What is the immediate treatment for hyperkalemia?

Immediate Treatment for Hyperkalemia

The immediate treatment for hyperkalemia requires a three-step approach: cardiac membrane stabilization with intravenous calcium, shifting potassium into cells with insulin/glucose and beta-agonists, and eliminating potassium from the body through diuretics, potassium binders, or hemodialysis. 1

Assessment of Severity

• Hyperkalemia is classified as mild (5.0-5.9 mEq/L), moderate (6.0-6.4 mEq/L), or severe (≥6.5 mEq/L), with severe hyperkalemia being life-threatening 1, 2
• ECG changes (peaked T waves, flattened P waves, prolonged PR interval, widened QRS) indicate urgent treatment regardless of potassium level 1
• Symptoms may be nonspecific, and ECG findings can be variable and less sensitive than laboratory tests 2

Step 1: Cardiac Membrane Stabilization

• Administer intravenous calcium to protect the heart from arrhythmias:
  • Calcium chloride (10%): 5-10 mL (500-1000 mg) IV over 2-5 minutes, OR
  • Calcium gluconate (10%): 15-30 mL IV over 2-5 minutes 1, 2
• Effects begin within 1-3 minutes but are temporary (30-60 minutes) and do not reduce serum potassium 1
• Caution: In patients with malignant hyperthermia and hyperkalemia, calcium should only be used in extreme cases as it may contribute to calcium overload of the myoplasm 2

Step 2: Shift Potassium into Cells

• Administer insulin with glucose: 10 units regular insulin IV with 25g glucose (50 mL of D50W) over 15-30 minutes 1
  • Onset within 15-30 minutes, effect lasts 4-6 hours 1, 3
• Administer nebulized albuterol: 10-20 mg over 15 minutes 1
  • Can be used in combination with insulin/glucose for enhanced effect 4
• Consider sodium bicarbonate (50 mEq IV over 5 minutes) only if concurrent metabolic acidosis is present 1, 2
  • Less effective when used alone 4

Step 3: Eliminate Potassium from Body

• For patients with adequate renal function, administer loop diuretics (furosemide: 40-80 mg IV) 1, 2
• Administer cation exchange resins:
  • Traditional option: Sodium polystyrene sulfonate (Kayexalate): 15-50 g orally or rectally with sorbitol 1
  • Newer, safer options: Patiromer or sodium zirconium cyclosilicate 1, 3
• Consider hemodialysis for severe hyperkalemia, especially in patients with renal failure or when other measures are ineffective 1, 3

Important Clinical Considerations

• Temporary measures (insulin/glucose, albuterol) provide only transient effects (1-4 hours); rebound hyperkalemia can occur after 2 hours 1
• Monitor potassium levels closely during treatment to avoid overcorrection and hypokalaemia 1
• Review and adjust medications that may contribute to hyperkalemia (ACE inhibitors, ARBs, MRAs, NSAIDs, beta-blockers) 1, 2
• Absent or atypical ECG changes do not exclude the necessity for immediate intervention in severe hyperkalemia 4
• The combination of insulin with glucose and albuterol is more effective than either agent alone 4

Treatment Algorithm for Different Severity Levels

• For mild hyperkalemia (5.0-5.9 mEq/L) without ECG changes:

  • Loop diuretics if renal function is adequate 2
  • Potassium binders for chronic management 2, 3

• For moderate hyperkalemia (6.0-6.4 mEq/L) or mild with ECG changes:

  • Begin with steps 1 and 2 (calcium, insulin/glucose, albuterol) 1, 2
  • Follow with elimination strategies 1

• For severe hyperkalemia (≥6.5 mEq/L) or any level with significant ECG changes:

  • Implement all three steps immediately 1, 5
  • Consider hemodialysis if response is inadequate or renal failure is present 1, 3