Hyperkalemia Emergency Treatment

Place patients with potassium greater than 6.0 mmol/L on continuous cardiac monitoring and obtain a 12-lead ECG. Refer patients with potassium greater than 6.0 mmol/L or any hyperkalemia-associated ECG change to an emergency setting capable of immediate monitored treatment. Wolters Kluwer+2Wolters KluwerAcute hyperkalemia in the emergency department - OvidWolters KluwerRecent Advances in Nephrology: The Research Gaps... : Nigerian Journal of Clinical PracticeWolters KluwerAcute hyperkalemia in adults : Turkish Journal of Emergency Medicine

Do not use a normal ECG to exclude clinically consequential hyperkalemia. Reported manifestations include peaked T waves, PR prolongation, P-wave flattening, QRS widening, and ventricular fibrillation, but ECG changes need not progress sequentially and ventricular fibrillation can occur without preceding classic findings. Wolters KluwerWolters KluwerAcute hyperkalemia in adults : Turkish Journal of Emergency Medicine

Repeat potassium promptly when hemolysis, collection artifact, or pseudohyperkalemia is plausible, but do not allow confirmation to delay therapy in a patient with potassium greater than 6.0 mmol/L plus ECG toxicity or clinical instability. Obtain rapid biochemical confirmation and assess for acute kidney injury, chronic kidney disease, end-stage kidney disease, metabolic acidosis, diabetes, heart failure, and medication contributors. Wolters Kluwer+2Wolters KluwerRecent Advances in Nephrology: The Research Gaps... : Nigerian Journal of Clinical PracticeWolters KluwerAcute hyperkalemia in adults : Turkish Journal of Emergency MedicineWolters KluwerEMCREG-International Multidisciplinary Consensus... : Cardiorenal Medicine

Administer IV calcium immediately when hyperkalemia-associated ECG changes are present. The KDIGO emergency algorithm lists either calcium gluconate 1 g IV, repeatable up to three 1-g doses using 10 mL of 10% solution per dose, or calcium chloride 1 g IV using 10 mL of 10% solution. Wolters Kluwer+1Wolters KluwerAcute hyperkalemia in adults : Turkish Journal of Emergency MedicinePubMedAcute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conference

Select calcium as myocardial protection while concurrently initiating therapies that shift and remove potassium. It is not a potassium-lowering therapy; failure to pair calcium with redistribution and elimination permits recurrent electrical toxicity as serum potassium remains elevated. Wolters Kluwer+1Wolters KluwerAcute hyperkalemia in adults : Turkish Journal of Emergency MedicinePubMedAcute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conference

Use IV regular insulin with dextrose as a principal rapid intracellular-shift therapy. A KDIGO emergency regimen is regular insulin 5 units IV plus 25 g glucose IV; other guideline-referenced regimens use 5 to 10 units of IV insulin with 25 to 50 g dextrose. PubMed+1PubMedAcute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conferencePubMedHyperkalemia Management with Intravenous Insulin in Patients with Reduced Kidney Function - PMC A commonly used alternative is 10 units of regular insulin IV with 25 g dextrose. PubMedPubMedHypoglycemia in the treatment of hyperkalemia with insulin in patients with end-stage renal disease

Add nebulized albuterol 10 mg when further rapid redistribution is needed and no patient-specific concern precludes beta-agonist use. Insulin and albuterol may have additive effects, although albuterol is ineffective in some patients; expected adverse effects include tremor, palpitations, headache, and mild hyperglycemia. PubMed+1PubMedHyperkalemia management in the emergency department - PMC - NIHPubMedAcute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conference

Reserve IV sodium bicarbonate for patients with concomitant metabolic acidosis rather than routine use in normoacidic hyperkalemia. The KDIGO algorithm lists 50 mmol IV over 15 minutes; bicarbonate has little potassium-lowering effect without acidosis and is not indicated as routine acute therapy. PubMed+2PubMedHyperkalemia management in the emergency department - PMC - NIHPubMedAcute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conferenceccjmDiagnosis and treatment of hyperkalemia

Hemodialysis is the preferred and most effective method of urgent potassium elimination. Arrange it early for severe hyperkalemia when kidney function is too poor for meaningful renal potassium excretion, when hyperkalemia persists despite medical management, or when recurrent elevation is expected while temporizing therapies wear off. asn-online+2asn-online[PDF] Kidney News - May 2010 - American Society of NephrologyPubMedHyperkalemia management in the emergency department - PMC - NIHPubMedAcute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conference

If the patient has sufficient kidney function, loop diuretics can support urinary potassium removal; their utility depends on preserved renal function. asn-online+1asn-online[PDF] Kidney News - May 2010 - American Society of NephrologyccjmDiagnosis and treatment of hyperkalemia Correct the precipitating process that is limiting potassium excretion or creating ongoing release, including acute kidney injury, chronic kidney disease, metabolic acidosis, and potassium-raising medication combinations. Wolters Kluwer+1Wolters KluwerEMCREG-International Multidisciplinary Consensus... : Cardiorenal MedicineccjmDiagnosis and treatment of hyperkalemia

Gastrointestinal binders may contribute to potassium elimination but should not replace immediate calcium, insulin-dextrose, albuterol, or dialysis planning in ECG-toxic hyperkalemia. The KDIGO algorithm lists sodium polystyrene sulfonate 15 to 60 g orally or rectally without sorbitol and sodium zirconium cyclosilicate 10 g orally three times daily; it states that patiromer is not advisable for emergency use because onset is approximately 7 hours. PubMedPubMedAcute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conference

Reevaluate serum potassium frequently after treatment to document response and identify recurrence after redistribution therapy. Continue cardiac monitoring until the acute electrical risk has resolved and a durable potassium-elimination strategy is in place. Wolters Kluwer+1Wolters KluwerAcute hyperkalemia in adults : Turkish Journal of Emergency MedicinePubMedAcute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conference

After IV insulin, use serial glucose testing because hypoglycemia can occur despite dextrose coadministration and may be delayed in ESRD or reduced kidney function. In ESRD, monitor for at least 3 hours after insulin treatment. PubMed+1PubMedHypoglycemia in the treatment of hyperkalemia with insulin in patients with end-stage renal diseasePubMedHyperkalemia Management with Intravenous Insulin in Patients with Reduced Kidney Function - PMC

Before disposition, establish why potassium rose and whether potassium can be eliminated without dialysis. Patients with persistent severe elevation, ECG abnormalities, inadequate renal clearance, or need for urgent dialysis require continued monitored care rather than discharge after a transient laboratory improvement. Wolters Kluwer+3Wolters KluwerRecent Advances in Nephrology: The Research Gaps... : Nigerian Journal of Clinical PracticeWolters KluwerAcute hyperkalemia in adults : Turkish Journal of Emergency MedicinePubMedHyperkalemia management in the emergency department - PMC - NIHPubMedAcute hyperkalemia in the emergency department: a summary from a Kidney Disease: Improving Global Outcomes conference