What is the immediate treatment for hyperkalemia?

Immediate Treatment for Hyperkalemia

For severe hyperkalemia (K+ ≥6.5 mEq/L) or any ECG changes, immediately administer IV calcium for cardiac protection, followed simultaneously by insulin with glucose and nebulized albuterol to shift potassium intracellularly, then initiate definitive potassium removal with loop diuretics or hemodialysis. 1

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

Administer calcium first if K+ ≥6.5 mEq/L OR any ECG changes are present (peaked T waves, flattened P waves, prolonged PR interval, widened QRS, or arrhythmias). 1, 2

Calcium Dosing Options:

• Calcium chloride 10%: 5-10 mL (500-1000 mg) IV over 2-5 minutes - preferred for faster ionized calcium increase 1, 3
• Calcium gluconate 10%: 15-30 mL IV over 2-5 minutes - alternative if only peripheral access available 1, 2

Critical Calcium Considerations:

• Effects begin within 1-3 minutes but last only 30-60 minutes 1, 2
• Calcium does NOT lower potassium - it only temporarily stabilizes cardiac membranes 1, 3
• If no ECG improvement within 5-10 minutes, repeat the dose 2
• Continuous cardiac monitoring is mandatory during administration 2
• Use central line for calcium chloride when possible due to tissue necrosis risk with extravasation 1

Common Pitfall: Never delay calcium while waiting for repeat labs if ECG changes are present - ECG changes indicate urgent need regardless of exact potassium value. 2

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

Give all three agents together for maximum effect: 2

Insulin + Glucose (Most Effective):

• 10 units regular insulin IV with 25g glucose (50 mL of D50W) over 15-30 minutes 1, 3
• Onset: 15-30 minutes, Duration: 4-6 hours 1
• Monitor glucose every 2-4 hours to prevent hypoglycemia 1
• Can repeat every 4-6 hours if hyperkalemia persists 1

Nebulized Albuterol:

• 10-20 mg nebulized over 15 minutes 1, 3
• Reduces potassium by 0.5-1.0 mEq/L 1
• Duration: 2-4 hours 2

Sodium Bicarbonate (ONLY if metabolic acidosis present):

• 50 mEq IV over 5 minutes 1, 3
• Only use if pH <7.35 and bicarbonate <22 mEq/L 2
• Onset: 30-60 minutes 2

Critical Pitfall: Never use sodium bicarbonate without metabolic acidosis - it is ineffective and wastes time. 2 Never give insulin without glucose - hypoglycemia can be life-threatening. 2

Step 3: Eliminate Potassium From Body (Definitive Treatment)

For Adequate Renal Function:

• Loop diuretics: Furosemide 40-80 mg IV 1, 3
• Increases renal potassium excretion 1
• Titrate to maintain euvolemia, not primarily for potassium management 2

For Subacute/Chronic Management:

Newer potassium binders are preferred over sodium polystyrene sulfonate: 1, 2

• Sodium zirconium cyclosilicate (SZC/Lokelma):

  • Acute: 10g three times daily for 48 hours 2
  • Maintenance: 5-15g once daily 2
  • Onset: 1 hour 2

• Patiromer (Veltassa):

  • Starting dose: 8.4g once daily with food 2
  • Titrate up to 25.2g daily 2
  • Onset: ~7 hours 2
  • Separate from other medications by 3 hours 2

Avoid sodium polystyrene sulfonate (Kayexalate) - associated with intestinal ischemia, colonic necrosis, and doubling of serious GI adverse events. 2

For Severe/Refractory Cases:

• Hemodialysis is the most effective method for severe hyperkalemia 1, 3
• Indicated for: K+ unresponsive to medical management, oliguria, or end-stage renal disease 2
• Monitor for rebound hyperkalemia 4-6 hours post-dialysis 2

Treatment Algorithm by Severity

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

1. Calcium chloride 10%: 5-10 mL IV over 2-5 minutes (immediate) 1, 3
2. Insulin 10 units + glucose 25g IV AND albuterol 10-20 mg nebulized (within 15 minutes) 1, 3
3. Sodium bicarbonate 50 mEq IV ONLY if acidosis present 1
4. Loop diuretics OR hemodialysis for definitive removal 1, 3

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

1. Insulin/glucose and albuterol for intracellular shift 3
2. Loop diuretics or potassium binders 3
3. Calcium only if ECG changes develop 2

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

1. Review and discontinue offending medications 3
2. Initiate potassium binder for chronic management 3
3. Maintain RAAS inhibitor therapy with potassium binder support 3

Medication Management During Acute Episode

Temporarily discontinue or reduce at K+ ≥6.5 mEq/L: 2

• ACE inhibitors, ARBs, mineralocorticoid receptor antagonists
• NSAIDs
• Potassium-sparing diuretics (spironolactone, amiloride, triamterene)
• Trimethoprim, heparin, beta-blockers
• Potassium supplements and salt substitutes

After acute resolution (K+ <5.5 mEq/L): 2

• Restart RAAS inhibitors at lower dose with concurrent potassium binder 2
• Do not permanently discontinue RAAS inhibitors - they provide mortality benefit in cardiovascular and renal disease 2, 3

Critical Monitoring

• Check potassium every 2-4 hours after initial treatment 1
• Monitor glucose to prevent hypoglycemia from insulin 1
• Continuous ECG monitoring during calcium administration 2
• Rebound hyperkalemia can occur after 2 hours - temporary measures (insulin/glucose, albuterol) last only 1-4 hours 1

Common Pitfalls to Avoid

• Never delay treatment while waiting for repeat labs if ECG changes present 2
• Never rely solely on ECG findings - they are variable and less sensitive than lab values 2
• Never use sodium bicarbonate without metabolic acidosis 2
• Never give insulin without glucose 2
• Remember calcium, insulin, and beta-agonists are temporizing only - they do NOT remove potassium from the body 2, 3
• Do not permanently discontinue RAAS inhibitors - use potassium binders instead 2, 3