What is the recommended management of hyperkalemia in a child with serum potassium >6.5 mEq/L or electrocardiogram (ECG) changes, including when to use calcium gluconate intravenously (IV), insulin with dextrose, nebulized albuterol, sodium bicarbonate, loop diuretics, potassium‑binding resins such as patiromer or sodium zirconium cyclosilicate, and dialysis?

Hyperkalemia Management in Pediatric Patients

Immediate Emergency Treatment for Severe Hyperkalemia (K⁺ >6.5 mEq/L or ECG Changes)

Administer intravenous calcium gluconate immediately if the child has serum potassium >6.5 mEq/L OR any ECG changes (peaked T waves, widened QRS, prolonged PR interval, flattened P waves), as calcium stabilizes the cardiac membrane within 1–3 minutes but does NOT lower potassium levels. 1, 2

Step 1: Cardiac Membrane Stabilization (First-Line, Most Urgent)

• Give calcium gluconate 10% at 100–200 mg/kg/dose (maximum 3 grams or 30 mL) via slow IV infusion over 5–10 minutes with continuous ECG monitoring. 1
• Calcium gluconate is preferred for peripheral IV access due to lower tissue injury risk compared to calcium chloride. 1
• If no ECG improvement occurs within 5–10 minutes, repeat the same dose of calcium gluconate. 1, 2
• Critical caveat: Calcium does NOT remove potassium from the body—it only temporarily protects the heart for 30–60 minutes while you initiate potassium-lowering therapies. 1, 2
• In patients with tumor lysis syndrome or elevated phosphate, use calcium cautiously as it increases calcium-phosphate precipitation risk. 1

Step 2: Shift Potassium Intracellularly (Simultaneous with Calcium)

Administer all three agents together for maximum additive effect: 1, 2

1. Insulin with dextrose:

   • Give 0.1 units/kg regular insulin IV (typical pediatric dose: 5–10 units for adolescents, adjust for younger children) with 0.5–1 gram/kg dextrose (typically 25% dextrose 2–4 mL/kg or 50% dextrose 1–2 mL/kg). 1
   • Onset: 15–30 minutes; duration: 4–6 hours. 1
   • Monitor blood glucose every 30–60 minutes for at least 4–6 hours to prevent life-threatening hypoglycemia. 1
   • Patients at highest hypoglycemia risk: low baseline glucose, no diabetes history, female sex, altered renal function. 1

2. Nebulized albuterol:

   • Administer 10–20 mg (2.5–5 mg for younger children) nebulized over 10 minutes. 1, 2
   • Onset: 30 minutes; duration: 2–4 hours. 1
   • Use as adjunctive therapy—do NOT rely on albuterol alone. 1

3. Sodium bicarbonate (ONLY if metabolic acidosis present):

   • Give 1–2 mEq/kg IV over 5–10 minutes ONLY if pH <7.35 or bicarbonate <22 mEq/L. 1, 2
   • Do NOT use bicarbonate without documented acidosis—it is ineffective and wastes critical time. 1, 2
   • Onset: 30–60 minutes. 1

Step 3: Remove Potassium from the Body (Definitive Treatment)

Choose based on renal function and clinical urgency: 1

1. Loop diuretics (if adequate kidney function):

   • Furosemide 1–2 mg/kg IV (maximum 40–80 mg) to increase renal potassium excretion. 1
   • Requires eGFR >30 mL/min/1.73 m² and adequate urine output. 1

2. Potassium binders (for subacute/chronic management):

   • Sodium zirconium cyclosilicate (SZC/Lokelma): 10 g three times daily for 48 hours, then 5–15 g once daily for maintenance (approved for adults; pediatric dosing not established). 1
     • Onset: ~1 hour (fastest-acting binder). 1
   • Patiromer (Veltassa): 8.4 g once daily, titrated to 25.2 g daily (approved for adults; pediatric dosing not established). 1
     • Onset: ~7 hours. 1
     • Separate from other oral medications by ≥3 hours. 1
   • Avoid sodium polystyrene sulfonate (Kayexalate): Delayed onset, limited efficacy, and serious risk of bowel necrosis. 1, 3

3. Hemodialysis (most effective for severe cases):

   • Indicated for: severe hyperkalemia unresponsive to medical management, oliguria, end-stage renal disease, or ongoing potassium release (tumor lysis syndrome, rhabdomyolysis). 1, 2
   • Hemodialysis is the most reliable and effective method for potassium removal. 1

Monitoring Protocol

• Recheck serum potassium within 1–2 hours after insulin/glucose administration, then every 2–4 hours during acute treatment until stabilized. 1, 2
• Continuous cardiac monitoring is mandatory for K⁺ >6.5 mEq/L or any ECG changes. 1, 2
• Monitor blood glucose closely after insulin to prevent hypoglycemia. 1
• Assess for rebound hyperkalemia within 4–6 hours post-dialysis, especially in patients with ongoing potassium release. 1

Medication Management During Acute Episode

Temporarily discontinue or reduce the following medications at K⁺ >6.5 mEq/L: 1

• RAAS inhibitors (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: Preventing Recurrence

• Initiate a potassium binder (patiromer or SZC) and restart RAAS inhibitors at a lower dose once K⁺ <5.5 mEq/L, as these medications provide mortality benefit in cardiovascular and renal disease. 1
• Implement dietary potassium restriction (limit high-potassium foods, avoid salt substitutes). 1
• Monitor potassium levels 7–10 days after restarting or adjusting RAAS inhibitors. 1
• Individualize monitoring frequency based on comorbidities (CKD, diabetes, heart failure). 1

Critical Pitfalls to Avoid

• Never delay calcium administration while waiting for repeat lab confirmation if ECG changes are present—ECG changes indicate urgent need regardless of exact potassium value. 1, 2
• Never give insulin without glucose—hypoglycemia can be life-threatening. 1
• Never use sodium bicarbonate without metabolic acidosis—it is ineffective and wastes time. 1, 2
• Remember that calcium, insulin, and beta-agonists are temporizing measures only—they do NOT remove potassium from the body. 1, 2
• Do NOT rely solely on ECG findings—they are highly variable and less sensitive than laboratory tests. 1, 2
• Pseudohyperkalemia from hemolysis or poor phlebotomy technique should be excluded by repeating the measurement with appropriate technique. 1