17/07/2025
Management of hyperkalaemia focuses on three key aims:
1. Stabilise the myocardium: To prevent life-threatening arrhythmias, intravenous calcium gluconate (10 ml of 10% solution over 5–10 minutes) is administered if ECG changes are present or K+ ≥6.5 mmol/L. Calcium antagonises the membrane effects of hyperkalaemia but does not lower serum potassium.
2. Shift potassium intracellularly: Temporarily reduce serum potassium by promoting cellular uptake:
Insulin with glucose: 10 units of short-acting insulin IV with 25 g glucose to prevent hypoglycaemia; onset within 15–30 minutes.
Beta-2 agonists: Nebulised salbutamol (10–20 mg) can be used adjunctively.
Sodium bicarbonate: Consider if metabolic acidosis is present; effect is variable.
3. Remove potassium from the body: Definitive treatment to reduce total body potassium:
Loop diuretics (if renal function allows) to promote renal excretion.
Sodium polystyrene sulfonate (resonium) – limited evidence and slower onset.
Dialysis – indicated in severe/refractory cases, especially with renal failure or fluid overload.
Additional considerations:
Identify and treat precipitating causes such as acute kidney injury, tissue breakdown, or medication-induced hyperkalaemia (e.g., ACE inhibitors, ARBs, potassium-sparing diuretics).
Continuous ECG monitoring is essential until potassium normalises and ECG changes resolve.
ECG changes progression:
Peaked T waves (earliest sign)
Flattening/loss of P waves
Widening of QRS complexes
Sine wave pattern preceding ventricular fibrillation or asystole
The presence of ECG changes mandates urgent treatment regardless of serum potassium level.
