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Management of mild-moderate hyperkalaemia

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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Mild-moderate hyperkalaemia is plasma potassium in the range 5.5-6.4 mmol/l.

Identify the cause of hyperkalaemia and treat as appropriate.

The management of the hyperkalaemic patient involves:

  • ECG
    • all patients with a serum potassium value ≥ 6.0 mmol/L should have an urgent 12-lead ECG performed and assessed for changes of hyperkalaemia
  • treatment of hyperkalaemia (1)
    • protect the heart: calcium gluconate, calcium chloride
      • equivalent dose (6.8 mmol) of IV calcium is given to patients with hyperkalaemia in the presence of ECG changes at a dose and rate of 30ml 10% Calcium Gluconate over 10 minutes OR 10ml 10% Calcium Chloride over 5 minutes guided by the clinical setting
      • IV Calcium Chloride is the preferred calcium salt in resuscitation (cardiac arrest or peri-arrest) and IV Calcium Gluconate should be used for all other patients in the presence of ECG signs of hyperkalaemia
    • shift potassium into cells: insulin-glucose, salbutamol
      • insulin-glucose (10 units soluble insulin in 25g glucose) by intravenous infusion may be used to treat moderate (potassium 6.0-6.4 mmol/L) hyperkalaemia
      • nebulised salbutamol 10-20mg may be used as adjuvant therapy for moderate (potassium 6.0-6.4 mmol/L) hyperkalaemia
    • remove potassium from body: sodium zirconium cyclosilicate, patiromer
      • loop diuretics (furosemide at a dose of 40 to 80 mg intravenously) is useful in removing potassium load from the system when renal function is preserved
      • use patiromer as an option in emergency management of acute hyperkalemia (serum K+ ≥ 6.0 mmol/l)
      • cation exchange resins
        • According to UK Kidney Associatioon, calcium resonium (calcium polystyrene sulfonate/ CPS, K-bind powder) should no longer be routinely used in the management of acute hyperkalaemia (1)
        • Based on European Resuscitation Council, consider oral administration of a potassium binder, e.g. Sodium Zirconium Cyclosilicate (SZC), or a cation exchange resin e.g., Patiromer or calcium resonium according to local practice (2)
  • address cause of hyperkalaemia and correct it
  • avoid potassium sparing or retaining drugs e.g. potassium sparing diuretics (e.g. frumil), beta-blockers, ACE inhibitors, NSAIDS, aspirin
  • a low potassium diet
  • haemodialysis: consider if oliguric; haemodialysis is more efficient than peritoneal dialysis at removing potassium (1,2)

Reference:

(1) UK Kidney Association. Clinical Practice Guidelines - Management of Hyperkalaemia in Adults. October 2023.

(2) Lott C et. al. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation. 2021 Apr;161:152-219. doi: 10.1016/j.resuscitation.2021.02.011.


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