What is the composition of a hyperkalemia cocktail?

Hyperkalemia Cocktail Composition

The standard hyperkalemia "cocktail" consists of three core components administered simultaneously: IV calcium for cardiac membrane stabilization, insulin with glucose for intracellular potassium shift, and nebulized beta-2 agonist (albuterol or salbutamol) for additional potassium redistribution. 1, 2

Core Components of the Hyperkalemia Cocktail

1. Cardiac Membrane Stabilization (Immediate - Within 1-3 Minutes)

Calcium administration is the first-line intervention when ECG changes are present, regardless of potassium level. 1, 2

• Calcium chloride (10%): 5-10 mL (500-1000 mg) IV over 2-5 minutes 1, 2

  • Preferred in critically ill patients due to more rapid increase in ionized calcium 2
  • Requires central venous access when possible due to tissue injury risk with extravasation 2

• Calcium gluconate (10%): 15-30 mL IV over 2-5 minutes 1, 2

  • Alternative when peripheral IV access only
  • Safer for peripheral administration 2

• Critical caveat: Effects begin within 1-3 minutes but last only 30-60 minutes 1, 2

• Does not lower serum potassium - only protects against arrhythmias 1, 2, 3

• Monitor heart rate during administration and stop if symptomatic bradycardia occurs 2

2. Intracellular Potassium Shift (Onset 15-30 Minutes, Duration 4-6 Hours)

Insulin with glucose is the most effective agent for acutely lowering serum potassium. 1, 4

• Standard dose: 10 units regular insulin IV with 25g glucose (50 mL of D50W) over 15-30 minutes 1, 2, 4

• Alternative for severe hyperkalemia (K+ >6.5 mEq/L): 20 units regular insulin infused over 60 minutes with 60g glucose 5

  • No statistically significant difference in potassium reduction between 10 units bolus versus 20 units infusion (0.78 vs 0.79 mmol/L decrease at 60 minutes, P=0.98) 5
  • Higher insulin doses increase hypoglycemia risk 5

• Onset of action: 15-30 minutes 1, 4

• Peak effect: 30-60 minutes 1

• Duration: 4-6 hours 1, 4

• Expected potassium reduction: 0.5-1.2 mEq/L 1, 5

Critical monitoring: Check glucose and potassium every 2-4 hours during acute treatment phase 1

3. Beta-2 Agonist (Onset 15-30 Minutes, Duration 2-4 Hours)

Nebulized albuterol or salbutamol provides additional potassium-lowering effect and should be administered concurrently with insulin-glucose. 1, 4, 6

• Albuterol: 10-20 mg nebulized over 15 minutes 1, 2, 4

• Salbutamol: 10-20 mg nebulized over 15 minutes 6

  • 10 mg dose: peak effect at 120 minutes (MD -1.29 mmol/L) 6
  • 20 mg dose: peak effect at 90 minutes (MD -1.18 mmol/L) 6

• Alternative: Salbutamol 1.2 mg via metered-dose inhaler produces significant decrease beginning at 10 minutes (MD -0.20 mmol/L) with maximal effect at 60 minutes (MD -0.34 mmol/L) 6

• Comparative efficacy: Salbutamol has similar effect to insulin-dextrose but is more effective than bicarbonate at 60 minutes (MD -0.46 mmol/L) 6

• Duration of effect: 2-4 hours 1

Optional Fourth Component: Sodium Bicarbonate

Sodium bicarbonate should ONLY be added if concurrent metabolic acidosis is present (pH <7.35, bicarbonate <22 mEq/L). 1, 4

• Dose: 50 mEq IV over 5 minutes 1, 2
• Mechanism: Promotes potassium excretion through increased distal sodium delivery and counters acidosis-induced potassium release 1
• Onset: 30-60 minutes 1
• Evidence limitation: Poor efficacy when used alone; lost favor as monotherapy 4

Common pitfall: Do not use sodium bicarbonate in patients without metabolic acidosis - it is only indicated when acidosis is present 1

Subsequent Potassium Elimination (Not Part of Initial "Cocktail")

After the initial cocktail stabilizes the patient, definitive potassium removal must be initiated:

Loop Diuretics

• Furosemide: 40-80 mg IV 1
• Effective only with adequate renal function 1, 2
• Increases renal potassium excretion 1

Potassium Binders

• Sodium zirconium cyclosilicate (SZC): 10g three times daily for 48 hours, then 5-15g once daily 1

  • Onset: ~1 hour 1
  • Preferred over older agents 1

• Patiromer: 8.4g once daily, titrated to 25.2g daily 1

  • Onset: ~7 hours 1

• Sodium polystyrene sulfonate (Kayexalate): 15-50g orally or rectally 2

  • Significant limitations including delayed onset and risk of bowel necrosis 1
  • Should be avoided for acute management 1

Hemodialysis

• Most effective method for severe hyperkalemia, especially with renal failure 1, 2
• Reserved for severe cases unresponsive to medical management 1

Clinical Algorithm for Administration

1. Assess severity immediately: Check ECG for peaked T waves, flattened P waves, prolonged PR interval, widened QRS 1, 2

2. If ECG changes present OR K+ ≥6.5 mEq/L:

   • Administer calcium (chloride or gluconate) immediately 1, 2
   • Simultaneously prepare insulin-glucose and nebulized albuterol 4
   • Give insulin-glucose and albuterol together 4
   • Add sodium bicarbonate ONLY if pH <7.35 1

3. Monitor closely:

   • Recheck potassium within 1-2 hours after insulin-glucose administration 1
   • Continue monitoring every 2-4 hours until stabilized 1
   • Monitor glucose to prevent hypoglycemia 5

4. Initiate definitive removal:

   • Start loop diuretics if adequate renal function 1
   • Begin potassium binder therapy 1
   • Arrange hemodialysis if severe or refractory 1, 2

Critical Pitfalls to Avoid

• Do not rely solely on ECG findings - they are highly variable and less sensitive than laboratory tests 1
• Remember that calcium, insulin, and beta-agonists do not remove potassium from the body - they only temporize 1
• Ensure glucose is administered with insulin to prevent hypoglycemia 1, 5
• Do not use sodium bicarbonate without metabolic acidosis 1
• Anticipate rebound hyperkalemia after 2-4 hours as temporary measures wear off 2, 4
• Never delay calcium administration when ECG changes are present, regardless of potassium level 1, 2