14/06/2026
The standard 3-step approach to treating hyperkalemia (elevated serum potassium, typically >5.5 mEq/L, with urgency increasing above 6.0–6.5 mEq/L or with ECG changes) focuses on:
1. Stabilizing the cardiac membrane (protect the heart).
2. Shifting potassium intracellularly (temporarily lower serum levels).
3. Eliminating potassium from the body (definitive removal). 
These steps are often addressed simultaneously in severe cases, alongside stopping all potassium intake/sources (supplements, IV fluids with K+, certain meds like ACEi/ARBs, spironolactone, NSAIDs, etc.) and addressing reversible causes (e.g., AKI, acidosis, rhabdomyolysis). Treatment is guided by severity, ECG findings (peaked T waves, widened QRS, etc.), symptoms, and kidney function. Always monitor ECG, repeat labs, and involve specialists (e.g., nephrology) as needed. 
Step 1: Membrane Stabilization (Protect the Heart)
• Primary agent: Intravenous calcium (does not lower K+ but antagonizes its cardiac effects).
• Calcium gluconate: Preferred in peripheral IV — 10 mL of 10% solution (1 g) over 2–5 minutes. Can repeat if ECG changes persist (after 5–10 min).
• Calcium chloride: 1 g (10 mL of 10%) over 2–5 minutes via central line (more irritating).
• Onset: 1–3 minutes; duration ~30–60 minutes.
• Indications: ECG changes, K+ >6.5–7 mEq/L, or symptomatic (arrhythmias, muscle weakness). Use even if ECG is normal in very severe cases. 
• Cautions: Avoid in digoxin toxicity (can worsen). Monitor for hypercalcemia.
This is the first priority in life-threatening hyperkalemia. 
Step 2: Shift Potassium Intracellularly (Temporary Redistribution)
This rapidly lowers serum K+ by driving it into cells (effects last 4–6 hours; rebound possible).
• Insulin + Glucose (most reliable):
• Regular insulin: 10 units IV bolus.
• With ~25–50 g dextrose (e.g., 1 amp D50W or D10W infusion) to prevent hypoglycemia.
• Onset: 15–30 min; peak 30–60 min; duration 4–6 hours.
• Monitor glucose hourly.
• Beta-2 agonists (add-on or alternative):
• Nebulized albuterol: 10–20 mg (higher dose than for asthma).
• Or subcutaneous terbutaline.
• Onset: ~30 min; additive to insulin.
• Other options (less routine):
• Sodium bicarbonate (if metabolic acidosis): 50–100 mEq IV.
• Avoid routine use without acidosis due to limited evidence and risks. 
Re-check K+ in 1–2 hours. These are bridging measures.
Step 3: Potassium Elimination/Removal (Definitive Therapy)
• Loop diuretics (e.g., furosemide 40–80 mg IV): If adequate urine output and eGFR >30–45; promotes urinary K+ excretion. Combine with IV fluids if volume-depleted (but avoid fluid overload). 
• Potassium binders:
• Newer agents preferred: Sodium zirconium cyclosilicate (SZC/Lokelma) or patiromer (Veltassa) — faster and better tolerated.
• Older: Sodium polystyrene sulfonate (Kayexalate) — slower, more GI side effects; use cautiously.
• Dialysis (hemodialysis): Most effective for rapid removal, especially in severe cases (K+ >6.5–7 with poor response, kidney failure, volume overload, or refractory hyperkalemia). Arrange urgently if needed.

• Other: Treat underlying issues (e.g., correct acidosis, stop offending drugs, manage constipation).
Monitoring & Follow-up: Continuous ECG, serial K+ levels (q1–2h initially), glucose, renal function. Hospitalize severe cases. For chronic/outpatient management, focus on diet (limit high-bioavailable K+ sources), meds optimization, and binders. 
