What is the treatment for hyperkalemia with a potassium level of 6.00, specifically a sample doctor's order for calcium gluconate (Ca gluconate) slow Intravenous (IV) push?

Sample Doctor's Order for Calcium Gluconate IV Push for Potassium 6.0 mEq/L

For a potassium level of 6.0 mEq/L with or without ECG changes, administer calcium gluconate 1,000 mg (10 mL of 10% solution) IV push over 5-10 minutes for immediate cardiac membrane stabilization, followed by measures to shift potassium intracellularly and promote elimination. 1, 2, 3

Complete Emergency Order Set for K+ 6.0 mEq/L

Immediate Cardiac Membrane Stabilization

• Calcium Gluconate 1,000 mg (10 mL of 10% solution) IV push over 5-10 minutes 3, 4
  • Dilute in 50-100 mL of normal saline or 5% dextrose to achieve concentration of 10-50 mg/mL 3
  • Maximum infusion rate: 200 mg/minute in adults, 100 mg/minute in pediatric patients 3
  • Effect onset: 1-3 minutes, duration: 30-60 minutes 2, 4
  • Place patient on continuous cardiac monitoring during administration 2, 3

Shift Potassium Intracellularly (Start Immediately After Calcium)

• Regular insulin 10 units IV push with 25 grams dextrose (50 mL of D50W) 1, 2

  • Check fingerstick glucose before and every 15-30 minutes for 2 hours 5
  • If baseline glucose >250 mg/dL, give insulin without dextrose 5
  • Effect onset: 15-30 minutes, duration: 4-6 hours 4, 6

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

  • Can repeat once if needed 6
  • Effect onset: 30 minutes, duration: 2-4 hours 4

Promote Potassium Elimination

• Furosemide 40-80 mg IV push (if adequate renal function and not oliguric) 1, 2

  • Enhances urinary potassium excretion 2

• Sodium polystyrene sulfonate 15-30 grams PO or 50 grams per rectum 7

  • Note: Efficacy is limited and onset is delayed (hours); newer agents (patiromer, sodium zirconium cyclosilicate) are preferred if available 7, 6

Monitoring Requirements

• Continuous cardiac monitoring mandatory 2, 3
• Recheck serum potassium every 2-4 hours 2
• Obtain 12-lead ECG immediately and after each intervention 1, 2
• Monitor for rebound hyperkalemia at 2-4 hours after temporary measures 1

Medication Review (Discontinue or Hold)

• Stop all RAAS inhibitors (ACE inhibitors, ARBs) 1, 2
• Stop mineralocorticoid receptor antagonists (spironolactone, eplerenone) 5, 1
• Stop NSAIDs 1
• Stop potassium supplements and potassium-sparing diuretics 2

Critical Pitfalls to Avoid

Calcium Administration Errors

• Never mix calcium gluconate with ceftriaxone - can form fatal precipitates, especially in neonates 3
• Never mix with bicarbonate or phosphate-containing solutions - causes precipitation 3
• Ensure secure IV access - extravasation causes tissue necrosis and calcinosis cutis 3
• Use extreme caution if patient is on digoxin - hypercalcemia increases digoxin toxicity and risk of arrhythmias; consider using calcium chloride instead or administering very slowly with continuous ECG monitoring 3

Insulin Administration Errors

• Avoid aggressive potassium repletion during insulin therapy - can cause asystole; target potassium 2.5-2.8 mEq/L during treatment 5
• Monitor glucose closely - hypoglycemia is common complication 8

When to Escalate to Hemodialysis

• Oliguria or end-stage renal disease 2, 4
• Refractory hyperkalemia despite medical management 2, 4
• Severe hyperkalemia >6.5 mEq/L with ECG changes 4

Evidence Quality Note

The FDA-approved dosing for calcium gluconate specifies dilution and maximum infusion rates that must be followed to prevent cardiovascular collapse 3. The American College of Cardiology and European Society of Cardiology both classify potassium ≥6.0 mEq/L as severe hyperkalemia requiring immediate hospital admission and emergent treatment 1, 2. The combination of calcium for membrane stabilization, insulin/glucose and albuterol for intracellular shift, and diuretics or dialysis for elimination represents the standard emergency protocol 1, 2, 4.