What is the initial management protocol for hyperkalemia?

Hyperkalemia Management Protocol

Immediate Assessment and Classification

For hyperkalemia, immediately obtain an ECG and classify severity: 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 potassium level. 1

• Verify the result is not pseudohyperkalemia from hemolysis, repeated fist clenching, or poor phlebotomy technique before initiating treatment 2, 1
• Look for peaked T waves, flattened P waves, prolonged PR interval, and widened QRS complexes on ECG, though these findings can be highly variable and less sensitive than laboratory values 2, 1
• Symptoms are typically nonspecific, making ECG and laboratory confirmation essential 2

Acute Hyperkalemia Management Algorithm

Severe Hyperkalemia (K+ ≥6.5 mEq/L or ANY ECG changes)

This is a medical emergency requiring immediate multi-step treatment within minutes. 3, 4

Step 1: Cardiac Membrane Stabilization (within 1-3 minutes)

• Administer calcium gluconate 10%: 15-30 mL IV over 2-5 minutes OR calcium chloride 10%: 5-10 mL IV over 2-5 minutes 5, 1, 3
• Effects begin within 1-3 minutes but last only 30-60 minutes and do not lower serum potassium 1, 3
• Repeat dose in 5-10 minutes if no ECG improvement is observed 2
• Caveat: In malignant hyperthermia with hyperkalemia, use calcium only in extremis due to risk of myoplasmic calcium overload 1

Step 2: Intracellular Potassium Shift (within 15-30 minutes)

• Insulin 10 units IV with 25-50g glucose (50 mL D50W) over 15-30 minutes 5, 1, 3

  • Onset: 15-30 minutes, duration: 4-6 hours 5, 1
  • Can be repeated every 4-6 hours if hyperkalemia persists, with careful glucose and potassium monitoring 1
  • Critical: Verify potassium is not below 3.3 mEq/L before administering insulin 1
  • Monitor for hypoglycemia, especially in patients with low baseline glucose, no diabetes, female sex, or altered renal function 1

• Nebulized albuterol 10-20 mg over 15 minutes as adjunctive therapy 3

  • Alternative: salbutamol 20 mg in 4 mL nebulized 2
  • Short duration of effect (2-4 hours) 2

• Sodium bicarbonate IV ONLY if concurrent metabolic acidosis is present (pH <7.35, bicarbonate <22 mEq/L) 2, 5, 1

  • Promotes potassium excretion through increased distal sodium delivery 2, 1
  • Effects take 30-60 minutes to manifest 1

Step 3: Potassium Removal from Body

• Loop diuretics (furosemide 40-80 mg IV) in patients with adequate kidney function and hypervolemia 1, 3

  • Effectiveness depends on residual kidney function 2, 3

• Hemodialysis for severe cases unresponsive to medical management, oliguria, or end-stage renal disease 2, 5, 3

  • Most reliable and effective method for potassium removal 4, 6

Moderate Hyperkalemia (K+ 6.0-6.4 mEq/L without ECG changes)

• Initiate insulin/glucose and albuterol for intracellular shift 3
• Follow with loop diuretics or potassium binders 3
• Monitor potassium levels every 2-4 hours after initial treatment 1

Mild Hyperkalemia (K+ 5.0-5.9 mEq/L)

• Review and discontinue offending medications (ACE inhibitors, ARBs, MRAs, NSAIDs, potassium-sparing diuretics, beta-blockers) 1, 3
• Initiate potassium binder for chronic management 3
• Do NOT discontinue RAAS inhibitors in patients requiring them—instead, add potassium-lowering agents 1, 3

Chronic Hyperkalemia Management

For recurrent hyperkalemia, use newer FDA-approved potassium binders (patiromer or sodium zirconium cyclosilicate) rather than traditional resins, while maintaining RAAS inhibitor therapy. 5, 1, 3

• Loop or thiazide diuretics promote urinary potassium excretion by stimulating flow to renal collecting ducts 2, 5, 1
• Fludrocortisone increases potassium excretion but carries risks of fluid retention, hypertension, and vascular injury 2, 5
• Sodium polystyrene sulfonate should NOT be used for emergency treatment due to delayed onset of action 7

RAAS Inhibitor Management in Chronic Hyperkalemia

• For K+ >5.0 mEq/L in patients on RAAS inhibitors: initiate potassium-lowering agent and maintain RAAS inhibitor therapy unless alternative treatable cause identified 1, 3
• For K+ >6.5 mEq/L: temporarily discontinue or reduce RAAS inhibitors, initiate potassium-lowering agent, and monitor closely 1
• Reassess potassium 7-10 days after starting or increasing RAAS inhibitor doses 2, 1

Monitoring Protocol

• Check potassium within 1 week of starting or escalating RAAS inhibitors 2
• Monitor every 2-4 hours after acute treatment initiation 1
• Individualize monitoring frequency based on comorbidities (CKD, diabetes, heart failure) and medications 2
• More frequent monitoring required in high-risk patients with history of hyperkalemia 2

Key Pitfalls to Avoid

• Do not rely solely on ECG findings—they are highly variable and less sensitive than laboratory tests 2, 1
• Do not use sodium bicarbonate in patients without metabolic acidosis—it is only indicated when acidosis is present 2, 5, 1
• Do not discontinue RAAS inhibitors prematurely—use potassium binders to maintain cardioprotective and renoprotective therapy 1, 3
• Do not use sodium polystyrene sulfonate for acute emergencies—it has delayed onset of action 7
• Ensure glucose is administered with insulin to prevent hypoglycemia 2
• Remember that calcium, insulin, and beta-agonists do not remove potassium from the body—they only temporize 2, 1, 3

Team Approach

• Optimal management involves specialists (cardiologists, nephrologists), primary care physicians, nurses, pharmacists, social workers, and dietitians 2, 5, 1
• Dietary counseling for low-potassium diet is essential for chronic management 8
• Maintain adequate hydration to support renal potassium excretion 5