What are the measures for managing hyperkalemia?

Hyperkalemia Management

Immediate Assessment and Classification

Hyperkalemia should be classified as mild (5.0-5.9 mEq/L), moderate (6.0-6.4 mEq/L), or severe (≥6.5 mEq/L), with ECG changes indicating urgent treatment regardless of the potassium level. 1

• First, exclude pseudohyperkalemia from hemolysis or improper blood sampling by repeating the measurement with appropriate technique or arterial sampling 1
• Obtain an ECG immediately to assess for peaked T waves, flattened P waves, prolonged PR interval, and widened QRS complexes 1
• ECG findings can be highly variable and less sensitive than laboratory tests, but their presence mandates urgent treatment 2, 1
• A critical pitfall: absent or atypical ECG changes do not exclude the necessity for immediate intervention 3

Acute Hyperkalemia Management Algorithm

Step 1: Cardiac Membrane Stabilization (Within 1-3 Minutes)

For severe hyperkalemia (>6.5 mEq/L) or any ECG changes, immediately administer intravenous calcium gluconate 10%: 15-30 mL IV over 2-5 minutes. 4, 1

• Calcium stabilizes cardiac membranes within 1-3 minutes but does not lower serum potassium 2, 1
• Effects are temporary (30-60 minutes) 1
• If no effect is observed within 5-10 minutes, repeat the dose 2
• In cardiac arrest situations, use calcium chloride 10%: 5-10 mL IV over 2-5 minutes instead 1, 5

Step 2: Intracellular Potassium Shift (Within 15-30 Minutes)

Administer 10 units of regular insulin intravenously with 50 mL of 50% glucose (or 25 grams dextrose), which begins working within 15-30 minutes and lasts 4-6 hours. 4, 1, 3

• Monitor glucose levels closely to avoid hypoglycemia, particularly in patients with low baseline glucose, no diabetes history, female sex, and altered renal function 1
• Verify that potassium levels are not below 3.3 mEq/L before administering insulin 1
• Insulin can be repeated every 4-6 hours as needed, with potassium monitoring every 2-4 hours 1

Combine insulin/glucose with inhaled beta-agonists (albuterol 10-20 mg by nebulizer) for additive effect. 2, 4, 3

• Beta-agonists promote intracellular potassium shift with onset within 15-30 minutes 4, 1
• This combination is more effective than either agent alone 3

Step 3: Sodium Bicarbonate (Conditional)

Administer intravenous sodium bicarbonate ONLY if metabolic acidosis is present (pH < 7.35, bicarbonate < 22 mEq/L). 2, 1

• Bicarbonate promotes potassium excretion through increased distal sodium delivery and counters acidosis-induced potassium release 2, 1
• Effects are not immediate and may take 30-60 minutes 1
• Sodium bicarbonate alone has poor efficacy as a potassium-lowering agent and should not be used as monotherapy 3

Step 4: Potassium Removal from the Body

For patients with adequate kidney function, administer loop diuretics (furosemide 40-80 mg IV) to increase renal potassium excretion. 1, 6

• Diuretics stimulate flow and delivery of potassium to the renal collecting ducts 2
• Effectiveness depends on residual kidney function 2

Hemodialysis is the most effective and definitive method for severe hyperkalemia, especially in patients with renal failure or cases refractory to medical treatment. 2, 1, 7

• Dialysis should be instituted after implementing other acute measures 2
• This is the most reliable method to remove potassium from the body 7, 8

Chronic Hyperkalemia Management

For long-term management, use newer FDA-approved potassium binders (patiromer or sodium zirconium cyclosilicate) as first-line agents. 4, 1, 5

• These agents avoid the limitations of older therapies and are preferred for chronic management 2, 4
• Avoid chronic use of sodium polystyrene sulfonate (SPS) alone or with sorbitol due to risk of gastrointestinal necrosis 9

Loop or thiazide diuretics can be used to promote urinary potassium excretion in patients with adequate kidney function. 2, 4, 1

• Diuretics may increase risk of gout, volume depletion, and worsening kidney function 2
• Their effectiveness relies on residual kidney function 2

Review and adjust medications that contribute to hyperkalemia, including ACE inhibitors, ARBs, mineralocorticoid antagonists, NSAIDs, and beta-blockers. 1, 6

• For patients on RAAS inhibitors with potassium >5.0 mEq/L, initiate a potassium-lowering agent and maintain RAAS inhibitor therapy unless an alternative cause is identified 1
• When potassium >6.5 mEq/L, discontinue or reduce RAAS inhibitors temporarily, initiate a potassium-lowering agent, and monitor closely 1

Monitoring and Prevention

Patients with cardiovascular disease on RAAS inhibitors require potassium assessment 7-10 days after starting or increasing doses. 1

• Patients with chronic kidney disease, heart failure, or diabetes are at higher risk and require more frequent monitoring 1, 9
• Dietary potassium restriction and medication review are essential for preventing recurrence 6, 3
• Prolonged fasting may provoke hyperkalemia in dialysis patients, which can be prevented by administering intravenous dextrose 8

A team approach involving cardiologists, nephrologists, primary care physicians, nurses, pharmacists, and dietitians is optimal for chronic hyperkalemia management. 2, 4, 1