What is the treatment for hyperkalemia (elevated potassium level) greater than 6?

Management of Hyperkalemia with Potassium >6 mEq/L

For severe hyperkalemia with potassium >6 mEq/L, immediate treatment is required with calcium administration for cardiac membrane stabilization, followed by insulin/glucose, beta-agonists, and sodium bicarbonate to shift potassium intracellularly, while simultaneously initiating measures to eliminate potassium from the body. 1, 2

Emergency Management Algorithm

Step 1: Cardiac Membrane Stabilization (Immediate Effect)

• Administer calcium chloride 10% (5-10 mL IV over 2-5 minutes) or calcium gluconate 10% (15-30 mL IV over 2-5 minutes) to protect the heart from hyperkalemia's effects 1
• This stabilizes cardiac membranes but does not lower potassium levels 2
• Calcium administration is particularly crucial when ECG changes are present (peaked T waves, flattened P waves, prolonged PR interval, widened QRS) 1

Step 2: Shift Potassium Into Cells (30-60 minute effect)

• Administer insulin and glucose: 10 units regular insulin with 25g glucose (50 mL of D50W) IV over 15-30 minutes 1
• Give nebulized albuterol: 10-20 mg nebulized over 15 minutes 1, 2
• Consider sodium bicarbonate: 50 mEq IV over 5 minutes (especially if metabolic acidosis is present) 1

Step 3: Eliminate Potassium From Body

• Administer loop diuretics: furosemide 40-80 mg IV (if renal function permits) 1
• Consider potassium binders: sodium polystyrene sulfonate (Kayexalate) 15-50g orally or rectally with sorbitol 1
• Note: Sodium polystyrene sulfonate should not be used as emergency treatment due to its delayed onset of action 3
• Initiate hemodialysis for severe, refractory cases or in patients with renal failure 1, 2

Special Considerations

Monitoring and Follow-up

• Continuous cardiac monitoring is essential during treatment 2
• Repeat serum potassium measurements frequently to assess treatment efficacy 2
• Monitor for hypoglycemia when using insulin/glucose therapy 4
• Watch for cardiac ischemia or arrhythmias with beta-2 agonists 4

Medication Review and Adjustment

• Identify and temporarily discontinue medications contributing to hyperkalemia 2
• Common culprits include ACE inhibitors, ARBs, mineralocorticoid receptor antagonists (MRAs), NSAIDs, and potassium-sparing diuretics 5
• For patients on MRAs, guidelines recommend stopping the medication when potassium exceeds 6.0 mEq/L 1

Risk Stratification

• Patients with comorbidities such as heart failure, chronic kidney disease, and diabetes mellitus are at higher risk for complications 1, 2
• Mortality risk increases significantly with potassium levels >6.0 mEq/L 1
• The presence of ECG changes indicates higher risk and necessitates more aggressive treatment 1, 2

Common Pitfalls to Avoid

• Do not delay treatment of severe hyperkalemia while waiting for confirmation of repeat laboratory values if clinical suspicion is high 2
• Avoid permanently discontinuing beneficial RAAS inhibitors; consider dose reduction and addition of potassium binders once acute episode is resolved 2
• Do not rely solely on potassium binders for acute management of severe hyperkalemia 3
• Be vigilant for rebound hyperkalemia after initial treatment, especially when transcellular shifts were the primary mechanism of correction 6

By following this structured approach to managing severe hyperkalemia, clinicians can effectively reduce potassium levels while minimizing the risk of adverse events and mortality.