eMedicine Specialties > Emergency Medicine > Endocrine & Metabolic
Hyperkalemia: Treatment & Medication
Updated: Aug 6, 2009
- Overview
- Differential Diagnoses & Workup
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Treatment
Prehospital Care
A patient with known hyperkalemia or a patient with renal failure with suspected hyperkalemia should have intravenous access established and should be placed on a cardiac monitor.7 In the presence of hypotension or marked QRS widening, intravenous bicarbonate, calcium, and insulin given together with 50% dextrose may be appropriate as discussed in Medication. Avoid calcium if digoxin toxicity is suspected. Magnesium sulfate (2 g over 5 min) may be used alternatively in the face of digoxin-toxic cardiac arrhythmias.
Emergency Department Care
- Perform continuous ECG monitoring with frequent vital sign checks when hyperkalemia is suspected or when laboratory values indicative of hyperkalemia are received.
- Initial management includes assessment of the ABCs and prompt evaluation of the patient's cardiac status with an ECG.
- Discontinue any potassium-sparing drugs or dietary potassium.
- If the hyperkalemia is severe (potassium >7.0 mEq/L) or if the patient is symptomatic, begin treatment before diagnostic investigation of the underlying cause.
- Individualize treatment based upon the patient's presentation, potassium level, and ECG.
- Not all patients should receive every medication listed in Medication. Patients with mild hyperkalemia, for example, may need only excretion enhancement.
Consultations
Consult a nephrologist or the dialysis team for patients with either severe symptomatic hyperkalemia or renal failure. Admit these patients to an ICU.
Medication
Direct treatment is aimed at stabilizing the myocardium, shifting potassium from the extracellular environment to the intracellular compartment, and promoting the renal excretion and GI loss of potassium.
Electrolyte supplements
These agents are used to treat hyperkalemia and to reduce the risk of ventricular fibrillation caused by hyperkalemia. They act quickly and can be lifesaving, thus they are the first-line treatment for severe hyperkalemia when the ECG shows significant abnormalities (eg, widening of QRS interval, loss of P wave, cardiac arrhythmias). Calcium usually is not indicated when the ECG shows only peaked T waves.
Calcium chloride or calcium gluconate (Kalcinate)
Calcium increases threshold potential, thus restoring normal gradient between threshold potential and resting membrane potential, which is elevated abnormally in hyperkalemia. One ampule of calcium chloride has approximately 3 times more calcium than calcium gluconate. Onset of action is <5 min and lasts about 30-60 min. Doses should be titrated with constant monitoring of ECG changes during administration; repeat dose if ECG changes do not normalize within 3-5 min.
Adult
Calcium chloride: 5 mL of 10% sol IV over 2 min (stop infusion if bradycardia develops)
Calcium gluconate: 10 mL of 10% sol IV over 2 min (stop infusion if bradycardia develops)
Pediatric
Calcium chloride: 0.2 mL/kg/dose of 10% sol IV over 5 min; not to exceed 5 mL (stop infusion if bradycardia develops)
Calcium gluconate: 100 mg/kg (1 mL/kg) of 10% sol IV over 3-5 min; not to exceed 10 mL (stop infusion if bradycardia develops)
May decrease effects of tetracyclines, atenolol, salicylates, iron salts, and fluoroquinolones; antagonizes effects of verapamil; large intakes of dietary fiber may decrease absorption and levels
Renal calculi; hypercalcemia; hypophosphatemia; renal or cardiac disease; digitalis toxicity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in digitalized patients, respiratory failure, acidosis, or severe hyperphosphatemia
Antidotes
Insulin is administered with glucose to facilitate the uptake of glucose into the cell, bringing potassium with it.
Dextrose (D-Glucose)
Glucose and insulin temporarily shift K+ into cells; effects occur within first 30 min of administration.
Adult
1-2 amps D50W and 5-10 U regular insulin IV
Pediatric
0.5 g/kg (2 mL/kg) 25% dextrose solution with 0.1 U/kg regular insulin (1 U regular insulin/5 g glucose) IV over 30 min
Caution when administering parenteral fluids to patients receiving corticosteroids or corticotropin, especially if solution contains Na+ ions
Diabetic coma if blood glucose levels extremely high
Avoid in severely dehydrated patients, especially those with delirium tremens, hepatic coma, or glucose-galactose malabsorption syndrome
Do not administer concentrated solution if intraspinal or intracranial hemorrhage is present
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause nausea, which also may occur with hypoglycemia; IV dextrose solutions may result in dilution of serum electrolyte concentrations or overhydration when patient is fluid overloaded; caution in patients suffering from congested states or pulmonary edema; hypertonic dextrose given peripherally may cause thrombosis (administer instead through central venous catheter); caution in subclinical diabetes mellitus or carbohydrate intolerance; increased risk of inducing significant hyperglycemia or hyperosmolar syndrome if solution administered rapidly, especially in patients with chronic uremia or carbohydrate intolerance; concentrated solutions should not be administered SC or IM; rates of dextrose infusion higher than 0.5 g/kg/h may produce glycosuria; at infusion rates of 0.8 g/kg/h, incidence of glycosuria is 5%; monitor fluid balance, electrolyte concentrations, and acid-base balance closely; dextrose administration may produce vitamin B complex deficiency
Insulin (Humulin, Humalog, Novolin)
Stimulates cellular uptake of K+ within 20-30 min; administer glucose along with insulin to prevent hypoglycemia (monitor blood glucose levels closely).
Adult
5-10 U regular insulin and 1-2 amps D50W IV bolus
Pediatric
0.5 g/kg (2 mL/kg) 25% dextrose solution with 0.1 U/kg regular insulin (1 U regular insulin/5 g glucose) IV over 30 min
Medications that may decrease hypoglycemic effects of insulin include acetazolamide, AIDS antivirals, asparaginase, phenytoin, nicotine, isoniazid, diltiazem, diuretics, corticosteroids, thiazide diuretics, thyroid, estrogens, ethacrynic acid, calcitonin, oral contraceptives, diazoxide, dobutamine phenothiazines, cyclophosphamide, dextrothyroxine, lithium carbonate, epinephrine, morphine sulfate, and niacin
Medications that may increase hypoglycemic effects of insulin include calcium, ACE inhibitors, alcohol, tetracyclines, beta-blockers, lithium carbonate, anabolic steroids, pyridoxine, salicylates, MAOIs, mebendazole, sulfonamides, phenylbutazone, chloroquine, clofibrate, fenfluramine, guanethidine, octreotide, pentamidine, and sulfinpyrazone
Documented hypersensitivity; hypoglycemia
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Hyperthyroidism may increase renal clearance of insulin and may increase dose of insulin needed to treat hyperkalemia; hypothyroidism may delay insulin turnover, requiring less insulin to treat hyperkalemia; monitor glucose levels carefully; dose adjustments may be necessary in patients with renal and hepatic dysfunction
Alkalinizing agents
These agents increase the pH, which results in a temporary potassium shift from the extracellular to the intracellular environment. These agents enhance the effectiveness of insulin in patients with acidemia.
Sodium bicarbonate (Neut)
Bicarbonate ion neutralizes hydrogen ions and raises urinary and blood pH. Onset of action within minutes, lasts approximately 15-30 min. Only likely to be efficacious if underlying acidosis present. Monitor blood pH to avoid excess alkalosis.
Use 8.4% solution in adults and children, 4.2% solution in infants.
Adult
1 mEq/kg slow IV push or continuous IV drip; not to exceed 50-100 mEq
Pediatric
Infants: 0.5 mEq/kg IV over 5-10 min; repeat in 10 min prn (only use 4.2% sol, not 8.4% sol used in older children and adults)
Children: 1-2 mEq/kg IV over 5-10 min; repeat in 10 min prn; monitor ABGs to avoid arterial pH >7.55
Urinary alkalinization induced by increased sodium bicarbonate concentrations may cause decreased levels of lithium, tetracyclines, chlorpropamide, methotrexate, and salicylates; increases levels of amphetamines, pseudoephedrine, flecainide, anorexiants, mecamylamine, ephedrine, quinidine, and quinine
Documented hypersensitivity; alkalosis; hypernatremia; hypocalcemia; severe pulmonary edema
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Use only to treat documented metabolic acidosis and hyperkalemia-induced cardiac arrest; can cause alkalosis, decreased plasma potassium, hypocalcemia, and hypernatremia; caution in electrolyte imbalances such as those seen in patients with CHF, cirrhosis, edema, corticosteroid use, or renal failure; avoid extravasation since can cause tissue necrosis
Beta2-adrenergic agonists
These agents promote cellular reuptake of potassium, possibly via the cyclic gAMP receptor cascade.
Albuterol (Ventolin, Proventil)
Adrenergic agonist that increases plasma insulin concentration, which may in turn help shift K+ into intracellular space. Lowers K+ level by 0.5-1.5 mEq/L. Can be very beneficial in patients with renal failure when fluid overload is concern. Onset of action is 30 min; duration of action is 2-3 h.
Adult
5 mg mixed with 3 mL isotonic saline via high-flow nebulizer q20min as tolerated
Pediatric
<1 year: 0.05-0.15 mg/kg/dose with 3 mL isotonic saline nebulized
1-5 years: 1.25-2.5 mg/dose with 3 mL isotonic saline nebulized
5-12 years: 2.5 mg/dose with 3 mL isotonic saline nebulized
>12 years: 2.5-5 mg/dose with 3 mL isotonic saline nebulized
Beta-adrenergic blockers antagonize effects; inhaled ipratropium may increase duration of bronchodilatation by albuterol; MAOIs, inhaled anesthetics, tricyclic antidepressants, and sympathomimetic agents may increase cardiovascular effects
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperthyroidism, diabetes mellitus, and cardiovascular disorders
Diuretics
These agents cause the loss of potassium through the kidney.
Furosemide (Lasix)
Effects are slow and frequently take an hour to begin. Lowers potassium level by inconsistent amount. Large doses may be needed in renal failure.
Adult
20-40 mg IV push in patients not already on this drug
Double daily PO dose as IV slow push in patients already taking this drug
Pediatric
Neonates: 0.5-2 mg/kg/dose IV; not to exceed 2 mg/kg/dose
Infants and children: 0.5-2 mg/kg/dose IV; if response unsatisfactory, may increase by 1-2 mg/kg q6-8h; not to exceed 6 mg/kg/dose
Metformin decreases concentrations; interferes with hypoglycemic effect of antidiabetic agents and antagonizes muscle-relaxing effect of tubocurarine; may increase auditory toxicity of aminoglycosides, and hearing loss of varying degrees may occur; may enhance anticoagulant activity of warfarin; may increase plasma levels and toxicity of lithium
Documented hypersensitivity; hepatic coma; anuria; severe electrolyte depletion
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Perform frequent serum electrolyte, CO2, glucose, creatinine, uric acid, calcium, and BUN determinations during first few months of therapy and periodically thereafter
Ethacrynic acid (Edecrin)
Increases excretion of water by interfering with chloride-binding cotransport system, which in turn inhibits sodium and chloride reabsorption in ascending loop of Henle and distal renal tubule.
Adult
Oral: 25-400 mg qd or divided bid
Intravenous: 0.5-1 mg/kg/dose, may repeat q8-12h; not to exceed 100 mg/dose
Pediatric
Oral: 1 mg/kg qd, may increase gradually (q3d), not to exceed 3 mg/kg/d
Intravenous: 1 mg/kg/dose, may repeat q8-12h
May cause additive ototoxicity with aminoglycosides or cisplatin; increases hypotensive effects of other diuretics or antihypertensives; may cause hypokalemia and increase toxicity of digoxin; may increase anticoagulant effect of warfarin; increases lithium serum levels
Documented hypersensitivity; hepatic coma; anuria; state of severe electrolyte depletion
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution with blood dyscrasias, liver, or kidney; monitor electrolytes, calcium, glucose, uric acid, CO2, creatinine, and BUN levels
Binding resins
These agents promote exchange of potassium for sodium in GI system.
Sodium polystyrene sulfonate (Kayexalate)
Exchanges Na+ for K+ and binds it in gut, primarily in large intestine, decreasing total body potassium. Onset of action after PO ranges from 2-12 h (longer when administered rectally). Lowers K+ over 1-2 h with duration of action of 4-6 h. Potassium level drops by approximately 0.5-1 mEq/L.
Multiple doses usually necessary.
Adult
25-50 g mixed with 100 mL of 20% sorbitol PO/PR
Pediatric
1 g/kg/dose PO/PR
Magnesium hydroxide, aluminum carbonate, or similar antacids or laxatives may cause systemic alkalosis
Documented hypersensitivity; hypernatremia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in patients who can be affected adversely by small increases in sodium loads, such as those with severe hypertension, severe congestive heart failure, or marked edema; constipation may occur, with possibility of fecal impaction—treat with 10-20 mL of 70% sorbitol every 2 h or as necessary to produce at least 1-2 watery stools daily
Electrolytes
These agents have been successfully used in the treatment of acute SLOW released oral potassium overdose.
Magnesium sulfate
Nutritional supplement in hyperalimentation; cofactor in enzyme systems involved in neurochemical transmission and muscular excitability. In adults, 60-180 mEq of potassium, 10-30 mEq of magnesium, and 10-40 mmol of phosphate per day may be necessary for optimum metabolic response. Give IV for acute suppression of torsade. Repeat doses are dependent upon continuing presence of patellar reflex and adequate respiratory function.
Adult
1-2 g IV over 30-60 s, repeat in 5-15 min if necessary; alternatively, 3-10 mg/min IV infusion
Pediatric
Not established
Concurrent use with nifedipine may cause hypotension and neuromuscular blockade; may increase neuromuscular blockade seen with aminoglycosides and potentiate neuromuscular blockade produced by tubocurarine, vecuronium, and succinylcholine; may increase CNS effects and toxicity of CNS depressants, betamethasone, and cardiotoxicity of ritodrine
Documented hypersensitivity; heart block; Addison disease; myocardial damage; severe hepatitis
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Magnesium may alter cardiac conduction leading to heart block in digitalized patients; respiratory rate, deep tendon reflex, and renal function should be monitored when electrolyte is administered parenterally; caution when administering magnesium dose since may produce significant hypotension or asystole; in overdose, calcium gluconate, 10-20 mL IV of 10% solution, can be given as antidote for clinically significant hypermagnesemia
More on Hyperkalemia |
| Overview: Hyperkalemia |
| Differential Diagnoses & Workup: Hyperkalemia |
 Treatment & Medication: Hyperkalemia |
| Follow-up: Hyperkalemia |
| Multimedia: Hyperkalemia |
| References |
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Further Reading
Keywords
hyperkalemia, high potassium level, electrolyte imbalance, sodium-potassium pump, potassium level greater than 5.5 mEq/L, acute renal failure, chronic renal failure, potassium-sparing diuretics, urinary obstruction, sickle cell disease, Addison disease, systemic lupus erythematosus, SLE, rhabdomyolysis, hemolysis, acidosis, acute digitalis toxicity, beta-blockers toxicity, succinylcholine toxicity, pseudohyperkalemia
