What is the treatment for hyperkalemia (elevated potassium levels) intraoperatively (during surgery)?

From the Guidelines

Intraoperative hyperkalemia should be treated promptly with calcium gluconate 10% (10-20 mL IV over 2-3 minutes) to stabilize cardiac membranes and prevent arrhythmias, especially if ECG changes are present, as recommended by the most recent and highest quality study 1.

Treatment Approach

The treatment of intraoperative hyperkalemia involves a combination of therapies aimed at shifting potassium into cells and enhancing elimination.

• The first step is to stabilize cardiac membranes with calcium gluconate 10% (10-20 mL IV over 2-3 minutes), which provides immediate protection against cardiac complications by increasing the threshold potential for myocardial cells 1.
• Next, administer insulin and glucose (10 units regular insulin with 25g dextrose IV) to drive potassium intracellularly, which acts within 30 minutes to promote redistribution of serum K+ into the intracellular space 1.
• Sodium bicarbonate (50-100 mEq IV) can be given if metabolic acidosis is present, as it promotes potassium shift into cells and counters the release of K+ into the blood caused by metabolic acidosis 1.
• Beta-2 agonists like albuterol (10-20 mg nebulized) can also facilitate intracellular potassium movement, acting within 30 minutes to promote redistribution of serum K+ into the intracellular space 1.

Additional Considerations

• For ongoing hyperkalemia, consider loop diuretics such as furosemide (20-40 mg IV) if the patient has adequate renal function, which increases K+ elimination from the body 1.
• In severe cases (K+ >7.0 mEq/L with ECG changes), emergency dialysis may be necessary to increase K+ elimination from the body 1.
• Continuous cardiac monitoring is essential throughout treatment to promptly identify any cardiac complications. These interventions work by either temporarily shifting potassium into cells (insulin/glucose, bicarbonate, albuterol) or increasing elimination (diuretics, dialysis), while calcium provides immediate protection against cardiac complications by increasing the threshold potential for myocardial cells 1.

From the FDA Drug Label

Sodium Polystyrene Sulfonate Powder, for Suspension is indicated for the treatment of hyperkalemia. Limitation of Use: Sodium Polystyrene Sulfonate Powder, for Suspension should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action [see Clinical Pharmacology (12.2)] CLINICAL STUDIES Medical literature also refers to the administration of calcium chloride in the treatment of magnesium intoxication due to overdosage of magnesium sulfate, and to combat the deleterious effects of hyperkalemia as measured by electrocardiogram (ECG), pending correction of the increased potassium level in the extracellular fluid.

For the treatment of hyperkalemia intraop,

• Polystyrene sulfonate (PO) should not be used as an emergency treatment for life-threatening hyperkalemia because of its delayed onset of action 2.
• Calcium chloride (IV) may be used to combat the deleterious effects of hyperkalemia, pending correction of the increased potassium level in the extracellular fluid 3. Key consideration: The choice of treatment should be based on the severity of the hyperkalemia and the clinical context.

From the Research

Treatment of Hyperkalemia Intraoperatively

The treatment of hyperkalemia intraoperatively involves several key strategies to manage this potentially life-threatening condition.

• Stabilization of cardiac membranes is crucial and can be achieved with calcium gluconate 10% dosed 10 mL intravenously, unless the patient is in cardiac arrest, in which case 10 mL calcium chloride is warranted 4.
• Shifting potassium from extracellular to intracellular stores can be accomplished with beta-agonists and intravenous insulin, with some experts recommending the use of synthetic short-acting insulins rather than regular insulin 4.
• Promoting potassium excretion is also vital, and dialysis is the most efficient means to enable removal of excess potassium 4, 5.
• Loop and thiazide diuretics can also be useful in this context 4.

Pharmacological Interventions

Several pharmacological interventions have been studied for the acute treatment of hyperkalemia:

• Insulin in combination with glucose, inhaled salbutamol, intravenous salbutamol dissolved in glucose, or a combination of these, have been shown to reduce potassium levels in adult patients without cardiac arrest 6.
• The use of bicarbonate has been found to have no effect on potassium levels 6.
• In neonatal and pediatric populations, inhaled salbutamol and intravenous salbutamol have been shown to reduce potassium levels 6.
• New medications such as patiromer and sodium zirconium cyclosilicate, which promote gastrointestinal potassium excretion, hold promise for the treatment of hyperkalemia 4, 7.

Clinical Considerations

It is essential to determine the need for urgent treatment of hyperkalemia based on a combination of history, physical examination, laboratory, and electrocardiography findings 8.

• Indications for urgent treatment include severe or symptomatic hyperkalemia, abrupt changes in potassium levels, electrocardiography changes, or the presence of certain comorbid conditions 8.
• The treatment of hyperkalemia should be tailored to the individual patient's needs and clinical context, taking into account the underlying cause of the condition and the presence of any comorbidities 4, 8, 7.