Hyperkalemia Management Protocol
Immediate Assessment and Classification
Verify true hyperkalemia by excluding pseudohyperkalemia from hemolysis, repeated fist clenching, or poor phlebotomy technique—repeat with proper technique or arterial sampling before initiating treatment. 1, 2
Severity classification:
Obtain immediate ECG looking for peaked T waves, flattened P waves, prolonged PR interval, and widened QRS complexes—these findings indicate urgent treatment regardless of potassium level, though ECG changes are highly variable and less sensitive than laboratory values. 1, 2
Acute Management Algorithm
Step 1: Cardiac Membrane Stabilization (if K+ ≥6.5 mEq/L OR any ECG changes)
Administer IV calcium immediately—this does NOT lower potassium but stabilizes cardiac membranes within 1-3 minutes for 30-60 minutes: 1, 2
- Calcium gluconate (10%): 15-30 mL IV over 2-5 minutes (preferred for peripheral access) 1, 2
- Calcium chloride (10%): 5-10 mL IV over 2-5 minutes 1
- Repeat dosing may be necessary if no ECG improvement within 5-10 minutes 1
- Continuous cardiac monitoring is mandatory during and after administration 1
Step 2: Shift Potassium Intracellularly (for K+ ≥6.0 mEq/L)
Administer all three agents together for maximum effect: 1
Insulin + Glucose: 10 units regular insulin IV with 25g dextrose (50 mL of 50% dextrose)—onset 15-30 minutes, duration 4-6 hours 1, 2
- Critical: Verify potassium is not below 3.3 mEq/L before administering insulin 1
- Monitor glucose every 2-4 hours to prevent hypoglycemia, especially in patients with low baseline glucose, no diabetes, female sex, or altered renal function 1
- Can repeat every 4-6 hours if hyperkalemia persists, carefully monitoring potassium and glucose 1
Nebulized albuterol: 20 mg in 4 mL—onset 15-30 minutes, duration 2-4 hours 1, 2
Sodium bicarbonate: 50 mEq IV over 5 minutes ONLY if metabolic acidosis present (pH <7.35, bicarbonate <22 mEq/L)—onset 30-60 minutes 1, 2
- Do not use without metabolic acidosis—it is ineffective and wastes time 1
Step 3: Remove Potassium from Body
Choose based on renal function and clinical context: 1
Loop diuretics (if adequate kidney function): Furosemide 40-80 mg IV to increase renal potassium excretion—titrate to maintain euvolemia, not primarily for potassium management 1, 2
Hemodialysis: Most effective and reliable method for severe hyperkalemia, especially in patients with renal failure, oliguria, ESRD, or unresponsive to medical management 1, 2
Avoid sodium polystyrene sulfonate (Kayexalate) for acute management due to delayed onset of action and risk of bowel necrosis 1, 3
Step 4: Medication Review During Acute Episode
Temporarily discontinue or reduce at K+ ≥6.5 mEq/L: 1
- RAAS inhibitors (ACE inhibitors, ARBs, mineralocorticoid antagonists)
- NSAIDs
- Potassium-sparing diuretics
- Trimethoprim
- Heparin
- Beta-blockers
- Potassium supplements and salt substitutes
Chronic Hyperkalemia Management
For Patients on RAAS Inhibitors
Do NOT permanently discontinue RAAS inhibitors—they provide mortality benefit in cardiovascular and renal disease. 1, 2
Treatment algorithm based on potassium level: 1
K+ 5.0-6.5 mEq/L: Initiate approved potassium-lowering agent (patiromer or sodium zirconium cyclosilicate) and maintain RAAS inhibitor therapy unless alternative treatable cause identified 1, 2
K+ >6.5 mEq/L: Temporarily discontinue or reduce RAAS inhibitor, initiate potassium-lowering agent, then restart RAAS inhibitor at lower dose once K+ <5.5 mEq/L 1, 2
Potassium Binder Therapy (Preferred for Long-Term Management)
- Starting dose: 8.4 g once daily
- Titrate up to 25.2 g daily based on potassium levels
- Onset of action: ~7 hours
Sodium zirconium cyclosilicate (SZC/Lokelma): 1, 2
- Starting dose: 10 g three times daily for 48 hours
- Maintenance: 5-15 g once daily
- Onset of action: ~1 hour (can be used for acute hyperkalemia ≥5.8 mEq/L)
Additional Chronic Management Options
- Loop or thiazide diuretics to promote urinary potassium excretion if adequate renal function present 1, 2
- Fludrocortisone increases potassium excretion but carries risks of fluid retention, hypertension, and vascular injury—use cautiously and only when other options exhausted 1
Monitoring Protocol
Check potassium within 1 week of starting or escalating RAAS inhibitors, with reassessment 7-10 days after dose changes. 1, 2
After initiating potassium binder therapy: Reassess at 7-10 days 1
Individualize monitoring frequency based on: 1, 2
- CKD stage (optimal range broader in advanced CKD: 3.3-5.5 mEq/L for stage 4-5 vs. 3.5-5.0 mEq/L for stage 1-2)
- Heart failure
- Diabetes mellitus
- History of hyperkalemia
High-risk patients require more frequent monitoring. 1, 2
Monitor closely for hypokalemia in patients on potassium binders—hypokalemia may be even more dangerous than hyperkalemia. 1
Management by Severity
Mild Hyperkalemia (5.0-5.9 mEq/L)
Do NOT initiate acute interventions (calcium, insulin, albuterol) for mild hyperkalemia without ECG changes or symptoms. 1
Management approach: 1
- Eliminate or reduce contributing medications (NSAIDs, trimethoprim, heparin, beta-blockers, potassium supplements, salt substitutes)
- Avoid potassium supplements and salt substitutes
- Consider loop diuretics if adequate renal function
- Dietary restriction should be approached cautiously—potassium-rich diet provides cardiovascular benefits including blood pressure reduction, and evidence linking dietary potassium to serum levels is limited
Moderate Hyperkalemia (6.0-6.4 mEq/L)
Treat with insulin and glucose, nebulized albuterol to shift potassium into cells, and calcium IV if ECG changes present. 1
For long-term elimination: 1
- Patiromer 8.4 g once daily, titrated up to 25.2 g per day (onset ~7 hours)
- OR sodium zirconium cyclosilicate 10 g three times daily for 48 hours, then 5-15 g once daily (onset ~1 hour)
Do NOT discontinue RAAS inhibitors—use potassium binders to maintain these life-saving medications. 1
Severe Hyperkalemia (≥6.5 mEq/L)
Administer IV calcium first to protect against arrhythmias within 1-3 minutes. 1
Give all three agents together for maximum effect: 1
- Insulin 10 units regular IV + 25g dextrose
- Nebulized albuterol 10-20 mg in 4 mL
- Sodium bicarbonate 50 mEq IV over 5 minutes ONLY if metabolic acidosis present
Choose method to remove potassium: 1
- Loop diuretics (if adequate renal function)
- Hemodialysis (most effective and reliable for severe hyperkalemia)
Temporarily discontinue or reduce RAAS inhibitors at K+ ≥6.5 mEq/L. 1
After acute resolution: Initiate potassium binder and restart RAAS inhibitors at lower dose once K+ <5.5 mEq/L. 1
Special Populations
CKD Patients
Maintain RAAS inhibitors aggressively in proteinuric CKD using potassium binders—these drugs slow CKD progression. 1
Optimal potassium range is broader in advanced CKD: 3.3-5.5 mEq/L for stage 4-5 CKD versus 3.5-5.0 mEq/L for stage 1-2 CKD. 1
For moderate hyperkalemia with no ECG changes: Loop diuretics (furosemide) as initial management to increase renal potassium excretion 1
Dialysis reserved for: Severe cases unresponsive to medical management, oliguria, or ESRD 1
Cardiovascular Disease Patients
Patients with cardiovascular disease on RAAS inhibitors require careful monitoring with assessment 7-10 days after starting or increasing doses. 1, 2
High "normal" potassium concentrations (>5.0 mEq/L) may be associated with adverse outcomes in patients with heart failure, hypertension, or CKD. 1
Critical Pitfalls to Avoid
Never delay treatment while waiting for repeat lab confirmation if ECG changes are present. 1
Do not rely solely on ECG findings—they are highly variable and less sensitive than laboratory tests. 1, 2
Never give insulin without glucose—hypoglycemia can be life-threatening. 1
Never use sodium bicarbonate without metabolic acidosis—it is ineffective and wastes time. 1, 2
Remember that calcium, insulin, and beta-agonists are temporizing measures only—they do NOT remove potassium from the body. 1, 2
Ensure glucose is administered with insulin to prevent hypoglycemia. 1, 2
Team Approach
Optimal chronic hyperkalemia management involves a multidisciplinary team: cardiologists, nephrologists, primary care physicians, nurses, pharmacists, social workers, and dietitians. 1