Pediatric Hyperkalemia Medication

Updated: Dec 30, 2019
  • Author: Michael J Verive, MD, FAAP; Chief Editor: Timothy E Corden, MD  more...
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Medication Summary

Treatment for severe hyperkalemia consists of 3 steps: (1) immediate stabilization of the myocardial cell membrane, (2) rapidly shifting potassium intracellularly, and (3) enhancing total body potassium elimination (see Medical Care).

In addition, all sources of exogenous potassium should be immediately discontinued; including intravenous (IV) and oral (PO) potassium supplementation, total parenteral nutrition, and any blood product transfusion. Drugs associated with hyperkalemia should also be discontinued.

Albuterol and other beta-adrenergic agents induce the intracellular movement of potassium via the stimulation of the sodium/potassium–adenosine triphosphate (Na+/K+ -ATP) pump. Studies have shown that IV salbutamol (not available in the United States) is highly effective in lowering serum potassium levels. Some studies in adults and children using nebulized albuterol indicate that this method of therapy is effective in lowering serum potassium levels. However, peak response is unclear; therefore, it has not been established as the first line of therapy in severe hyperkalemia.


Myocardium stabilizers

Class Summary

Calcium does not lower serum potassium levels. It is primarily used to protect the myocardium from the deleterious effects of hyperkalemia (ie, arrhythmias) by antagonizing the membrane actions of potassium.

Calcium chloride

IV calcium is indicated in all cases of severe hyperkalemia (ie, >7 mEq/L), especially when accompanied by ECG changes. Calcium chloride contains about 3 times more elemental calcium than an equal volume of calcium gluconate. Therefore, when hyperkalemia is accompanied by hemodynamic compromise, calcium chloride is preferred over calcium gluconate.

Administration of calcium should be accompanied by the use of other therapies that actually help lower the K+ serum levels.

Other calcium salts (eg, glubionate, gluceptate) have even less elemental calcium than calcium gluconate and are generally not recommended for therapy of hyperkalemia. Calcium chloride 1 g = 270 mg (13.5 mEq) of elemental calcium.

Calcium gluconate 1 g = 90 mg (4.5 mEq) of elemental calcium.


Intracellular transporters

Class Summary

Regular insulin and glucose cause a transcellular shift of potassium into muscle cells, thereby temporarily lowering K+ serum levels.

Insulin and dextrose, IV

Regular insulin presence results in intracellular movement of glucose, followed by K+ entry into muscle cells. Although effect is almost immediate, it is temporary, and, therefore, should be followed by therapy that actually enhances potassium clearance (eg, sodium polystyrene sulfonate).


Alkalinizing agents

Class Summary

Sodium bicarbonate IV is used as a buffer that breaks down to water and carbon dioxide after binding free hydrogen ions.

Sodium bicarbonate

IV infusion helps shift K+ into cells, further lowering serum K+ levels. Can be considered in treatment of hyperkalemia even in absence of metabolic acidosis. Also increases sodium delivery to the kidney, which assists in potassium excretion.


Exchange resins

Class Summary

Sodium polystyrene sulfonate is an exchange resin that can be used to treat mild-to-moderate hyperkalemia. Each mEq of potassium is exchanged for 1 mEq of sodium.

Sodium polystyrene sulfonate (Kayexalate)

Exchanges sodium for potassium and binds it in the gut, primarily in large intestine, and decreases total body potassium. Onset of action after PO administration ranges from 2-12 hours and is longer when administered PR.

Do not use as a first-line therapy for severe life-threatening hyperkalemia. Use in second stage of therapy to reduce total body potassium.