Hyperkalemia Management

1. See Also
   1. Hyperkalemia
   2. Hyperkalemia Causes
   3. Hyperkalemia due to Medications
   4. BRASH Syndrome
   5. Acute Kidney Injury Management
   6. Hyperkalemia Related EKG Changes
2. 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 Dialysis
      1. Do NOT use Sodium Channel Blockers (Class I Antiarrhythmic) such as Amiodarone or Lidocaine
      2. Do NOT use Succinylcholine (Depolarizing agents)
3. 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. NS is acidotic and increases extracellular Potassium while LR contains Potassium
         2. Neither is likely to appreciably increase Potassium
            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
         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 are given until QRS narrows
         3. See above precautions regarding avoiding Sodium Channel Blockers (e.g. Amiodarone) and Succinylcholine
      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
      2. See Hyperkalemia Causes
4. Management: Mnemonic - CBIGKD (See BIG Potassium Drop)
   1. Calcium
   2. Bicarbonate (no longer indicated unless acidosis)
   3. Insulin and Glucose
   4. Kayexalate
   5. Dialysis
5. 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 (1.4 mEq/ml)
         1. Dose: 5 ml over 10 minutes
         2. May repeat second dose in 5 minutes if EKG not improved
         3. 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
         4. In Peri-Arrest patients, use repeated doses (2-3 ampules in the first minutes of Resuscitation)
            1. Administer until the QRS narrows
      5. Calcium Gluconate 10% (0.4 mEq/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. Second dose after 5 minutes if EKG not improved
   2. Magnesium
      1. Consider as Calcium alternative in Digoxin Toxicity
6. Management: Potassium shift from intravascular 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 AND
         2. Dextrose 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. Give a second ampule (additional 50 ml D50W) if normal starting Glucose or Renal Failure
            4. Consider maintenance dextrose, especially in Renal Failure (e.g. D10 100 cc/h)
               1. Post initial bolus to cover further Insulin effect
               2. Insulin may last longer than 30-60 min of dextrose (esp. in ESRD)
            5. 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)
      3. Onset: 15-30 minutes
      4. Duration: 2-6 hours
      5. Lowers Serum Potassium 0.6 to 1 mEq/L
      6. Monitoring
         1. Follow bedside Serum Glucose every 60 minutes for 4 hours (5-6 hours if Renal Failure)
         2. Give 25 g dextrose (50 ml D50W) prn Blood Glucose <70 mg/dl
      7. 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. Administer 10-20 mg (very high dose) nebulized over 10 minutes
      3. Effect: 10 mg Albuterol neb lowers Potassium 0.5 mEq
         1. Zitek (2016) Acad Emerg Med 23(6): 718-21 +PMID:26857949 [PubMed]
      4. Onset: 15-30 minutes
      5. Duration: 2-3 hours
      6. May repeat 2-3 times for total dose of 20 mg inhaled Albuterol
      7. Serum Potassium may increase transiently
   3. Bicarbonate
      1. 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
      2. 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. Alternatively, may use isotonic bicarbonate
         1. D5W with 3 ampules of bicarbonate as isotonic infusion for 1-2 liters
         2. Do not exceed bicarbonate deficit (risk of alkalosis)
   4. Onset in 30 minutes
      1. Duration: 1-2 hours
      2. May also add to Glucose infusion below
      3. Avoid bicarbonate until Hypocalcemia corrected
         1. Risk of Tetany and Seizures
7. Management: Lowering of total body Potassium with diuresis or Dialysis
   1. Furosemide (Lasix)
      1. Dose: 20-40 mg IV
      2. Coadminister Normal Saline if dehydrated
      3. Onset: 15-60 minutes
      4. Duration: 4 hours
   2. Kaliuresis ("Diuretic Bomb")
      1. 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
      2. Very high dose Diuretics are given
         1. Furosemide 60 to 180 mg IV
         2. Chlorothiazide 500 mg to 1000 mg IV
         3. Acetazolamide 250 to 500 mg IV
         4. Consider Fludrocortisone 0.2 mg orally
         5. Consider Mannitol (controversial)
      3. These doses are extremely high and require close monitoring of Urine Output
      4. Not typically effective in patients already on Dialysis
      5. 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
8. 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 in chronic Hyperkalemia (often in cases to allow continuation of ACE Inhibitor or ARB)
   2. Patiromer (Veltassa)
      1. Potassium Binding agent that exchanges Calcium for Potassium in the Gastrointestinal Tract
      2. Risk of Hypomagnesemia (monitor) and gastrointestinal side effects
   3. 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)
9. 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)
   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
10. 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]
11. Resources
    1. Hyperkalemia in Internet Book of Critical Care (EM-Crit)
       1. https://emcrit.org/ibcc/hyperkalemia/
12. References
    1. Swaminathan and Weingart in Herbert (2019) EM:Rap 19(10): 18-9
    2. Weisberg (2008) Crit Care Med 36(12):1-6 [PubMed]
    3. Hollander-Rodriguez (2006) Am Fam Physician 73:283-90 [PubMed]
    4. Kim (2002) Nephron 92:33-40 [PubMed]
    5. Viera (2015) Am Fam Physician 92(6): 487-95 [PubMed]