Hyperkalemia Management

Aka: Hyperkalemia Management, Kaliuresis, Acute Hyperkalemia Management, Chronic Hyperkalemia Management, Hyperkalemia Prevention

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II. Precautions

  1. Significant Hyperkalemia (esp. Serum Potassium >6.0 to 6.5 mg/dl) is a medical emergency
    1. Institute rapid emergent management as below
    2. Reassess frequently as Potassium levels and related EKG changes may change rapidly (esp. Acute Renal Failure)
  2. Peri-Arrest patients require repeated myocardial stabilization doses of Calcium bridging to emergent Hemodialysis
    1. Do NOT use Sodium Channel Blockers (Class I Antiarrhythmic) such as Amiodarone or Lidocaine
    2. Do NOT use Succinylcholine (Depolarizing agents)
  3. Severe, Refractory, Unstable Hyperkalemia is more common in specific conditions
    1. Intravascular Hemolysis
    2. Tumor Lysis Syndrome
    3. Compartment Syndrome
    4. Severe Rhabdomyolysis

III. Protocol

  1. Step 1: Start evaluation as described in Hyperkalemia
    1. Confirm Hyperkalemia (exclude Pseudohyperkalemia)
    2. Stop any exogenous Potassium sources
    3. Consider any obvious causes of Transcellular Potassium Shift
    4. Selection of which crystalloid is controversial (Normal Saline or Lactated Ringers)
      1. Lactated Ringers (LR) is typically preferred
        1. LR contains insignificant amounts of Potassium
      2. Normal Saline (NS) is acidotic
        1. May increase extracellular Potassium via Hyperchloremic Metabolic Acidosis
      3. Neither is likely to appreciably increase Potassium, but LR is preferred
        1. Some start with NS for the first 1-2 liters, and then switch to Lactated Ringers
        2. Consider isotonic bicarbonate as an alternative (see below)
  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 mEq/L
    2. Emergent treatment indications: Go to Step 3
      1. Rapid and recent rise in Serum Potassium
      2. Renal Insufficiency, Acute Kidney Injury or end-stage renal disease (CKD 4-5, Hemodialysis)
      3. Metabolic Acidosis
      4. EKG changes consistent with Hyperkalemia
        1. See Hyperkalemia Related EKG Changes
        2. EKG changes suggest life-threatening Hyperkalemia
        3. 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 Chloride or Calcium Gluconate below
      2. In Peri-Arrest patients multiple ampules of Calcium (without limit) are given until QRS narrows
      3. See above precautions regarding avoiding Sodium Channel Blockers (e.g. Amiodarone) and Succinylcholine
      4. Calcium's stabilization effect is transient (<1 hour) and is unlikely to benefit stable patients with reassuring EKG
    3. Temporarily shift Potassium into intracellular space
      1. See Insulin and Glucose below
      2. See Nebulized Albuterol below
    4. Manage Hypotension or shock state
      1. Consider Epinephrine 2 to 10 mcg/min IV to titrate to Blood Pressure and perfusion
    5. Monitoring and disposition
      1. Continuous cardiac monitoring
      2. Initiate lowering of total body Potassium (see Step 4 below)
      3. EKG every 5-10 minutes until Potassium-related ekg changes normalize, then every 30-60 minutes
      4. Early involvement of consultants for definitive management (e.g. Hemodialysis)
  4. Step 4: Lowering of total body Potassium
    1. Individual medication protocols are described below
    2. Enhance Potassium excretion
      1. Gastrointestinal excretion: See Potassium binders (e.g. Lokelma) 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
    2. See Hyperkalemia Causes

IV. Management: Mnemonic - CBIGKD (See BIG K Drop)

  1. Calcium
  2. Bicarbonate (no longer indicated unless Metabolic Acidosis)
  3. Insulin and Glucose
  4. Kayexalate (replaced by other Potassium binders, e.g. Lokelma)
  5. Dialysis

V. Management: Myocardium Stabilization

  1. Calcium
    1. Antagonizes Hyperkalemia cardiac, neurologic effects
      1. Further Calcium beyond first 1-2 doses are ineffective
      2. No additional myocardial stabilization with further doses unless Hypocalcemia
    2. Course
      1. Onset: Effect occurs in 1-3 minutes (anticipate EKG improvement within 3 minutes)
      2. Duration: Lasts for 30-60 minutes
    3. Caution in Digoxin Toxicity (may worsen)
      1. Use slower infusion (over 20-30 minutes)
      2. Consider Calcium Gluconate 10 ml in 100 ml of D5 infused over 20-30 minutes
      3. Consider Magnesium as alternative to Calcium
    4. Calcium Chloride 10% (1.4 mEq/ml or 1 g/10 ml)
      1. Dose: 500 to 1000 mg IV (5-10 ml) over 10 minutes (or 10 ml IV more rapidly in Peri-Arrest)
        1. May repeat for 1-2 doses each after 5 minutes if EKG not improved
        2. In Peri-Arrest patients, use repeated doses (2-3 ampules in the first minutes of Resuscitation)
          1. Administer until the QRS narrows (no limit)
          2. May increase Ionized Calcium to 2.0 to 2.5 mg/dl
      2. Preferred historically for shock or cardiac instability (especially if central access)
        1. However Calcium Gluconate likely has same efficacy with better peripheral IV safety
        2. See Intravenous Calcium for differences between Calcium preparations
    5. Calcium Gluconate 10% (0.4 mEq/ml, 950 mg/10 ml)
      1. Preferred agent if only peripheral IV available (decreased venous sclerosis with infusion)
      2. Initial dose: 10 ml over 2-5 minutes (10-30 minutes is lower risk if time allows)
      3. Faster administration may result in Nausea and Vomiting
      4. May repeat for 1-2 doses each after 5 minutes if EKG not improved
  2. Magnesium
    1. Consider as Calcium alternative in Digoxin Toxicity

VI. Management: Potassium Shift from Intravascular and Interstitial to Intracellular

  1. Glucose and Insulin Infusion
    1. Insulin activates Sodium-Potassium ATPase pumps
    2. Protocol
      1. Insulin Regular 0.1 unit/kg up to 5-10 units IV (10 units is typically used in most adults) AND
      2. Dextrose 50% (D50W) 50 ml (25 grams)
        1. Indicated with Insulin if Serum Glucose <250 mg/dl
        2. Give Dextrose 1 ampule (50 ml or 25 g D50W) IV over 5 minutes
        3. Consider a second Dextrose ampule (additional 50 ml or 25 g D50W)
          1. If normal starting Glucose (<100 mg/dl), Renal Failure or other Hypoglycemia risk as below
        4. Consider maintenance dextrose infusion after boluses if Hypoglycemia risk (see below)
    3. Hypoglycemia Risk
      1. Risk Factors for Hypoglycemia with Insulin
        1. Pretreatment Blood Glucose <150 mg/dl
        2. No Diabetes Mellitus history
        3. Body weight <60 kg
        4. Female gender
        5. Comorbidity including Renal Failure (Acute Kidney Injury or Chronic Kidney Disease)
      2. Consider maintenance dextrose if Hypoglycemia risk
        1. Infuse D10 at 50 to 100 cc/hour after initial dextrose boluses as above
        2. Post initial bolus to cover further Insulin effect
        3. Insulin may last longer than 30-60 min of dextrose (esp. in ESRD)
    4. Onset: 15-30 minutes
    5. Duration: 2 hours (up to 6 hours)
    6. Lowers Serum Potassium 0.6 to 1 mEq/L at one hour
    7. Monitoring
      1. Give 25 g dextrose (50 ml D50W) prn Blood Glucose <70 mg/dl
      2. Follow bedside Serum Glucose every 60 minutes for 4 hours
        1. Monitor hourly Glucose for at least 6 hours if Renal Failure or other Hypoglycemia risks (see above)
    8. References
      1. Moussavi (2019) J Emerg Med 57(1): 36-42 +PMID:31084947 [PubMed]
  2. Nebulized Albuterol 5 mg/ml (typical neb is 2.5 mg/ml)
    1. Albuterol activates Sodium-Potassium ATPase pumps via beta-2 receptor stimulation
    2. Dosing
      1. Administer 10-20 mg (very high dose) nebulized over 10 minutes
      2. May repeat 2-3 times for total dose of 20 mg inhaled Albuterol
    3. Effect
      1. Albuterol Neb 10 mg lowers Potassium 0.5 mEq
      2. Onset: 15-30 minutes
      3. Duration: 2-3 hours
      4. Zitek (2016) Acad Emerg Med 23(6): 718-21 +PMID:26857949 [PubMed]
    4. Precautions
      1. Serum Potassium may increase transiently
      2. Albuterol may be ineffective in lowering Potassium for those on nonselective Beta Blockers
  3. Sodium Bicarbonate
    1. Avoid in end-stage renal disease
    2. Indicated primarily for Hyperkalemia with severe Metabolic Acidosis
      1. Not otherwise routinely recommended (historically used as routine adjunct to Calcium)
      2. Consider in severe Metabolic Acidosis
      3. Consider with QRS Widening
    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
      3. Single ampules are unlikely to significantly lower Potassium (consider isotonic bicarbonate instead)
    4. Isotonic bicarbonate (150 mEq in 1 L D5W) is a preferred alternative to single ampules
      1. 1 Liter D5W with 3 ampules of bicarbonate as isotonic infusion delivered over 2-4 hours
      2. Do not exceed bicarbonate deficit (risk of alkalosis)
    5. Sodium Bicarbonate Effects
      1. Onset in 30 minutes
      2. Duration: 1-2 hours
      3. May also add to Glucose infusion below
      4. Avoid bicarbonate until Hypocalcemia corrected
        1. Risk of Tetany and Seizures

VII. Management: Lowering of Total Body Potassium with Diuresis or Hemodialysis

  1. Furosemide (Lasix)
    1. Dose: 20 to 40 mg up to 160 to 240 mg IV
    2. Coadminister Normal Saline if dehydrated
    3. Onset: 15-60 minutes
    4. Duration: 4 hours
    5. Exercise caution in Hypovolemia
    6. In non-emergent Hyperkalemia
      1. Furosemide 20 to 40 mg orally OR
      2. Bumetanide 0.5 to 1 mg orally once to twice daily OR
      3. Torsemide 10 to 20 mg orally daily
  2. Kaliuresis ("Diuretic Bomb")
    1. Avoid in Hypovolemia
    2. May be indicated in acute or End-Stage Renal Disease patients needing Dialysis (but not yet on Dialysis)
      1. Temporizing measure with cardiac instability until emergent Dialysis
    3. Very high dose Diuretics are given
      1. Furosemide 60 to 180 mg IV AND
      2. Chlorothiazide 500 mg to 1000 mg IV (or Metolazone) AND
      3. Acetazolamide 250 to 500 mg IV AND
      4. Consider Fludrocortisone 0.2 mg orally
      5. Consider Mannitol (controversial)
    4. These doses are extremely high and require close monitoring of Urine Output
    5. Not typically effective in patients already on Hemodialysis
    6. Swaminathan and Farkas in Herbert (2019) EM:Rap 19(11): 11-2
  3. Hemodialysis (if persistent Hyperkalemia despite above measures)
    1. May experience significant Hyperkalemia on rebound

VIII. Management: Lowering of Total Body Potassium with Potassium Binding Agents

  1. Precaution
    1. Potassium Binding Agents have relatively slow onset, and are not recommended in emergent Hyperkalemia
    2. Consider Potassium Binding Agents after initial stabilization (e.g. acute hospital admission)
    3. Consider in chronic Hyperkalemia (often in cases to allow continuation of ACE Inhibitor or ARB)
  2. Sodium Zirconium Cyclosilicate (Lokelma)
    1. Preferred first-line agent
    2. Dose: 10 g orally three times daily for 48 hours, then 10 g orally daily (range 5-15 g/day)
  3. Patiromer (Veltassa)
    1. Dose: 8.4 g orally daily (may titrate up to 16.8 g to 25.2 g per day)
    2. Potassium Binding agent that exchanges Calcium for Potassium in the Gastrointestinal Tract
    3. Risk of Hypomagnesemia (monitor) and gastrointestinal side effects
  4. Sodium Polystyrene Sulfonate (SPS, Kayexalate, Cation-Exchange Resin)
    1. Other methods of lowering Potassium are preferred
      1. Kayexalate has marginal efficacy, is poorly tolerated, and has delayed onset of action
      2. Kayexalate carries risk of potentially lethal bowel necrosis
    2. Dose: 15 grams in 50-100 ml of 20% Sorbitol
      1. May be repeated up to 4 times daily
      2. Doses of 30-60 g have been used, but are not recommended
      3. Rectal enemas may have faster activity, but are not recommended
        1. Higher risk for colonic necrosis
    3. Pharmacokinetics
      1. Onset: Up to 4-6 hours for oral route
      2. Duration: Lowers Serum Potassium 1 mEq/L over 24 hours
    4. Precautions
      1. Avoid Sorbitol if bowel necrosis risk
      2. Use caution if risk of Congestive Heart Failure
        1. Consider concurrent Furosemide (Lasix)

IX. Management: Chronic Hyperkalemia

  1. Eliminate Medication Causes of Elevated Serum Potassium
  2. Non-specific therapy
    1. Loop Diuretics (Lasix)
    2. Potassium Binding Agents
      1. Oral Patiromer (Veltassa)
      2. Sodium Zirconium Cyclosilicate (Lokelma)
      3. Sodium Polystyrene Sulfonate (SPS, Kayexalate, other agents are preferred)
  3. Specific therapy
    1. Hyporeninemic Hypoaldosteronism
      1. Loop Diuretics (Lasix)
      2. Fludrocortisone 0.1 mg orally 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

X. Prevention: Hyperkalemia

  1. Limit or keep constant Dietary Potassium sources (esp. salt substitute)
  2. Decrease Potassium Supplementation in Loop Diuretic use
    1. Titrate to keep Serum Potassium ideally 4.0 to 5.0 mg/dl
  3. Avoid provocative medications
    1. See Medication Causes of Elevated Serum Potassium
    2. NSAIDs
    3. Trimethoprim-Sulfamethoxazole
  4. Increase Loop Diuretic dosing
  5. Reduce dosing of medications needed for comorbid conditions
    1. ACE Inhibitors
    2. Angiotensin Receptor Blockers
    3. Entresto (Sacubitril/Valsartan)
  6. Consider agents used for chronic Hyperkalemia as above
    1. Consider Potassium Binding Agents (see above)
  7. References
    1. (2021) Presc Lett 28(8): 44
    2. Ferreira (2020) J Am Coll Cardiol 75(22):2836-50 +PMID: 32498812 [PubMed]

XI. Resources

  1. Hyperkalemia in Internet Book of Critical Care (EM-Crit)
    1. https://emcrit.org/ibcc/hyperkalemia/

XII. References

  1. (2024) Presc Lett 31(3): 13-4
  2. Mattu and Swaminathan (2024, Feb) EM:Rap, accessed 2/2/2024
  3. Swaminathan and Weingart in Herbert (2019) EM:Rap 19(10): 18-9
  4. Mallemat and Swaminathan (2024) Refractory Hyperkalemia, EM:Rap, 5/5/2024
  5. Weisberg (2008) Crit Care Med 36(12):1-6 [PubMed]
  6. Hollander-Rodriguez (2006) Am Fam Physician 73:283-90 [PubMed]
  7. Kim (2023) Am Fam Physician 107(1): 59-70 [PubMed]
  8. Kim (2002) Nephron 92:33-40 [PubMed]
  9. Viera (2015) Am Fam Physician 92(6): 487-95 [PubMed]

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