Treatment of Severe Hyperkalemia
For severe hyperkalemia (K+ ≥6.5 mEq/L or any ECG changes), immediately administer IV calcium to stabilize cardiac membranes, followed simultaneously by insulin/glucose and nebulized albuterol to shift potassium intracellularly, then initiate definitive potassium removal with loop diuretics or hemodialysis. 1, 2, 3
Immediate Emergency Treatment (Within 5 Minutes)
Step 1: Cardiac Membrane Stabilization
- Administer calcium first to prevent fatal arrhythmias—this is your most urgent intervention 1, 2, 3
- Calcium chloride (10%): 5-10 mL (500-1000 mg) IV over 2-5 minutes 1, 3
- Onset: 1-3 minutes, Duration: only 30-60 minutes 2, 3
- Critical caveat: Calcium does NOT lower potassium—it only temporarily protects the heart 2, 3
- Repeat the dose if no ECG improvement within 5-10 minutes 2
- Continuous cardiac monitoring is mandatory during and after administration 2
Step 2: Shift Potassium Intracellularly (Start Simultaneously)
Administer all three agents together for maximum effect 2:
Insulin + Glucose: Mix 10 units regular insulin with 25g glucose (50 mL D50W) IV over 15-30 minutes 1, 2, 3
Nebulized Albuterol: 10-20 mg in 4 mL nebulized over 15 minutes 1, 2, 3
Sodium Bicarbonate: 50 mEq IV over 5 minutes 1
Definitive Potassium Removal (Within 30-60 Minutes)
For Patients with Adequate Kidney Function:
- Loop diuretics: Furosemide 40-80 mg IV 1, 2, 3
- Increases renal potassium excretion by stimulating flow to collecting ducts 2
- Only effective if eGFR allows adequate urine output 3
For Patients with Renal Failure or Refractory Cases:
- Hemodialysis is the most effective and reliable method for severe hyperkalemia 1, 2, 3, 4
- Indicated for: severe hyperkalemia unresponsive to medical management, oliguria, or end-stage renal disease 2
- Monitor for rebound hyperkalemia 4-6 hours post-dialysis as intracellular potassium redistributes 2
Subacute Potassium Removal (Not for Emergency):
- Sodium polystyrene sulfonate (Kayexalate): 15-50 g plus sorbitol PO or PR 1
- FDA limitation: Should NOT be used as emergency treatment due to delayed onset of action 5
- Avoid due to safety concerns: Associated with intestinal ischemia, colonic necrosis, and doubling of serious GI adverse events 2
Medication Management During Acute Episode
Immediately review and temporarily hold 2, 3:
- RAAS inhibitors (ACE inhibitors, ARBs, MRAs) if K+ >6.5 mEq/L 2
- NSAIDs 2
- Potassium-sparing diuretics (spironolactone, amiloride, triamterene) 2
- Trimethoprim 2
- Heparin 2
- Beta-blockers 2
- Potassium supplements and salt substitutes 2
After Acute Resolution: Preventing Recurrence
For Patients Requiring RAAS Inhibitors (Heart Failure, CKD):
- Do NOT permanently discontinue RAAS inhibitors—they provide mortality benefit 2, 3
- Once K+ <5.5 mEq/L, restart RAAS inhibitors at lower dose with concurrent potassium binder 2
Initiate Newer Potassium Binders:
Sodium zirconium cyclosilicate (SZC/Lokelma): 10g three times daily for 48 hours, then 5-15g once daily 2, 3
- Onset: 1 hour (suitable for urgent scenarios) 2
Patiromer (Veltassa): 8.4g once daily with food, titrate up to 25.2g daily 2, 3
Critical Pitfalls to Avoid
- Never delay calcium administration while waiting for repeat labs if ECG changes are present 2
- Never give insulin without glucose—hypoglycemia can be fatal 2
- Never use sodium bicarbonate without metabolic acidosis—it is ineffective 2
- Never rely on calcium, insulin, or beta-agonists alone—they are temporizing measures only and do NOT remove potassium from the body 2
- Never administer calcium through the same IV line as sodium bicarbonate—precipitation will occur 2
- Do not rely solely on ECG findings—they are highly variable and less sensitive than laboratory values 2