For mild elevation (5 to 6 mEq/L), remove potassium from the body with Furosemide and Kayexalate.
For moderate elevation (6 to 7 mEq/L), shift potassium intracellularly with Glucose plus insulin, Sodium bicarbonate, and Nebulized albuterol
For severe elevation (>7 mEq/L with toxic ECG changes), you need to shift potassium into the cells and eliminate potassium from the body. Therapies that shift potassium will act rapidly but they are temporary; if the serum potassium rebounds you may need to repeat those therapies. In order of priority, treatment includes the following:
-Shift potassium into cells: Sodium bicarbonate; Glucose PLUS insulin; Nebulized albuterol.
-Promote potassium excretion: Furosemide, Kayexalate, and dialysis.
| Treatment | Onset | Comments |
| Stabilize Cell Membrane | ||
| Calcium gluconate 1000 mg (10 mL of a 10% solution) IV infused over 2-3 minutes OR *Calcium chloride 500 to 1000 mg (5 to 10 mL of a 10% solution), also infused over 2-3 minutes |
< 3 min. | Stabilizes cell membrane of heart. The effect is transient, lasting 30-60 minutes. Constant cardiac monitoring is required. Repeat dose after five minutes if the ECG changes persist or recur. Calcium gluconate is generally preferred because calcium chloride may cause local irritation at the injection site. |
| Shift potassium into cells | ||
| Glucose plus insulin -Regular Insulin 10 U IV bolus, followed immediately by -50 mL of D50 W (25 g of glucose) IV |
15-30 min. | Shifts K into cells. The effect is transient, lasting 30-60 minutes. To avoid hypoglycemia (which is common) after giving the insulin bolus, start the patient on an infusion of 10 % dextrose at 50 to 75 mL/hour and closely monitor of blood glucose levels every hour for five to six hours. |
| Sodium bicarbonate 50 mEq IV over 5 minutes | -Exchanges K for H+ in cells. -The effect is also transient, lasting about 60 minutes. -Give especially if the patient is acidemic. -Maybe less effective for patients with ESRD |
|
| Beta-2 agonist Albuterol 10 to 20mg in 4ml of saline given nebulized over 10 minutes. This is 4 to 8 times the dose used for bronchodilation. |
-Drives K into cells. -The effect is transient as well and may last 2 hours. |
|
| Decrease total body Potassium / Promote potassium excretion | ||
| Kayexalate 15 to 30 g PO / PR (retention enema) | 1-2h | -Decreases total body K by exchanging Na for K in the GI tract. |
| Diuretics Furosemide 40 to 80 mg IV |
30 min | -Decreases total body K via renal excretion. |
| Hemodialysis | -Decreases total body K | |
Note: Intravenous calcium gluconate solution does not lower serum potassium. It stabilizes the cell membranes and is indicated to prevent arrhythmias in patients with hyperkalemia and EKG changes.
D50 W = 50 % dextrose
Calcium chloride contains three times the concentration of elemental calcium compared with calcium gluconate (13.6 versus 4.6 meq in 10 mL of a 10 percent solution. Calcium gluconate is the preferred drug because calcium chloride often causes local irritation at the injection site.
*** Don’t use Kayexalate on a long-term basis because cation resins like Kayexalate can cause severe side effects, particularly intestinal necrosis, which may be fatal.
References
http://circ.ahajournals.org/content/112/24_suppl/IV-121