What is the immediate treatment for hyperkalemia?

Immediate Treatment for Hyperkalemia

For life-threatening hyperkalemia (≥6.5 mEq/L or any ECG changes), immediately administer intravenous calcium to stabilize the cardiac membrane, followed by insulin with glucose and nebulized albuterol to shift potassium intracellularly, then initiate definitive potassium removal strategies. 1

Severity Assessment

Before initiating treatment, classify the severity and verify the result is not pseudohyperkalemia from hemolysis or poor phlebotomy technique 2:

• Mild hyperkalemia: 5.0-5.9 mEq/L 1
• Moderate hyperkalemia: 6.0-6.4 mEq/L 1
• Severe hyperkalemia: ≥6.5 mEq/L (life-threatening) 1

ECG changes mandate urgent treatment regardless of potassium level 1. Look for peaked T waves, flattened P waves, prolonged PR interval, and widened QRS complexes, though these findings can be variable and less sensitive than laboratory values 2.

Three-Step Treatment Algorithm

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

Administer intravenous calcium first to protect against fatal arrhythmias 1:

• Calcium chloride (10%): 5-10 mL (500-1000 mg) IV over 2-5 minutes (preferred option as it provides more rapid increase in ionized calcium) 1
• Calcium gluconate (10%): 15-30 mL IV over 2-5 minutes (alternative, safer for peripheral IV) 1

Critical considerations for calcium administration 1:

• Effects begin within 1-3 minutes but last only 30-60 minutes 2
• Does NOT lower serum potassium—only stabilizes cardiac membranes 1
• Use central venous catheter when possible for calcium chloride to avoid tissue injury from extravasation 1
• Monitor heart rate and stop if symptomatic bradycardia occurs 1
• May repeat dose if no ECG improvement within 5-10 minutes 3

Step 2: Shift Potassium into Cells (Onset 15-30 Minutes, Duration 4-6 Hours)

Administer all three agents simultaneously for maximum effect 1:

Insulin with glucose (most effective shifting agent) 1:

• 10 units regular insulin IV with 25g glucose (50 mL of D50W) over 15-30 minutes 1
• Onset: 15-30 minutes, duration: 4-6 hours 1
• Monitor glucose closely to prevent hypoglycemia 2
• Can repeat every 4-6 hours if hyperkalemia persists, checking potassium every 2-4 hours 2

Nebulized albuterol (adjunctive therapy) 1:

• 10-20 mg nebulized over 15 minutes 1
• Reduces potassium by approximately 0.5-1.0 mEq/L 1
• Effects last 2-4 hours 2

Sodium bicarbonate (ONLY if metabolic acidosis present) 1:

• 50 mEq IV over 5 minutes 1
• Use ONLY when pH <7.35 or bicarbonate <22 mEq/L 2
• Effects take 30-60 minutes to manifest 2
• Do NOT use routinely without acidosis 2

Step 3: Eliminate Potassium from Body (Definitive Treatment)

For patients with adequate renal function 1:

• Loop diuretics: Furosemide 40-80 mg IV to increase renal potassium excretion 1

For chronic or recurrent hyperkalemia 2:

• Patiromer (Veltassa): 8.4 g once daily, titrated up to 25.2 g daily (onset ~7 hours) 2
• Sodium zirconium cyclosilicate (Lokelma): 10 g three times daily for 48 hours, then 5-15 g once daily (onset ~1 hour) 2
• These newer potassium binders are preferred over sodium polystyrene sulfonate (Kayexalate), which has delayed onset and risk of bowel necrosis 2

For severe or refractory cases 1:

• Hemodialysis: Most effective method for potassium removal, especially in renal failure, oliguria, or cases unresponsive to medical management 1, 4

Critical Pitfalls to Avoid

• Do NOT rely solely on ECG findings—they are highly variable and less sensitive than laboratory tests 2
• Remember that calcium, insulin, and beta-agonists are temporizing measures only—they do NOT remove potassium from the body 2
• Rebound hyperkalemia can occur after 2 hours as shifting agents wear off 1
• Always administer glucose with insulin to prevent life-threatening hypoglycemia 2
• Do NOT use sodium bicarbonate without metabolic acidosis—it is ineffective and potentially harmful 2
• Verify the result is not pseudohyperkalemia before initiating aggressive treatment 1

Special Populations

Patients on RAAS inhibitors (ACE inhibitors, ARBs, MRAs) 2:

• For K+ 5.0-6.5 mEq/L: Initiate potassium binder and MAINTAIN RAAS inhibitor therapy 2
• For K+ >6.5 mEq/L: Temporarily discontinue or reduce RAAS inhibitor, initiate potassium binder, monitor closely 2
• Do NOT permanently discontinue these life-saving medications—use potassium binders to enable continuation 2

Patients with chronic kidney disease 2:

• Optimal potassium range is broader: 3.3-5.5 mEq/L for stage 4-5 CKD 2
• Maintain RAAS inhibitors aggressively using potassium binders, as these drugs slow CKD progression 2
• Dialysis is definitive treatment for severe hyperkalemia in ESRD 5

Monitoring Protocol

• Check potassium every 2-4 hours after initial treatment 2
• Reassess within 1 week of starting or escalating RAAS inhibitors 2
• More frequent monitoring required in high-risk patients with CKD, heart failure, or diabetes 2
• Review and eliminate contributing medications: NSAIDs, trimethoprim, heparin, potassium supplements, salt substitutes 2