurrent Management of Hypocalcemia

• For symptomatic hypocalcemia:
  • Administer 10-20 mL of 10% calcium gluconate in 50-100 mL of 5% dextrose IV over 10 minutes
  • Follow with calcium gluconate infusion: 100 mL of 10% calcium gluconate in 1L of normal saline or 5% dextrose at 50-100 mL/h 4
  • Titrate infusion rate to achieve normocalcemia

Monitoring and Follow-up

• Monitor serum potassium, calcium, and magnesium levels frequently
• Perform continuous ECG monitoring for patients with severe hyperkalemia
• Watch for ECG changes that correlate with potassium levels:

  Potassium Level	ECG Changes
  5.5-6.5 mmol/L	Peaked/tented T waves
  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

Special Considerations

• Avoid sodium polystyrene sulfonate in patients with:

  • Obstructive bowel disease
  • Reduced gut motility
  • History of intestinal disease or surgery 3

• Monitor for electrolyte disturbances:

  • Sodium polystyrene sulfonate can bind other cations like magnesium and calcium
  • This may worsen existing hypocalcemia 3

• Medication timing:

  • Administer other oral medications at least 3 hours before or 3 hours after sodium polystyrene sulfonate
  • Patients with gastroparesis may require a 6-hour separation 3

• Fluid overload risk:

  • Each 15g dose of sodium polystyrene sulfonate contains 1500mg (60 mEq) of sodium
  • Monitor patients with heart failure or hypertension for fluid overload 3

Treatment Algorithm Based on Severity

1. Severe hyperkalemia (>6.5 mmol/L) with ECG changes:

   • Immediate calcium gluconate IV
   • Insulin + glucose IV
   • Consider nebulized beta-agonists
   • Initiate potassium elimination therapy

2. Moderate hyperkalemia (5.5-6.5 mmol/L) with hypocalcemia:

   • Calcium gluconate IV
   • Insulin + glucose if potassium >6.0 mmol/L
   • Oral or rectal sodium polystyrene sulfonate

3. Mild hyperkalemia (5.0-5.5 mmol/L) with hypocalcemia:

   • Correct calcium deficit first
   • Consider oral sodium polystyrene sulfonate if potassium remains elevated

Pitfalls to Avoid

• Don't delay calcium administration in severe hyperkalemia with ECG changes, even in the presence of hypocalcemia
• Don't administer sodium bicarbonate routinely unless there is concurrent metabolic acidosis
• Don't use sorbitol with sodium polystyrene sulfonate as it increases risk of intestinal necrosis 3
• Don't forget to monitor glucose levels during insulin therapy to prevent hypoglycemia
• Don't overlook the need for maintenance therapy after acute management to prevent recurrence