Hyperkalemia Management

1. See Also
   1. Hyperkalemia
2. Protocol
   1. Step 1: Start evaluation as described in Hyperkalemia
      1. Confirm Hyperkalemia
   2. Step 2: Determine urgency of treatment
      1. Non-Emergent treatment: Go to Step 4
         1. Emergent treatment criteria not met below or
         2. Serum Potassium <6.0
      2. Emergent treatment indications: Go to Step 3
         1. Rapid and recent rise in Serum Potassium
         2. Renal insufficiency
         3. Metabolic Acidosis
         4. EKG changes consistent with Hyperkalemia
            1. EKG changes suggest life-threatening Hyperkalemia
            2. Hyperkalemia may be serious despite normal EKG
   3. Step 3: Emergent management of Hyperkalemia
      1. Individual medication protocols are described below
      2. Stabilize Myocardium
         1. See Calcium Gluconate below
      3. Temporarily shift potassium into intracellular space
         1. See Insulin and Glucose below
         2. See Nebulized Albuterol below
   4. Step 4: Non-emergent lowering of total body sodium
      1. Individual medication protocols are described below
      2. Enhance potassium excretion
         1. Gastrointestinal excretion: See Kayexalate below
         2. Renal excretion: See Furosemide below
         3. Consider Hemodialysis in severe, refractory cases
   5. Step 5: Consider long-range plan
      1. See Chronic Hyperkalemia Management below
3. Management: Mnemonic - CBIGKD (See BIG Potassium Drop)
   1. Calcium
   2. Bicarbonate (no longer indicated unless acidosis)
   3. Insulin and Glucose
   4. Kayexalate
   5. Dialysis
4. Management: Myocardium Stabilization
   1. Calcium Gluconate
      1. Antagonizes Hyperkalemia cardiac, neurologic effects
      2. Calcium Gluconate 10%
         1. Initial dose: 10 ml over 2-5 minutes
         2. Second dose after 5 minutes if no response
         3. Further calcium ineffective unless Hypocalcemia
      3. Effect occurs in minutes and lasts for 30-60 minutes
         1. Anticipate EKG improvement within 3 minutes
      4. Caution in Digoxin Toxicity (may worsen)
         1. Use slower infusion (over 20-30 minutes)
         2. Consider Magnesium as alternative to Calcium
   2. Magnesium
      1. Consider as calcium alternative in Digoxin Toxicity
5. Management: Potassium shift from intravascular to intracellular
   1. Glucose and Insulin Infusion
      1. Insulin Regular 10 units IV
      2. Glucose 50% (D50W) 50 ml (25 grams)
         1. Indicated with Insulin if Serum Glucose <250 mg/dl
         2. Give 1 ampule IV over 5 minutes
         3. Consider maintenance (e.g. D5 1/2NS 100 cc/h)
            1. Post initial bolus to cover further Insulin
      3. Onset: 15-30 minutes
      4. Duration: 2-6 hours
      5. Monitoring: Follow bedside Serum Glucose
   2. Nebulized Albuterol 5 mg/ml (typical neb is 2.5 mg/ml)
      1. Administer 10-20 mg over 10 minutes
      2. Onset: 15-30 minutes
      3. Duration: 2-3 hours
      4. Serum Potassium may increase briefly
   3. Bicarbonate (no longer used unless Metabolic Acidosis)
      1. Historically used as adjunct to Calcium above
      2. Consider in severe Metabolic Acidosis
      3. Sodium Bicarbonate 7.5% (44.6 meq)
         1. Give 1 ampule IV over 5 minutes
         2. May repeat every 10-15 min if EKG changes persists
      4. Onset in 30 minutes
      5. Duration: 1-2 hours
      6. May also add to Glucose infusion below
      7. Avoid bicarbonate until Hypocalcemia corrected
         1. Risk of Tetany and Seizures
6. Management: Lowering of total body potassium
   1. Sodium Polystyrene Sulfonate (Kayexalate)
      1. Cation-Exchange resin
      2. Dose: 50 grams
         1. Oral: Administer in 30 ml of Sorbitol
         2. Rectal: Enema activity is faster than oral
      3. Onset: Up to 4-6 hours for oral route
      4. Precautions
         1. Avoid Sorbitol if bowel necrosis risk
         2. Use caution if risk of Congestive Heart Failure
            1. Consider concurrent Furosemide (Lasix)
   2. Furosemide (Lasix)
      1. Dose: 20-40 mg IV
      2. Coadminister normal saline if dehydrated
      3. Onset: 15-60 minutes
      4. Duration: 4 hours
   3. Dialysis (last resort)
      1. May experience significant Hyperkalemia on rebound
7. Management: Chronic Hyperkalemia
   1. Eliminate Medication Causes of Elevated Serum Potassium
   2. Non-specific therapy
      1. Loop Diuretics (Lasix)
      2. Oral Kayexalate chronically
   3. Specific therapy
      1. Hyporeninemic Hypoaldosteronism
         1. Loop Diuretics (Lasix)
         2. Fludrocortisone 0.1 mg daily
            1. Taper gradually as an outpatient
            2. Restart if Hyperkalemia recurs
      2. Renal Failure (GFR < 10 ml/min)
         1. Restrict Dietary Potassium to 40-60 meq/day
      3. Renal Failure and ACE or ARB induced Hyperkalemia
         1. Indications: Metabolic Acidosis
         2. Sodium Bicarbonate
            1. Dose A: 8 meq tabs, 2 tabs twice daily
            2. Dose B: 0.5 to 1 tsp baking soda daily
8. References
   1. Hollander-Rodriguez (2006) Am Fam Physician 73:283-90
   2. Kim (2002) Nephron 92:33-40