Hyperkalemia: Difference between revisions

(Convert key medications to MedicationDose template with SMW; dosing verified)
(Convert medication dosing to MedicationDose templates for SMW integration (8 medications: calcium gluconate, calcium chloride, insulin, albuterol, sodium bicarbonate, furosemide, kayexalate, lokelma))
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''Indicated if there are any ECG changes or evidence of arrhythmias. Consider if K >7 mEq/L''
''Indicated if there are any ECG changes or evidence of arrhythmias. Consider if K >7 mEq/L''
*Either one of the following:
*Either one of the following:
**{{MedicationDose|drug=Calcium gluconate|dose=10 mL of 10% (1 g) over 5-10 min|route=IV|context=Cardiac membrane stabilization|indication=Hyperkalemia|population=Adult|onset=1-3 min|duration=30-60 min}}. In severe cases may have to start with higher dose of 3 grams (30 mLs) and repeat doses (up to 9-15 grams total).
**{{MedicationDose|drug=Calcium gluconate|dose=10mL of 10% solution (1 gram) IV over 5-10 min; in severe cases may start with 3 grams (30 mL), repeat doses up to 9-15 grams total|route=IV|context=Cardiac membrane stabilization (preferred)|indication=Hyperkalemia|onset=15-30 min|duration=30-60 min|notes=Only 1/3 elemental calcium vs calcium chloride; can cause hypotension}}
***Only 1/3 the elemental calcium compared to calcium chloride.
**{{MedicationDose|drug=Calcium chloride|dose=1 gram IV over 1-2 min|route=IV|context=Cardiac membrane stabilization (code situations)|indication=Hyperkalemia|onset=15-30 min|duration=30-60 min|notes=Extravasation risk: use a good IV; usually given in code situations}}
***Can cause hypotension due to osmotic shift
*Do serial [[ECG]]s to track progress: may need to give multiple doses
**[[Calcium chloride]] 1 gram IV  
*(If given for hyperkalemic cardiac arrest, need to continue resuscitation for at least 30 minutes)
***Give over 1 - 2 minutes
***Extravasation is bad: use a good IV
***Usually given in code situations  
*Takes effect in 15-30 minutes<ref>http://lifeinthefastlane.com/hyperkalemia/. Accessed 02/22/2016</ref>
**(If given for hyperkalemic cardiac arrest, need to continue resuscitation for at least 30 minutes)
*Duration of action: 30 - 60 minutes <ref> The Effect of Calcium on Severe Hyperkalemia http://hqmeded-ecg.blogspot.com/2015/04/the-effect-of-calcium-on-severe.html</ref>
*Use caution in patients taking [[Digitalis Toxicity|Digoxin]] although risk of [[Stone heart]] may be unsubstantiated <ref>Erickson CP, Olson KR. Case files of the medical toxicology fellowship of the California poison control system-San Francisco: calcium plus digoxin-more taboo than toxic? J Med Toxicol. 2008 Mar;4(1):33-9</ref>
*Use caution in patients taking [[Digitalis Toxicity|Digoxin]] although risk of [[Stone heart]] may be unsubstantiated <ref>Erickson CP, Olson KR. Case files of the medical toxicology fellowship of the California poison control system-San Francisco: calcium plus digoxin-more taboo than toxic? J Med Toxicol. 2008 Mar;4(1):33-9</ref>
*Do serial [[ECG]]s to track progress: may need to give multiple doses


===Shift K+ intracellularly===
===Shift K+ intracellularly===
*Intravenous [[insulin]] + [[dextrose]]
*{{MedicationDose|drug=Insulin|dose=10 units regular insulin IV with 25-50g of D50 (1-2 ampules)|route=IV|context=Potassium shifting|indication=Hyperkalemia|duration=4-6 hours|notes=May withhold dextrose if blood sugar >300 mg/dL; consider 5 units if glucose <150, AKI/CKD, no DM, weight <60kg, or female}}
**{{MedicationDose|drug=Insulin|dose=10 units regular with 25-50 g dextrose (1-2|route=IV|context=Potassium shifting|indication=Hyperkalemia|population=Adult|onset=20-30 min|duration=4-6 hr|link=no}} (1 - 2 50 mL ampules) of 50% dextrose (D50)
***Consider mixing in 10 cc NS syringe to ensure small volume of 10 units insulin fully administered via stopcock<ref>Sterns R, Grieff M, Bernstein P (2016). Treatment of hyperkalemia: Something old, something new. Kidney International, 89(3), 546-554.</ref>
***May withhold dextrose if blood sugar >300mg/dl (>17 mmol/L)
***Follow glucose levels q30-60 min and supplement dextrose to avoid hypoglycemia (occurs in ~75% of patients)<ref> Apel J, Reutrakul S, Baldwin D. Hypoglycemia in the Treatment of Hyperkalemia With Insulin in Patients With End-Stage Renal Disease. Clin Kidney J. 2014;7(3):248-250</ref>
***Duration of effect: 4 - 6 hours
*{{MedicationDose|drug=Albuterol|dose=15-20 mg nebulized|route=Nebulized|context=Potassium shifting|indication=Hyperkalemia|onset=30 min (peak)|duration=2 hours|notes=Response is dose-dependent}}
***Consider mixing in 10 cc NS syringe to ensure small volume of 10 units insulin fully administered via IV
*{{MedicationDose|drug=Sodium bicarbonate|dose=3 amps in 1L D5W (isotonic bicarbonate drip)|route=IV drip|context=Potassium shifting (if metabolic acidosis)|indication=Hyperkalemia|notes=Generally not considered unless pH <7.1; pushing ampules of hypertonic bicarb ineffective in RCTs}}
***Insulin cleared renally, be careful about inducing hypoglycemia (ESRD patients).  
**For '''normovolemic or hypovolemic''' patients with '''metabolic acidosis'''
****In a [https://onlinelibrary.wiley.com/doi/abs/10.1002/phar.2038 small 2017 retrospective cohort study], researchers found that giving 5 units of insulin instead of 10 units reduced serum potassium to the same extent as 10 units, with a lower rate of hypoglycemia.
****Consider decreasing to 5 units or increasing dextrose dose to 50g with following risk factors: pretreatment blood glucose <150, acute kidney injury/chronic kidney disease, no history of DM, weight <60kg, female sex <ref> Moussavi K1, Fitter S2, Gabrielson SW3, Koyfman A4, Long B5. Management of Hyperkalemia With Insulin and Glucose: Pearls for the Emergency Clinician. J Emerg Med. 2019 Jul;57(1):36-42. </ref>
*Nebulized [[albuterol]] 15 - 20mg
**Response is dose-dependent  
**Peak effect: 30 minutes
**Duration of effect: 2 hours
*[[Sodium bicarbonate]]
**Generally not considered unless pH <7.1
**Pushing "ampules of hypertonic bicarbonate have been proven to be ineffective in RCTs"<ref>[https://emcrit.org/ibcc/hyperkalemia/ IBCC Hyperkalemia Chapter]</ref>
**For '''normovolemic or hypovolemic''' patients with '''metabolic acidosis''':
***Give three amps of bicarbonate in a liter of D5W or sterile water


===Remove K+ from body===
===Remove K+ from body===
*Intravenous [[furosemide]] (Lasix) 40 - 80mg
*{{MedicationDose|drug=Furosemide|dose=40-80 mg IV|route=IV|context=Potassium elimination|indication=Hyperkalemia|display=Furosemide (Lasix)|notes=Ensure adequate urine output first}}
**Ensure adequate urine output first
**Decreases potassium by dilution, shifting into muscle cells, and promoting renal excretion via alkalosis<ref>[https://emcrit.org/ibcc/hyperkalemia/ IBCC Hyperkalemia Chapter]</ref>
**Decreases the potassium in three ways: dilution, shifting of potassium into muscle cells, and promotion of renal potassium excretion by alkalosis<ref>[https://emcrit.org/ibcc/hyperkalemia/ IBCC Hyperkalemia Chapter]</ref>
*{{MedicationDose|drug=Sodium polystyrene sulfonate|dose=30 g PO or PR|route=PO/PR|context=Potassium binding|indication=Hyperkalemia|display=Kayexalate (SPS)|notes=Very controversial; high risk of bowel perforation}}
**More on how to use Lasix: [https://emcrit.org/ibcc/hyperkalemia/ IBCC Hyperkalemia Chapter]
**See: [[EBQ: Use of Kayexylate in Hyperkalemia]]
*[[Sodium polystyrene sulfonate]] (Kayexalate): 30 gm oral or per rectum
*{{MedicationDose|drug=Sodium zirconium cyclosilicate|dose=10 g PO TID x48 hours, then 10-15 g PO daily maintenance|route=PO|context=Potassium binding (preferred over Kayexalate)|indication=Hyperkalemia|display=Lokelma (SZC)|notes=Similar to Kayexalate but without bowel perforation risk}}<ref>Beccari, Mario V, and Calvin J Meaney. "Clinical utility of patiromer, sodium zirconium cyclosilicate, and sodium polystyrene sulfonate for the treatment of hyperkalemia: an evidence-based review." Core evidence vol. 12 11-24. 23 Mar. 2017, doi:10.2147/CE.S129555</ref>
**'''Very Controversial, High Risk of Bowel Perforation''', see: [[EBQ: Use of Kayexylate in Hyperkalemia]]
*[[Sodium zirconium cyclosilicate]] (Lokelma)
**Potassium binder, similar to [[Sodium polystyrene sulfonate|Kayexalate]] but without risk of bowel perforation<ref>Beccari, Mario V, and Calvin J Meaney. “Clinical utility of patiromer, sodium zirconium cyclosilicate, and sodium polystyrene sulfonate for the treatment of hyperkalemia: an evidence-based review.” Core evidence vol. 12 11-24. 23 Mar. 2017, doi:10.2147/CE.S129555</ref>
**10 mg PO TID for up to 48 hours, then 10-15 mg PO QD for maintenance
*Intravenous lactated ringers solution for volume expansion if dehydrated, rhabdomyolysis, diabetic ketoacidosis or other acidosis (avoid NS, causes hyperchloremic acidosis which shifts potassium out of cells increasing level)
*Intravenous lactated ringers solution for volume expansion if dehydrated, rhabdomyolysis, diabetic ketoacidosis or other acidosis (avoid NS, causes hyperchloremic acidosis which shifts potassium out of cells increasing level)
**consider isotonic bicarbonate if significant acidosis (D5W with 3 amps of bicarb per liter), can calculate bicarbonate deficit then divide by 150mEq/L to estimate number of liters of isotonic bicarbonate required) <ref> https://emcrit.org/pulmcrit/fluid-selection-using-ph-guided-resuscitation </ref>
**Consider isotonic bicarbonate if significant acidosis (D5W with 3 amps of bicarb per liter) <ref> https://emcrit.org/pulmcrit/fluid-selection-using-ph-guided-resuscitation </ref>
*[[Hydrocortisone]] if suspicious for [[adrenal insufficiency]]
*[[Hydrocortisone]] if suspicious for [[adrenal insufficiency]]
*Definitive treatment is [[hemodialysis]]
*Definitive treatment is [[hemodialysis]]

Revision as of 16:06, 20 March 2026

Background

  • Defined as >5.5 mEq/L
  • Potassium secretion is proportional to flow rate and sodium delivery through distal nephron
    • Thus, loop & thiazide diuretics cause hypokalmia
  • Most common cause is hemolysis from blood draw (pseudohyperkalemia)

Medication Causes

Alter transmembrane potassium movement

  • β blockers
  • Digoxin
  • Potassium-containing drugs
  • Potassium supplements
  • Salt substitutes
  • Hyperosmolar solutions (mannitol, glucose)
  • Suxamethonium
  • Intravenous cationic amino acids
  • Stored red blood cells (haemolysis releases potassium)
  • Herbal medicines (such as alfalfa, dandelion, horsetail, milkweed, and nettle)

Reduce aldosterone secretion

Block aldosterone binding to mineralocorticoid receptors

Clinical Features

Typically non-specific

Differential Diagnosis

Hyperkalemia

  • Pseudohyperkalemia: hemolyzed specimen, prolonged tourniquet use prior to blood draw, thrombocytosis or leukocytosis
  • Redistribution (shift from intracellular to extracellular space)
  • Increased total body potassium
    • Inadequate excretion: Acute/chronic renal failure, Addison's disease, type 4 RTA
    • Drug-induced: potassium-sparing diuretic (spironolactone), angiotensin converting enzyme inhibitors (ACE-I), nonsteroidal anti-inflammatory drugs (NSAIDs)
    • Excessive intake: diet, blood transfusion
  • Other causes: succinylcholine, digitalis, beta-blockers

Peaked T-waves

Wide-complex tachycardia

Assume any wide-complex tachycardia is ventricular tachycardia until proven otherwise (it is safer to incorrectly assume a ventricular dysrhythmia than supraventricular tachycardia with abberancy)

^Fixed or rate-related

Evaluation

Diagrammatic representation of ECG changes with increasing hyperkalemia
ECG in hyperkalemia with peaked T waves and small P waves
ECG with widened QRS complex and tall broad T waves
ECG showing sine wave pattern

Workup

  • ECG
  • Chem 10 (including potassium, magnesium, and phosphorus)
    • Consider point-of-care lab testing for more rapid result
  • Consider ABG/VBG to evaluate pH

ECG

Changes NOT always predictable and sequential

  • 6.5 - 7.5 mEq/L: peaked T waves, prolonged PR interval, shortened QT interval
  • 7.5 - 8.0 mEq/L: widened QRS interval, flattened P waves
  • 10 - 12 mEq/L: sine wave, ventricular fibrillation, heart block

Diagnosis

  • Based on lab testing (>5.5 mEq/L), although ECG may provide earlier information
  • Consider pseudohyperkalemia (e.g. from hemolysis)

Management

Stabilize cardiac membranes

Indicated if there are any ECG changes or evidence of arrhythmias. Consider if K >7 mEq/L

  • Either one of the following:
    • Calcium gluconate 10mL of 10% solution (1 gram) IV over 5-10 min; in severe cases may start with 3 grams (30 mL), repeat doses up to 9-15 grams total IV (onset 15-30 min, duration 30-60 min) — Only 1/3 elemental calcium vs calcium chloride; can cause hypotension
    • Calcium chloride 1 gram IV over 1-2 min IV (onset 15-30 min, duration 30-60 min) — Extravasation risk: use a good IV; usually given in code situations
  • Do serial ECGs to track progress: may need to give multiple doses
  • (If given for hyperkalemic cardiac arrest, need to continue resuscitation for at least 30 minutes)
  • Use caution in patients taking Digoxin although risk of Stone heart may be unsubstantiated [1]

Shift K+ intracellularly

  • Insulin 10 units regular insulin IV with 25-50g of D50 (1-2 ampules) IV (duration 4-6 hours) — May withhold dextrose if blood sugar >300 mg/dL; consider 5 units if glucose <150, AKI/CKD, no DM, weight <60kg, or female
      • Consider mixing in 10 cc NS syringe to ensure small volume of 10 units insulin fully administered via stopcock[2]
      • Follow glucose levels q30-60 min and supplement dextrose to avoid hypoglycemia (occurs in ~75% of patients)[3]
  • Albuterol 15-20 mg nebulized Nebulized (onset 30 min (peak), duration 2 hours) — Response is dose-dependent
  • Sodium bicarbonate 3 amps in 1L D5W (isotonic bicarbonate drip) IV drip — Generally not considered unless pH <7.1; pushing ampules of hypertonic bicarb ineffective in RCTs
    • For normovolemic or hypovolemic patients with metabolic acidosis

Remove K+ from body

  • Furosemide (Lasix) 40-80 mg IV IV — Ensure adequate urine output first
    • Decreases potassium by dilution, shifting into muscle cells, and promoting renal excretion via alkalosis[4]
  • Kayexalate (SPS) 30 g PO or PR PO/PR — Very controversial; high risk of bowel perforation
  • Lokelma (SZC) 10 g PO TID x48 hours, then 10-15 g PO daily maintenance PO — Similar to Kayexalate but without bowel perforation risk[5]
  • Intravenous lactated ringers solution for volume expansion if dehydrated, rhabdomyolysis, diabetic ketoacidosis or other acidosis (avoid NS, causes hyperchloremic acidosis which shifts potassium out of cells increasing level)
    • Consider isotonic bicarbonate if significant acidosis (D5W with 3 amps of bicarb per liter) [6]
  • Hydrocortisone if suspicious for adrenal insufficiency
  • Definitive treatment is hemodialysis

IV Fluid Choice

  • LR is preferred over NS, even in renal failure[7]
  • The small amount of 4 mEq/L of potassium in lactated ringers does not contribute to worsening hyperkalemia
  • Hyperkalemia worsens with metabolic acidosis, and large volume normal saline administration increases risk of hyperchloremic non-anion gap metabolic acidosis

Disposition

  • Consideration for ICU for frequent electrolyte checks and close cardiac monitoring

See Also

External Links

References

  1. ↑ Erickson CP, Olson KR. Case files of the medical toxicology fellowship of the California poison control system-San Francisco: calcium plus digoxin-more taboo than toxic? J Med Toxicol. 2008 Mar;4(1):33-9
  2. ↑ Sterns R, Grieff M, Bernstein P (2016). Treatment of hyperkalemia: Something old, something new. Kidney International, 89(3), 546-554.
  3. ↑ Apel J, Reutrakul S, Baldwin D. Hypoglycemia in the Treatment of Hyperkalemia With Insulin in Patients With End-Stage Renal Disease. Clin Kidney J. 2014;7(3):248-250
  4. ↑ IBCC Hyperkalemia Chapter
  5. ↑ Beccari, Mario V, and Calvin J Meaney. "Clinical utility of patiromer, sodium zirconium cyclosilicate, and sodium polystyrene sulfonate for the treatment of hyperkalemia: an evidence-based review." Core evidence vol. 12 11-24. 23 Mar. 2017, doi:10.2147/CE.S129555
  6. ↑ https://emcrit.org/pulmcrit/fluid-selection-using-ph-guided-resuscitation
  7. ↑ O'Malley CM, Frumento RJ, Hardy MA, Benvenisty AI, Brentjens TE, Mercer JS, Bennett-Guerrero E. A randomized, double-blind comparison of lactated Ringer's solution and 0.9% NaCl during renal transplantation. Anesth. Analg. 2005 May;100(5):1518-24.
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