Hyperkalemia Management

Classification and Initial Assessment

The American College of Cardiology recommends verifying the result is not pseudohyperkalemia from hemolysis, repeated fist clenching, or poor phlebotomy technique by repeating the measurement with proper technique or arterial sampling 2, 3
Severity classification is defined as: Mild (5.0-5.9 mEq/L), Moderate (6.0-6.4 mEq/L), and Severe (≥6.5 mEq/L) 2, 3

For acute hyperkalemia with ECG changes or potassium ≥6.5 mEq/L, immediately administer IV calcium gluconate (10%): 15-30 mL over 2-5 minutes to stabilize cardiac membranes, followed by insulin 10 units with 50 mL of 50% dextrose IV and nebulized albuterol 20 mg to shift potassium intracellularly 1, 2
Administer IV calcium immediately if potassium >6.5 mEq/L or any ECG changes are present 2
Dosing options for calcium include: Calcium gluconate (10%): 15-30 mL IV over 2-5 minutes, and Calcium chloride (10%): 5-10 mL IV over 2-5 minutes 2, 4

Review and adjust medications that may contribute to hyperkalemia, such as ACE inhibitors, ARBs, mineralocorticoid antagonists (MRAs), NSAIDs, and beta-blockers 2
Consider using newer FDA-approved potassium binders, such as patiromer and sodium zirconium cyclosilicate, for long-term management 2, 3, 4

Reassess potassium within 1 week of starting or escalating RAAS inhibitors, and check potassium 7-10 days after starting or increasing RAAS inhibitor doses 1, 2
High-risk patients, such as those with chronic kidney disease, heart failure, diabetes mellitus, or a history of hyperkalemia, require more frequent monitoring 2

Patients with cardiovascular disease on RAAS inhibitors require careful monitoring of potassium levels, with assessment 7-10 days after starting or increasing doses 2
Patients requiring thromboprophylaxis should maintain thromboprophylaxis in patients with mild or moderate hyperkalemia, and consider temporary suspension only in cases of severe hyperkalemia 3

Do not rely solely on ECG findings, as they are highly variable and less sensitive than laboratory tests 2
Remember that calcium, insulin, and beta-agonists do not remove potassium from the body, but only temporize 2
Ensure glucose is administered with insulin to prevent hypoglycemia 2
Do not use sodium bicarbonate in patients without metabolic acidosis 2