What is the immediate treatment for a patient presenting with hyperkalemia?

Immediate Treatment for Hyperkalemia

For severe hyperkalemia (≥6.5 mEq/L) or any ECG changes, immediately administer IV calcium gluconate 15-30 mL (10%) over 2-5 minutes to stabilize cardiac membranes, followed by insulin 10 units IV with 25g glucose (50 mL D50W) and nebulized albuterol 10-20 mg to shift potassium intracellularly. 1

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

• Administer IV calcium first if potassium >6.5 mEq/L OR any ECG changes are present (peaked T waves, flattened P waves, prolonged PR interval, widened QRS) 2, 1
• Calcium gluconate (10%): 15-30 mL IV over 2-5 minutes is the preferred formulation for peripheral access 2, 1
• Calcium chloride (10%): 5-10 mL IV over 2-5 minutes provides more rapid ionized calcium increase but requires central access due to tissue injury risk 2, 1
• Critical caveat: Calcium does NOT lower serum potassium—it only temporarily stabilizes cardiac membranes for 30-60 minutes 2, 1
• If no ECG improvement within 5-10 minutes, repeat the calcium dose 2
• Continuous cardiac monitoring is mandatory during and after calcium administration 2

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

• Insulin with glucose: 10 units regular insulin IV with 25g glucose (50 mL D50W) over 15-30 minutes 2, 1

• Verify baseline glucose before administration; if glucose <250 mg/dL, give full 25g dextrose 2

• Monitor glucose every 1-2 hours for 4-6 hours post-administration to detect hypoglycemia 2, 3

• Never administer insulin without glucose—hypoglycemia can be life-threatening 2

• Nebulized albuterol: 10-20 mg over 15 minutes 2, 1

• Provides additive effect when combined with insulin/glucose 2, 4

• Reduces serum potassium by approximately 0.5-1.0 mEq/L 2

• Effects last 2-4 hours 2

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

• Ineffective and wastes time in patients without concurrent acidosis 2

• Onset of action 30-60 minutes 2

Step 3: Eliminate Potassium from Body (Definitive Treatment)

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

• Increases renal potassium excretion by stimulating flow to collecting ducts 2

• Titrate to maintain euvolemia, not primarily for potassium management 2

• Newer potassium binders (preferred over sodium polystyrene sulfonate): 2

  • Sodium zirconium cyclosilicate (SZC/Lokelma): 10g three times daily for 48 hours, then 5-15g once daily for maintenance 2
  • Onset of action ~1 hour, making it suitable for urgent scenarios 2
  • Patiromer (Veltassa): 8.4g once daily with food, titrated up to 25.2g daily 2
  • Onset of action ~7 hours 2
  • Separate from other oral medications by at least 3 hours 2

• Hemodialysis: Most effective method for severe hyperkalemia, especially in patients with renal failure, oliguria, or hyperkalemia refractory to medical management 2, 1

• Monitor for rebound hyperkalemia 4-6 hours post-dialysis as intracellular potassium redistributes 2

Step 4: Medication Review and Discontinuation

• Temporarily discontinue or reduce RAAS inhibitors (ACE inhibitors, ARBs, mineralocorticoid antagonists) if potassium >6.5 mEq/L 5, 2
• Review and hold: NSAIDs, potassium-sparing diuretics, trimethoprim, heparin, beta-blockers, potassium supplements, salt substitutes 2
• Do NOT permanently discontinue RAAS inhibitors in patients with cardiovascular disease or proteinuric CKD—restart at lower dose once potassium <5.5 mEq/L with concurrent potassium binder 2

Critical Monitoring Protocol

• Recheck potassium levels: 2
  • Within 1-2 hours after insulin/glucose or beta-agonist therapy (effects last 4-6 hours)
  • Every 2-4 hours during acute treatment phase until stabilized
  • Within 5-10 minutes if no ECG improvement after calcium administration
• Continuous cardiac monitoring until potassium <6.0 mEq/L and ECG changes resolve 2
• Monitor glucose every 1-2 hours for 4-6 hours after insulin administration 2, 3

Common Pitfalls to Avoid

• Never delay treatment while waiting for repeat lab confirmation if ECG changes are present—ECG changes indicate urgent need regardless of exact potassium value 2
• Never use sodium bicarbonate without metabolic acidosis—it is ineffective and wastes time 2
• Never rely solely on ECG findings—they are highly variable and less sensitive than laboratory tests 2
• Remember that calcium, insulin, and beta-agonists are temporizing measures only—they do NOT remove potassium from the body 2, 1
• Failure to initiate concurrent potassium-lowering therapies will result in recurrent life-threatening arrhythmias within 30-60 minutes 2
• Exclude pseudo-hyperkalemia from hemolysis or improper blood sampling before initiating aggressive treatment 2

Algorithm for Treatment Selection

If potassium >6.5 mEq/L OR ECG changes present:

1. IV calcium immediately 2, 1
2. Insulin + glucose AND albuterol simultaneously 2, 1
3. Sodium bicarbonate ONLY if pH <7.35 2, 1
4. Initiate potassium binder (SZC preferred for rapid onset) 2
5. Consider hemodialysis if refractory, oliguric, or ESRD 2, 1

If potassium 5.0-6.5 mEq/L without ECG changes:

1. Initiate potassium binder (patiromer or SZC) 5, 2
2. Maintain RAAS inhibitors unless alternative etiology identified 5, 2
3. Loop diuretics if adequate renal function 2
4. Close monitoring of potassium levels 5, 2