Hyperkalemia

Author: Michelle Lin, MD

Updated: 3/12/2010

Potassium regulation

Cardiac: Peaked T, wide QRS, loss of P wave, sine wave; although ventricular fibrillation may be first cardiac manifestation
Neuromuscular: Paresthesias,weakness
Metabolic: Mild hyperchloremic metabolic acidosis

Calcium: Reduces threshold potential in myocytes; check to be sure not on digoxin
- Medication: Ca gluconate 10%
- Dose: 10 mL over 10 min
- Onset: Immediate
- Duration: 30-60 min
- Complication: Hypercalcemia
Hypertonic saline: Only for severe hyponatremia in setting of hyperkalemia
- Medication: Hypertonic 3% NaCl
- Dose: 50 mL IV push
- Onset: Immediate
- Duration: Unknown
- Complication: Volume overload, hypertonicity

Insulin: Drives K intracellularly and drops serum K level by 0.6 mmol/L
- Medication: Insulin
- Dose: 10 units IVP with D50W
- Onset: 20 min
- Duration: 4-6 hr
- Complication: Hypoglycemia
Beta-agonist: Drives K intracellularly and 10 mg albuterol drops serum K level by 0.6 mmol/L (20 mg --> K drops by 1 mmol/L); effective in only 60% of patients
- Medication: Albuterol nebulized
- Dose: 20 mg/4 cc over 10 min
- Onset: 30 min
- Duration: 2 hrs
- Complication: Tachycardia

Bicarbonate: drives K out at distal nephron; best as infusion x 4-6 hrs
- Medication: Sodium bicarbonate
- Dose: 150 mmol/L IV
- Onset: Hours
- Duration: Infusion
- Complication: Metabolic alkalosis, volume overload
Loop diuretic
- Medication: Furosemide
- Dose: 40-80 mg IV
- Onset: 15 min
- Duration: 2-3 hr
- Complication: Volume depletion
Exchange resin (sodium polystyrene sulfonate): Of minimal to no benefit.
- Case reports of colonic necrosis
- Medication: Kayexalate
- Dose: 15-30 g
- Onset: >2 hrs
- Duration: 4-6 hr
- Complication: Variable efficacy
Hemodialysis
- Onset: immediate
- Duration: 3 hours
- Complication: arrhythmias

Weisberg LS. Management of severe hyperkalemia. Crit Care Med. 2008; 36:3246-51. [PubMed]