What is the treatment for hyperkalemia?

Treatment of Hyperkalemia

For hyperkalemia management, administer intravenous calcium (calcium gluconate 10%: 15-30 mL or calcium chloride 10%: 5-10 mL) for cardiac membrane stabilization, followed by insulin with glucose (10 units regular insulin IV with 25g glucose) to shift potassium into cells, and implement definitive measures to eliminate potassium from the body. 1, 2

Assessment and Classification

• Hyperkalemia is classified as mild (5.0-5.9 mEq/L), moderate (6.0-6.4 mEq/L), or severe (≥6.5 mEq/L) 1
• ECG changes (peaked T waves, flattened P waves, prolonged PR interval, widened QRS) indicate urgent treatment regardless of potassium level 2
• Symptoms may be nonspecific, making laboratory confirmation essential 1

Step-by-Step Management Algorithm

Step 1: Cardiac Membrane Stabilization (Immediate Action)

• Administer intravenous calcium gluconate (10%): 15-30 mL IV over 2-5 minutes, or calcium chloride (10%): 5-10 mL IV over 2-5 minutes 2
• Effects begin within 1-3 minutes but are temporary (30-60 minutes) and do not reduce serum potassium 1
• Avoid calcium in patients taking digoxin as it may potentiate digoxin toxicity 3

Step 2: Shift Potassium into Cells (15-30 minute onset)

• Administer insulin with glucose: 10 units regular insulin IV with 25g glucose (50 mL of D50W) over 15-30 minutes 2
• Consider nebulized albuterol: 10-20 mg over 15 minutes as an adjunct therapy 2
• For patients with concurrent metabolic acidosis, consider sodium bicarbonate: 50 mEq IV over 5 minutes 2
• These measures provide temporary effect (4-6 hours) and should be followed by definitive treatment 1, 2

Step 3: Eliminate Potassium from Body (Definitive Treatment)

• For patients with adequate kidney function, administer loop diuretics (furosemide 40-80 mg IV) 1, 2
• For chronic management, consider newer potassium binders such as patiromer and sodium zirconium cyclosilicate 1, 4
• Note that sodium polystyrene sulfonate should not be used as an emergency treatment for life-threatening hyperkalemia due to its delayed onset of action 5
• Hemodialysis is the most effective method for severe hyperkalemia, especially in patients with renal failure 1, 2

IV Fluid Management

• Normal saline (0.9% NaCl) is the first-line IV fluid for acute hyperkalemia, providing volume expansion and improving renal perfusion 3
• Avoid potassium-containing fluids such as Lactated Ringer's or other balanced solutions 3

Monitoring During Treatment

• Check serum potassium levels at 1-2 hour intervals during acute treatment 3
• Monitor blood glucose frequently to prevent hypoglycemia when using insulin 3
• Watch for rebound hyperkalemia 2-4 hours after treatment 2, 3

Chronic Hyperkalemia Management

• Review and adjust medications that may contribute to hyperkalemia (ACE inhibitors, ARBs, MRAs, NSAIDs, beta-blockers) 1, 2
• Use loop or thiazide diuretics to promote urinary excretion of potassium in patients with adequate kidney function 1
• Consider newer potassium binders for long-term management 1, 4

Special Considerations

• Patients with cardiovascular disease on RAAS inhibitors require careful monitoring of potassium levels, with assessment 7-10 days after starting or increasing doses 1
• Patients with chronic kidney disease, heart failure, or diabetes are at higher risk for hyperkalemia and require more frequent monitoring 1, 6
• Temporary measures (insulin/glucose, albuterol) provide only transient effects, and definitive treatment of the underlying cause is necessary 3, 7