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Hyperkalemia Management
Aka: Hyperkalemia Management, Kaliuresis, Acute Hyperkalemia Management, Chronic Hyperkalemia Management, Hyperkalemia Prevention
- See Also
- Hyperkalemia
- Hyperkalemia Causes
- Hyperkalemia due to Medications
- BRASH Syndrome
- Acute Kidney Injury Management
- Hyperkalemia Related EKG Changes
- Precautions
- Significant Hyperkalemia (esp. Serum Potassium >6.0 to 6.5 mg/dl) is a medical emergency
- Institute rapid emergent management as below
- Reassess frequently as Potassium levels and related EKG changes may change rapidly (esp. Acute Renal Failure)
- Peri-Arrest patients require repeated myocardial stabilization doses of Calcium bridging to emergent Dialysis
- Do NOT use Sodium Channel Blockers (Class I Antiarrhythmic) such as Amiodarone or Lidocaine
- Do NOT use Succinylcholine (Depolarizing agents)
- Protocol
- Step 1: Start evaluation as described in Hyperkalemia
- Confirm Hyperkalemia (exclude Pseudohyperkalemia)
- Stop any exogenous Potassium sources
- Consider any obvious causes of Transcellular Potassium Shift
- Selection of which crystalloid is controversial (Normal Saline or Lactated Ringers)
- NS is acidotic and increases extracellular Potassium while LR contains Potassium
- Neither is likely to appreciably increase Potassium
- Some start with NS for the first 1-2 liters, and then switch to Lactated Ringers
- Consider isotonic bicarbonate as an alternative (see below)
- Step 2: Determine urgency of treatment
- Non-Emergent treatment: Go to Step 4
- Emergent treatment criteria not met below or
- Serum Potassium <6.0 mEq/L
- Emergent treatment indications: Go to Step 3
- Rapid and recent rise in Serum Potassium
- Renal Insufficiency
- Metabolic Acidosis
- EKG changes consistent with Hyperkalemia
- See Hyperkalemia Related EKG Changes
- EKG changes suggest life-threatening Hyperkalemia
- Hyperkalemia may be serious despite normal EKG
- Step 3: Emergent management of Hyperkalemia
- Individual medication protocols are described below
- Stabilize Myocardium
- See Calcium Chloride or Calcium Gluconate below
- In Peri-Arrest patients multiple ampules of Calcium are given until QRS narrows
- See above precautions regarding avoiding Sodium Channel Blockers (e.g. Amiodarone) and Succinylcholine
- Temporarily shift Potassium into intracellular space
- See Insulin and Glucose below
- See Nebulized Albuterol below
- Step 4: Non-emergent lowering of total body Sodium
- Individual medication protocols are described below
- Enhance Potassium excretion
- Gastrointestinal excretion: See Kayexalate below
- Renal excretion: See Furosemide below
- Consider Hemodialysis in severe, refractory cases
- Step 5: Consider long-range plan
- See Chronic Hyperkalemia Management below
- See Hyperkalemia Causes
- Management: Mnemonic - CBIGKD (See BIG Potassium Drop)
- Calcium
- Bicarbonate (no longer indicated unless acidosis)
- Insulin and Glucose
- Kayexalate
- Dialysis
- Management: Myocardium Stabilization
- Calcium
- Antagonizes Hyperkalemia cardiac, neurologic effects
- Further Calcium beyond first 1-2 doses are ineffective
- No additional myocardial stabilization with further doses unless Hypocalcemia
- Course
- Onset: Effect occurs in 1-3 minutes (anticipate EKG improvement within 3 minutes)
- Duration: Lasts for 30-60 minutes
- Caution in Digoxin Toxicity (may worsen)
- Use slower infusion (over 20-30 minutes)
- Consider Calcium Gluconate 10 ml in 100 ml of D5 infused over 20-30 minutes
- Consider Magnesium as alternative to Calcium
- Calcium Chloride (1.4 mEq/ml)
- Dose: 5 ml over 10 minutes
- May repeat second dose in 5 minutes if EKG not improved
- Preferred historically for shock or cardiac instability (especially if central access)
- However Calcium Gluconate likely has same efficacy with better peripheral IV safety
- See Intravenous Calcium for differences between Calcium preparations
- In Peri-Arrest patients, use repeated doses (2-3 ampules in the first minutes of Resuscitation)
- Administer until the QRS narrows
- Calcium Gluconate 10% (0.4 mEq/ml)
- Preferred agent if only peripheral IV available (Decreased venous sclerosis with infusion)
- Initial dose: 10 ml over 2-5 minutes (10-30 minutes is lower risk if time allows)
- Faster administration may result in Nausea and Vomiting
- Second dose after 5 minutes if EKG not improved
- Magnesium
- Consider as Calcium alternative in Digoxin Toxicity
- Management: Potassium shift from intravascular to intracellular
- Glucose and Insulin Infusion
- Insulin activates Sodium-Potassium ATPase pumps
- Protocol
- Insulin Regular 0.1 unit/kg up to 5-10 units IV AND
- Dextrose 50% (D50W) 50 ml (25 grams)
- Indicated with Insulin if Serum Glucose <250 mg/dl
- Give 1 ampule IV over 5 minutes
- Give a second ampule (additional 50 ml D50W) if normal starting Glucose or Renal Failure
- Consider maintenance dextrose, especially in Renal Failure (e.g. D10 100 cc/h)
- Post initial bolus to cover further Insulin effect
- Insulin may last longer than 30-60 min of dextrose (esp. in ESRD)
- Risk Factors for Hypoglycemia with Insulin
- Pretreatment Blood Glucose <150 mg/dl
- No Diabetes Mellitus history
- Body weight <60 kg
- Female gender
- Comorbidity including Renal Failure (Acute Kidney Injury or Chronic Kidney Disease)
- Onset: 15-30 minutes
- Duration: 2-6 hours
- Lowers Serum Potassium 0.6 to 1 mEq/L
- Monitoring
- Follow bedside Serum Glucose every 60 minutes for 4 hours (5-6 hours if Renal Failure)
- Give 25 g dextrose (50 ml D50W) prn Blood Glucose <70 mg/dl
- References
- Moussavi (2019) J Emerg Med 57(1): 36-42 +PMID:31084947 [PubMed]
- Nebulized Albuterol 5 mg/ml (typical neb is 2.5 mg/ml)
- Albuterol activates Sodium-Potassium ATPase pumps via beta-2 receptor stimulation
- Administer 10-20 mg (very high dose) nebulized over 10 minutes
- Effect: 10 mg Albuterol neb lowers Potassium 0.5 mEq
- Zitek (2016) Acad Emerg Med 23(6): 718-21 +PMID:26857949 [PubMed]
- Onset: 15-30 minutes
- Duration: 2-3 hours
- May repeat 2-3 times for total dose of 20 mg inhaled Albuterol
- Serum Potassium may increase transiently
- Bicarbonate
- Indicated primarily for Hyperkalemia with severe Metabolic Acidosis
- Not otherwise routinely recommended (historically used as routine adjunct to Calcium)
- Consider in severe Metabolic Acidosis
- Consider with QRS Widening
- Sodium Bicarbonate 7.5% (44.6 meq)
- Give 1 ampule IV over 5 minutes
- May repeat every 10-15 min if EKG changes persists
- Alternatively, may use isotonic bicarbonate
- D5W with 3 ampules of bicarbonate as isotonic infusion for 1-2 liters
- Do not exceed bicarbonate deficit (risk of alkalosis)
- Onset in 30 minutes
- Duration: 1-2 hours
- May also add to Glucose infusion below
- Avoid bicarbonate until Hypocalcemia corrected
- Risk of Tetany and Seizures
- Management: Lowering of total body Potassium with diuresis or Dialysis
- Furosemide (Lasix)
- Dose: 20-40 mg IV
- Coadminister Normal Saline if dehydrated
- Onset: 15-60 minutes
- Duration: 4 hours
- Kaliuresis ("Diuretic Bomb")
- May be indicated in acute or End-Stage Renal Disease patients needing Dialysis (but not yet on Dialysis)
- Temporizing measure with cardiac instability until emergent Dialysis
- Very high dose Diuretics are given
- Furosemide 60 to 180 mg IV
- Chlorothiazide 500 mg to 1000 mg IV
- Acetazolamide 250 to 500 mg IV
- Consider Fludrocortisone 0.2 mg orally
- Consider Mannitol (controversial)
- These doses are extremely high and require close monitoring of Urine Output
- Not typically effective in patients already on Dialysis
- Swaminathan and Farkas in Herbert (2019) EM:Rap 19(11): 11-2
- Hemodialysis (if persistent Hyperkalemia despite above measures)
- May experience significant Hyperkalemia on rebound
- Management: Lowering of total body Potassium with Potassium Binding Agents
- Precaution
- Potassium Binding Agents have relatively slow onset, and are not recommended in emergent Hyperkalemia
- Consider in chronic Hyperkalemia (often in cases to allow continuation of ACE Inhibitor or ARB)
- Patiromer (Veltassa)
- Potassium Binding agent that exchanges Calcium for Potassium in the Gastrointestinal Tract
- Risk of Hypomagnesemia (monitor) and gastrointestinal side effects
- Sodium Polystyrene Sulfonate (SPS, Kayexalate, Cation-Exchange Resin)
- Other methods of lowering Potassium are preferred
- Kayexalate has marginal efficacy, is poorly tolerated, and has delayed onset of action
- Kayexalate carries risk of potentially lethal bowel necrosis
- Dose: 15 grams in 50-100 ml of 20% Sorbitol
- May be repeated up to 4 times daily
- Doses of 30-60 g have been used, but are not recommended
- Rectal enemas may have faster activity, but are not recommended
- Higher risk for colonic necrosis
- Pharmacokinetics
- Onset: Up to 4-6 hours for oral route
- Duration: Lowers Serum Potassium 1 mEq/L over 24 hours
- Precautions
- Avoid Sorbitol if bowel necrosis risk
- Use caution if risk of Congestive Heart Failure
- Consider concurrent Furosemide (Lasix)
- Management: Chronic Hyperkalemia
- Eliminate Medication Causes of Elevated Serum Potassium
- Non-specific therapy
- Loop Diuretics (Lasix)
- Potassium Binding Agents
- Oral Patiromer (Veltassa)
- Sodium Zirconium Cyclosilicate (Lokelma)
- Sodium Polystyrene Sulfonate (SPS, Kayexalate)
- Specific therapy
- Hyporeninemic Hypoaldosteronism
- Loop Diuretics (Lasix)
- Fludrocortisone 0.1 mg orally daily
- Taper gradually as an outpatient
- Restart if Hyperkalemia recurs
- Renal Failure (GFR < 10 ml/min)
- Restrict Dietary Potassium to 40-60 meq/day
- Renal Failure and ACE or ARB induced Hyperkalemia
- Indications: Metabolic Acidosis
- Sodium Bicarbonate
- Dose A: 8 meq tabs, 2 tabs twice daily
- Dose B: 0.5 to 1 tsp baking soda daily
- Prevention: Hyperkalemia
- Limit or keep constant Dietary Potassium sources (esp. salt substitute)
- Decrease Potassium Supplementation in Loop Diuretic use
- Titrate to keep Serum Potassium ideally 4.0 to 5.0 mg/dl
- Avoid provocative medications
- See Medication Causes of Elevated Serum Potassium
- NSAIDs
- Trimethoprim-Sulfamethoxazole
- Increase Loop Diuretic dosing
- Reduce dosing of medications needed for comorbid conditions
- ACE Inhibitors
- Angiotensin Receptor Blockers
- Entresto (Sacubitril/Valsartan)
- Consider agents used for chronic Hyperkalemia as above
- Consider Potassium Binding Agents (see above)
- References
- (2021) Presc Lett 28(8): 44
- Ferreira (2020) J Am Coll Cardiol 75(22):2836-50 +PMID: 32498812 [PubMed]
- Resources
- Hyperkalemia in Internet Book of Critical Care (EM-Crit)
- https://emcrit.org/ibcc/hyperkalemia/
- References
- Swaminathan and Weingart in Herbert (2019) EM:Rap 19(10): 18-9
- Weisberg (2008) Crit Care Med 36(12):1-6 [PubMed]
- Hollander-Rodriguez (2006) Am Fam Physician 73:283-90 [PubMed]
- Kim (2002) Nephron 92:33-40 [PubMed]
- Viera (2015) Am Fam Physician 92(6): 487-95 [PubMed]