What is the step-by-step guideline for treating hyperkalemia (elevated potassium levels) in the Emergency Department (ED)?

From the Guidelines

The management of hyperkalemia in the emergency department should follow a step-by-step approach, starting with membrane stabilization using IV calcium gluconate 10% (10 mL) or calcium chloride 10% (5-10 mL) administered over 2-3 minutes, as recommended by the most recent study 1.

Step 1: Assess and Stabilize

• Assess the patient's ECG for hyperkalemic changes (peaked T waves, widened QRS, prolonged PR interval) and obtain serum potassium levels.
• For severe hyperkalemia (K+ >6.5 mmol/L) or with ECG changes, begin with membrane stabilization using IV calcium gluconate 10% (10 mL) or calcium chloride 10% (5-10 mL) administered over 2-3 minutes, which can be repeated after 5 minutes if ECG abnormalities persist 1.

Step 2: Shift Potassium Intracellularly

• Shift potassium intracellularly using insulin and glucose: administer 10 units of regular insulin IV with 25g of dextrose (50 mL of D50W) unless blood glucose is >250 mg/dL.
• Consider nebulized albuterol 10-20 mg over 15 minutes as an adjunct therapy.

Step 3: Remove Excess Potassium

• Remove excess potassium using sodium polystyrene sulfonate (Kayexalate) 15-30g orally or rectally, or preferably newer agents like patiromer (8.4-16.8g orally) or sodium zirconium cyclosilicate (10g orally) 1.
• In severe cases, initiate emergent dialysis, particularly for patients with renal failure.

Step 4: Monitor and Address Underlying Cause

• Throughout treatment, continuously monitor ECG, vital signs, and serum potassium levels.
• Address the underlying cause of hyperkalemia (medication review, renal function assessment) to prevent recurrence. This approach targets hyperkalemia through three mechanisms: cardiac membrane stabilization, intracellular potassium shifting, and potassium elimination from the body, as supported by the latest evidence 1.

From the FDA Drug Label

Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia. Limitation of Use: Sodium Polystyrene Sulfonate Powder, for Suspension should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action [see Clinical Pharmacology (12.2)]. The intensity and duration of therapy depend upon the severity and resistance of hyperkalemia. Oral The average total daily adult dose of Sodium Polystyrene Sulfonate Powder, for Suspension is 15 g to 60 g, administered as a 15-g dose (four level teaspoons), one to four times daily. Rectal The average adult dose is 30 g to 50 g every six hours.

The step-by-step guideline for treating hyperkalemia in the Emergency Department (ED) using Sodium Polystyrene Sulfonate Powder, for Suspension is not explicitly provided in the drug label. However, the label does provide dosage information:

• Oral administration: 15 g to 60 g per day, given as 15-g doses (four level teaspoons) one to four times daily.
• Rectal administration: 30 g to 50 g every six hours. It is essential to note that Sodium Polystyrene Sulfonate Powder, for Suspension should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 2.

From the Research

Step-by-Step Guideline for Treating Hyperkalemia

• Identify the severity of hyperkalemia: mild (> 5.0-5.5 mEq/L), moderate (> 5.5-6.0), or severe (> 6.0) 3
• Assess patient characteristics, potassium levels, and treatments prior to and during the ED visit 3
• Perform electrocardiograms to identify cardiac conduction disturbances 4, 3
• Stabilize cardiac membrane potentials with calcium gluconate, especially in severe cases 5, 6
• Reduce serum potassium levels by shifting potassium from the extracellular fluid to intracellular fluid using:
  • Insulin injection 5, 4, 6
  • β2-agonists administration (e.g., nebulized) 5, 4, 6
• Eliminate potassium through excretion via:
  • Urinary excretion: saline diuresis, diuretics 5, 4
  • Fecal excretion: oral binding resins (e.g., patiromer, sodium zirconium cyclosilicate) 4
• Consider hemodialysis in cases refractory to medical treatment, especially in patients with end-stage renal disease or severe renal impairment 5, 4, 3
• Monitor potassium levels closely and adjust treatment as needed 3
• Address underlying causes of hyperkalemia, such as dietary factors, medications, or renal impairment 5, 4
• Provide long-term management, including dietary counseling and adjusting causative medications 4