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Pediatric Hyperkalemia Treatment & Management

  • Author: Michael J Verive, MD, FAAP; Chief Editor: Timothy E Corden, MD  more...
Updated: Jan 08, 2016

Medical Care

Hyperkalemia, by itself, is not a disease and is generally the result of diseases such as congenital adrenal hyperplasia, acute renal failure, rhabdomyolysis, or tumor lysis syndrome.

Hyperkalemia is a true medical emergency, with three primary goals of immediate management (in addition to prompt discontinuation of potassium-containing fluids and medications that lead to hyperkalemia), as summarized below.[17, 18]

Goals of management

Stabilization of myocardial cell membrane

Stabilize the myocardial cell membrane to prevent lethal cardiac arrhythmia (and to gain time to shift potassium intracellularly and enhance potassium elimination - Intravenous (IV) calcium chloride or gluconate

Enhancement of cellular uptake of potassium

This achieved with the following:

  • Sodium bicarbonate IV
  • Regular insulin and glucose IV
  • Beta-adrenergic agents, such as albuterol (used to manage hyperkalemia with variable results), terbutaline, dobutamine

Enhancement of total body potassium elimination

This achieved with the following:

  • Sodium polystyrene sulfonate (Kayexalate) orally (PO)/rectally (PR)
  • Furosemide (only if renal function is maintained)
  • Emergent hemodialysis

Clinical management

Arrhythmias due to hyperkalemia are very difficult to treat with defibrillation, epinephrine, or antiarrhythmic drugs without emergently lowering the serum potassium level.

After initial stabilization, further workup should be performed to diagnose the etiology of the hyperkalemia. Children with acquired Addison disease or other primary adrenal disease require stress-dose steroid supplementation and children with hypoaldosteronism require mineralocorticoid supplementation.

Emergent hemodialysis is sometimes necessary to treat severe symptomatic hyperkalemia that is resistant to drug therapy, particularly in patients without adequate renal function.

Even in patients with severe hyperkalemia and a high gradient, peritoneal dialysis (PD) is not as efficient as hemodialysis in the removal of potassium. Rates of removal with PD are almost equal to the removal rate using sodium polystyrene sulfonate (Kayexalate).

Continuous arteriovenous hemofiltration with dialysis (CAVHD) or continuous veno-venous hemofiltration with dialysis (CVVHD) have also been used to remove potassium. However, potassium removal with these methods is similar to that of PD and sodium polystyrene sulfonate (Kayexalate). CVVHD or CAVHD may be used for long-term removal of potassium, but in acute, severe, life-threatening hyperkalemia unresponsive to medical therapy, hemodialysis remains the procedure of choice.

Following emergent management and stabilization of hyperkalemia, the patient should be hospitalized, and further workup should be initiated to determine the inciting cause and to prevent recurrence.


Patients with acute life-threatening hyperkalemia should receive care in a pediatric or neonatal ICU capable of providing emergent hemodialysis.

Any child who develops hyperkalemia as a result of renal failure should be referred to a pediatric nephrologist for continuing care.


Potassium intake must be closely monitored (and possibly restricted) in patients with renal failure.


Surgical Care

Tumor debulking may be considered to decrease the risk of hyperkalemia from tumor lysis syndrome for solid tumors.[19]



Consultations with the following specialists may be necessary in cases of hyperkalemia that result from certain conditions or disease states:

  • Pediatric intensivist or neonatologist - Management of life-threatening hyperkalemia (hyperkalemia with ECG changes)
  • Nephrologist - Hyperkalemia associated with renal failure
  • Hematologist/oncologist - Hyperkalemia resulting from tumor lysis syndrome
  • Social services specialist - Children who develop hyperkalemia following unintentional ingestions or poisonings
  • Nutritional support specialist - Particularly for patients whose hyperkalemia is caused by renal failure, which requires close regulation of potassium and sodium intake
  • Endocrinologist - Patients with suspected mineralocorticoid abnormalities such as congenital adrenal hyperplasia
Contributor Information and Disclosures

Michael J Verive, MD, FAAP Pediatrician, UP Health System Portage

Michael J Verive, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, Society for Pediatric Sedation

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Barry J Evans, MD Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Timothy E Corden, MD Associate Professor of Pediatrics, Co-Director, Policy Core, Injury Research Center, Medical College of Wisconsin; Associate Director, PICU, Children's Hospital of Wisconsin

Timothy E Corden, MD is a member of the following medical societies: American Academy of Pediatrics, Phi Beta Kappa, Society of Critical Care Medicine, Wisconsin Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

G Patricia Cantwell, MD, FCCM Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami Leonard M Miller School of Medicine/ Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Director, Palliative Care Team, Holtz Children's Hospital; Medical Manager, FEMA, South Florida Urban Search and Rescue, Task Force 2

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

  1. Shaffer SG, Kilbride HW, Hayen LK, Meade VM, Warady BA. Hyperkalemia in very low birth weight infants. J Pediatr. 1992 Aug. 121(2):275-9. [Medline].

  2. Chhapola V, Kanwal SK, Sharma R, Kumar V. A comparative study on reliability of point of care sodium and potassium estimation in a pediatric intensive care unit. Indian J Pediatr. 2013 Sep. 80(9):731-5. [Medline].

  3. Bhananker SM, Ramamoorthy C, Geiduschek JM, et al. Anesthesia-related cardiac arrest in children: update from the Pediatric Perioperative Cardiac Arrest Registry. Anesth Analg. 2007 Aug. 105(2):344-50. [Medline].

  4. Schweiger B, Moriarty MW, Cadnapaphornchai MA. Case report: severe neonatal hyperkalemia due to pseudohypoaldosteronism type 1. Curr Opin Pediatr. 2009 Apr. 21(2):269-71. [Medline].

  5. Papaioannou V, Dragoumanis C, Theodorou V, Pneumatikos I. The propofol infusion 'syndrome' in intensive care unit: from pathophysiology to prophylaxis and treatment. Acta Anaesthesiol Belg. 2008. 59(2):79-86. [Medline].

  6. Mattu A, Brady WJ, Robinson DA. Electrocardiographic manifestations of hyperkalemia. Am J Emerg Med. 2000 Oct. 18(6):721-9. [Medline].

  7. Gurnaney H, Brown A, Litman RS. Malignant hyperthermia and muscular dystrophies. Anesth Analg. 2009 Oct. 109(4):1043-8. [Medline].

  8. Schweiger B, Moriarty MW, Cadnapaphornchai MA. Case report: severe neonatal hyperkalemia due to pseudohypoaldosteronism type 1. Curr Opin Pediatr. 2009 Apr. 21(2):269-71. [Medline].

  9. Lorenz JM, Kleinman LI, Markarian K. Potassium metabolism in extremely low birth weight infants in the first week of life. J Pediatr. 1997 Jul. 131(1 Pt 1):81-6. [Medline].

  10. Lee AC, Reduque LL, Luban NL, Ness PM, Anton B, Heitmiller ES. Transfusion-associated hyperkalemic cardiac arrest in pediatric patients receiving massive transfusion. Transfusion. 2014 Jan. 54 (1):244-54. [Medline].

  11. Sanchez-Carpintero I, Ruiz-Rodriguez R, Lopez-Gutierrez JC. [Propranolol in the treatment of infantile hemangioma: clinical effectiveness, risks, and recommendations]. Actas Dermosifiliogr. 2011 Dec. 102(10):766-79. [Medline].

  12. Pavlakovic H, Kietz S, Lauerer P, Zutt M, Lakomek M. Hyperkalemia complicating propranolol treatment of an infantile hemangioma. Pediatrics. 2010 Dec. 126(6):e1589-93. [Medline].

  13. Cummings CC, McIvor ME. Fluoride-induced hyperkalemia: the role of Ca2+-dependent K+ channels. Am J Emerg Med. 1988 Jan. 6(1):1-3. [Medline].

  14. Suzuki H, Terai M, Hamada H, Honda T, Suenaga T, Takeuchi T, et al. Cyclosporin A treatment for Kawasaki disease refractory to initial and additional intravenous immunoglobulin. Pediatr Infect Dis J. 2011 Oct. 30(10):871-6. [Medline].

  15. Nowicki TS, Bjornard K, Kudlowitz D, Sandoval C, Jayabose S. Early recognition of renal toxicity of high-dose methotrexate therapy: a case report. J Pediatr Hematol Oncol. 2008 Dec. 30(12):950-2. [Medline].

  16. Piotrowski AJ, Fendler WM. Hyperkalemia and cardiac arrest following succinylcholine administration in a 16-year-old boy with acute nonlymphoblastic leukemia and sepsis. Pediatr Crit Care Med. 2007 Mar. 8(2):183-5. [Medline].

  17. [Guideline] Advanced life support. In: 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 2005 Nov 29;112(22 Suppl):III25-54. [Full Text].

  18. Chime NO, Luo X, McNamara L, Nishisaki A, Hunt EA. A survey demonstrating lack of consensus on the sequence of medications for treatment of hyperkalemia among pediatric critical care providers. Pediatr Crit Care Med. 2015 Jun. 16 (5):404-9. [Medline].

  19. Bercovitz RS, Greffe BS, Hunger SP. Acute tumor lysis syndrome in a 7-month-old with hepatoblastoma. Curr Opin Pediatr. 2010 Feb. 22(1):113-6. [Medline].

  20. Behrman R, Kliegman R, Jenson H. Nelson Textbook of Pediatrics. 17th Ed. Philadelphia, PA: WB Saunders; 2004.

  21. Brenner B. Brenner & Rector's The Kidney. 7th ed. St Louis, MO: WB Saunders; 2004.

  22. Finberg L, Kravath R, Hellerstein S. Potassium. Water and Electrolytes in Pediatrics: Physiology, Pathophysiology, and Treatment. Philadelphia, PA: WB Saunders; 1993. 70-1.

  23. Goldfrank LR, ed. Goldfrank's Toxicologic Emergencies. 6th ed. Stanford, CT: Appleton & Lange; 1998.

  24. Kokko, JP, Tannen RL. Potassium disorders. Fluids and Electrolytes. Philadelphia, PA: WB Saunders; 1990. 195-300.

  25. Lieh-Lai, M, Asi-Bautista, M, Ling-McGeorge, K. Hyperkalemia. Pediatric Acute Care Handbook. Philadelphia, PA: Lippincott, Williams, & Wilkins; 1995.

  26. Maxwell MH, Kleeman CR. Maxwell and Kleeman's Clinical Disorders of Fluid and Electrolyte Metabolism. 5th Ed. New York, NY: McGraw-Hill; 1994.

  27. Odegard KC, DiNardo JA, Kussman BD, et al. The frequency of anesthesia-related cardiac arrests in patients with congenital heart disease undergoing cardiac surgery. Anesth Analg. 2007 Aug. 105(2):335-43. [Medline].

Peaked T waves.
Sinusoidal wave.
Hyperkalemia diagnosis and treatment flow chart.
Table. Select Factors Affecting Plasma Potassium
Factor Effect on Plasma K+ Mechanism
Aldosterone Decrease Increases sodium resorption, and increases K+ excretion
Insulin Decrease Stimulates K+ entry into cells by increasing sodium efflux (energy-dependent process)
Beta-adrenergic agents Decrease Increases skeletal muscle uptake of K+
Alpha-adrenergic agents Increase Impairs cellular K+ uptake
Acidosis (decreased pH) Increase Impairs cellular K+ uptake
Alkalosis (increased pH) Decrease Enhances cellular K+ uptake
Cell damage Increase Intracellular K+ release
Succinylcholine Increase Cell membrane depolarization
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