HIPERKALEMIA

Author: David Garth, MD, Attending Physician, Department

of Emergency Medicine, Mary Washington Hospital

Hyperkalemia is a potentially lifethreatening illness that can be difficult

to diagnose because of a paucity of
distinctive signs and symptoms.

Hyperkalemia is defined as a potassium

level greater than 5.5 mEq/L. Ranges
are as follows:

5.5-6.0 mEq/L - Mild condition

6.1-7.0 mEq/L - Moderate condition
7.0 mEq/L - Severe condition

Hyperkalemia results from the

following:

Decreased or impaired potassium excretion

(Acute or chronic renal failure (most
common), potassium-sparing diuretics)
Additions of potassium into extracellular
space
(rhabdomyolysis, and hemolysis)
Transmembrane shifts
(Acidosis and acute digitalis toxicity)
Factitious or pseudohyperkalemia
(Laboratory error)

Symptoms of hyperkalemia

Gastrointestinal
(Nausea, vomiting, intestinal colic, and
diarrhea)
Neuromuscular
(Weakness to ascending paralysis to
respiratory failure)
Cardiovascular
(Cardiac arrhythmias and arrest)

Direct treatment

Stabilizing the myocardium,

Shifting potassium from the
extracellular environment to the
intracellular compartment
Promoting the renal excretion and GI
loss of potassium.

Calcium chloride or calcium

gluconate (Kalcinate)

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)

Antidotes
Insulin is administered with glucose to facilitate
the uptake of glucose into the cell, bringing
potassium with it.
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

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

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
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 50100 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

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

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

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

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Davey M. Calcium for hyperkalaemia in digoxin toxicity. Emerg
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Gennari FJ. Disorders of potassium homeostasis. Hypokalemia
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THANK YOU