What is the appropriate management for a patient presenting with severe hyperkalemia?

Sample Doctor's Order for Severe Hyperkalemia Management

Immediate Stabilization Orders

For severe hyperkalemia (>6.0 mEq/L) with or without ECG changes, initiate the following orders immediately to prevent life-threatening cardiac arrhythmias:

Cardiac Membrane Stabilization

• Calcium Gluconate 10%: 15-30 mL IV push over 2-5 minutes 1
  • Onset within 1-3 minutes, duration 30-60 minutes 2
  • Repeat dose if no ECG improvement within 5-10 minutes 2
  • Continuous cardiac monitoring mandatory during and after administration 2
  • Critical: Calcium does NOT lower potassium—only stabilizes cardiac membranes temporarily 2

Intracellular Potassium Shift (Administer All Three Simultaneously)

• Regular Insulin 10 units IV push 1, 2

• Dextrose 50% 50 mL (25g) IV push (give with insulin to prevent hypoglycemia) 1, 2

  • Onset 15-30 minutes, duration 4-6 hours 2
  • Monitor glucose every 2 hours for 6 hours 2

• Albuterol 10-20 mg nebulized in 4 mL normal saline 1, 2

  • Onset 30 minutes, duration 2-4 hours 2

• Sodium Bicarbonate 50 mEq IV over 5 minutes ONLY if concurrent metabolic acidosis present (pH <7.35, HCO3 <22 mEq/L) 1, 2

  • Do NOT use if no acidosis—ineffective and wastes time 2

Potassium Removal from Body

• Sodium Zirconium Cyclosilicate (Lokelma) 10g PO three times daily for 48 hours 2, 3

  • Onset ~1 hour, most rapid potassium binder available 2
  • Mix powder in 45 mL water, stir well, drink immediately 3
  • Separate from other oral medications by at least 2 hours 3

• Furosemide 40-80 mg IV (if adequate renal function, eGFR >30 mL/min) 1, 2

• Consult Nephrology for urgent hemodialysis if: 1, 2

  • K+ >6.5 mEq/L unresponsive to medical therapy
  • Oliguria or anuric acute kidney injury
  • End-stage renal disease
  • Severe ECG changes persisting despite treatment

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Medication Review and Adjustment Orders

Immediately hold or reduce the following medications until K+ <5.0 mEq/L: 1, 2

• HOLD: ACE inhibitors, ARBs, mineralocorticoid receptor antagonists (spironolactone, eplerenone) 1, 2
• HOLD: Potassium-sparing diuretics (amiloride, triamterene) 2
• HOLD: NSAIDs, trimethoprim, heparin, beta-blockers 2
• HOLD: Potassium supplements and salt substitutes 1, 2

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Monitoring Orders

• Continuous cardiac telemetry 1, 2
• Stat ECG, repeat after calcium administration and every 2 hours until K+ <5.5 mEq/L 1, 2
• Serum potassium every 2-4 hours during acute treatment phase 2
• Basic metabolic panel (including creatinine, glucose) every 4 hours for first 12 hours 2
• Serum magnesium level (correct if <0.6 mmol/L) 1

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Transition to Maintenance Therapy (Once K+ <5.5 mEq/L)

• Sodium Zirconium Cyclosilicate (Lokelma) 5-15g PO once daily on maintenance 2, 3

  • Titrate dose based on potassium levels checked weekly 2
  • Monitor for edema (contains 400mg sodium per 5g dose) 3
  • Monitor for hypokalemia (4.1% risk, adjust dose if K+ <3.5 mEq/L) 3

• Restart RAAS inhibitors at 50% previous dose once K+ stable at 4.0-5.0 mEq/L 2

  • Do NOT permanently discontinue—these provide mortality benefit in cardiovascular and renal disease 1, 2
  • Recheck potassium 7-10 days after restarting 2

• Dietary potassium restriction <3g/day (50-70 mmol/day) 1

  • Avoid bananas, oranges, potatoes, tomatoes, salt substitutes 1

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Common Pitfalls to Avoid

• Never delay calcium administration while waiting for repeat labs if ECG changes present 2
• Never give insulin without glucose—hypoglycemia can be life-threatening 2
• Never use sodium bicarbonate without documented metabolic acidosis 2
• Remember: Calcium, insulin, and beta-agonists are temporizing only—they do NOT remove potassium from body 2
• Failure to initiate concurrent potassium removal will result in recurrent life-threatening arrhythmias within 30-60 minutes 2

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Follow-Up Orders

• Recheck potassium within 24-48 hours after discharge 1
• Schedule nephrology follow-up within 1 week 1, 2
• Patient education on low-potassium diet and medication adherence 1