I. See Also

II. 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 Chloride or 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

III. Management: Mnemonic - CBIGKD (See BIG Potassium Drop)

  1. Calcium
  2. Bicarbonate (no longer indicated unless acidosis)
  3. Insulin and Glucose
  4. Kayexalate
  5. Dialysis

IV. Management: Myocardium Stabilization

  1. Calcium
    1. Antagonizes Hyperkalemia cardiac, neurologic effects
      1. Further calcium beyond first 1-2 dose are ineffective for additional myocardial stabilization unless Hypocalcemia
    2. Effect occurs in minutes and lasts for 30-60 minutes
      1. Anticipate EKG improvement within 3 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
    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 minutes is lower risk if time allows)
      3. Second dose after 5 minutes if EKG not improved
  2. Magnesium
    1. Consider as calcium alternative in Digoxin Toxicity

V. 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. May repeat 2-3 times for total dose of 20 mg inhaled Albuterol
    5. Serum Potassium may increase transiently
  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

VI. Management: Lowering of total body potassium

  1. Sodium Polystyrene Sulfonate (Kayexalate)
    1. Other methods of lowering potassium are preferred due to marginal efficacy, poorly tolerated, risk of bowel necrosis and delayed onset of action
    2. Cation-Exchange Resin
    3. Dose: 50 grams
      1. Oral: Administer in 30 ml of Sorbitol
      2. Rectal: Enema activity is faster than oral
    4. Onset: Up to 4-6 hours for oral route
    5. 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

VII. 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

Images: Related links to external sites (from Google)

Ontology: Electrolyte management: hyperkalemia (C0150196)

Definition (NIC) Promotion of potassium balance and prevention of complications resulting from serum potassium levels higher than desired
Concepts Therapeutic or Preventive Procedure (T061)
SnomedCT 386266006
English Electrolyte Management: Hyperkalemia, Electrolyte management: hyperkalaemia, Electrolyte management: hyperkalemia (procedure), Electrolyte management: hyperkalemia
Spanish manejo de electrólitos: hipercaliemia (procedimiento), manejo de electrólitos: hipercaliemia