5th April 2024

Management

Initial management of a patient with hyperkalaemia requires an ABCDE approach. A 12 lead ECG should be performed looking for changes of hyperkalaemia and where serum potassium is > 6.0 mmol/L continuous monitoring of cardiac rhythm is required. 

Empirical treatment is advised where hyperkalaemia is suspected. This includes intravenous calcium to reduce the risk of arrhythmias and to stabilise cardiac myocytes. Initially, 30ml of 10% calcium gluconate may be given or 10 ml of 10% calcium chloride given over 10 minutes. 

Insulin with dextrose is administered to shift potassium into the intracellular space. Typically, 10 units of soluble insulin in 50ml of 50% dextrose is used. Alternatively, 125ml of 20% dextrose can be administered over 15 minutes. Nebulised salbutamol, a beta 2 receptor agonist, is also administered to shift potassium into the intracellular space. 

To facilitate renal excretion of potassium, any reversible renal disease should be treated, for example, stopping nephrotoxic drugs that cause intrinsic renal failure. This includes aminoglycoside antibiotics and amphotericin B, drugs which cause dose-related acute tubular necrosis. Fludrocortisone may be effective for managing chronic hyperkalaemia due to hypoaldosteronism. 

Gastrointestinal excretion is achieved by using potassium binders including calcium resonium, patiromer or sodium zirconium cyclosilicate. 

Refractory hyperkalaemia requires extracorporeal removal either by dialysis or hemofiltration.

Once hyperkalemia is treated, prevention of recurrence is achieved by:

• Dietary potassium restriction 
• Medication review of causative agents, i.e., changing spironolactone for a loop diuretic furosemide. 
• Correcting acidosis with sodium bicarbonate supplements 
• Potassium binding resins 
• Dialysis