What is the emergency intervention for hyperkalemia (elevated potassium levels)?

From the Guidelines

Emergency intervention for high potassium (hyperkalemia) requires prompt treatment to prevent life-threatening cardiac arrhythmias, and the most recent and highest quality study recommends immediate administration of 10 mL of 10% calcium gluconate IV over 2-3 minutes to stabilize cardiac membranes, followed by shifting potassium into cells using 10 units of regular insulin IV with 25g of glucose (50 mL of D50W) to prevent hypoglycemia, and considering nebulized albuterol 10-20 mg, as outlined in the 2021 study published in the Mayo Clinic Proceedings 1.

Treatment Approach

The treatment approach for hyperkalemia involves several key steps:

• Stabilizing cardiac membranes with calcium gluconate
• Shifting potassium into cells using insulin and glucose
• Considering the use of nebulized albuterol
• Definitive removal of potassium using sodium polystyrene sulfonate or emergency hemodialysis

Key Considerations

Some key considerations in the treatment of hyperkalemia include:

• The need for continuous cardiac monitoring throughout treatment
• The importance of identifying and addressing the underlying cause of hyperkalemia
• The need for repeat potassium measurements to guide ongoing treatment and ensure resolution of hyperkalemia
• The potential for rebound hyperkalemia after initial treatment, as noted in the 2018 study published in the European Heart Journal 1

Medication Adjustments

Medication adjustments may be necessary to manage hyperkalemia, including:

• Discontinuing or adjusting medications that may be contributing to hyperkalemia, such as potassium-sparing diuretics or renin-angiotensin-aldosterone system inhibitors
• Initiating medications that can help lower potassium levels, such as loop diuretics or potassium binders

Renal Dysfunction

Renal dysfunction is a common cause of hyperkalemia, and management may involve:

• Initiating dialysis in severe cases
• Adjusting medications to avoid further kidney damage
• Monitoring renal function closely to guide treatment decisions, as recommended in the 2010 study published in Circulation 1

From the Research

Emergency Intervention for High Potassium

• Hyperkalemia is a common electrolyte disorder that can result in morbidity and mortality if not managed appropriately 2
• The most severe effect of hyperkalemia includes various cardiac dysrhythmias, which may result in cardiac arrest and death 2, 3

Treatment Options

• Treatment includes measures to "stabilize" cardiac membranes, to shift K+ from extracellular to intracellular stores, and to promote K+ excretion 2
• Calcium gluconate 10% dosed 10 mL intravenously should be provided for membrane stabilization, unless the patient is in cardiac arrest, in which case 10 mL calcium chloride is warranted 2
• Beta-agonists and intravenous insulin should be given, and some experts recommend the use of synthetic short-acting insulins rather than regular insulin 2, 4
• Dextrose should also be administered, as indicated by initial and serial serum glucose measurements 2
• Dialysis is the most efficient means to enable removal of excess K+ 2, 4, 5
• Loop and thiazide diuretics can also be useful 2
• New medications to promote gastrointestinal K+ excretion, which include patiromer and sodium zirconium cyclosilicate, hold promise 2, 3, 6

Pharmacotherapies

• Sodium polystyrene sulfonate is not efficacious 2, 3
• Albuterol can be used alone or to augment the effect of insulin 4, 5
• Alkalinization with bicarbonate, although formerly recommended as a mainstay of therapy, is not efficacious 5
• Hemodialysis rapidly and reliably removes potassium and lowers [K+] 4, 5
• Exchange resins are also useful in removing potassium 5