Acute Hyperkalemia Management - Hospitalist

Algorithm Steps

1. ▶

   Start

   Hyperkalemia Detected

   K+ >5.5 mEq/L

   1. ●

      Action

      Confirm True Hyperkalemia

      Rule out pseudohyperkalemia

      • PSEUDOHYPERKALEMIA causes:
      • - Hemolyzed sample
      • - Prolonged tourniquet
      • - Fist clenching
      • - Thrombocytosis/leukocytosis
      • IF DOUBT: Repeat stat, no tourniquet
      • Check for consistency with clinical picture
      1. ⚠

         Warning

         Get STAT ECG

         Assess cardiac toxicity

         • ECG CHANGES (progressive):
         • 1. Peaked T waves (earliest)
         • 2. PR prolongation
         • 3. QRS widening
         • 4. Loss of P waves
         • 5. Sine wave pattern
         • 6. VF/asystole
         • ANY ECG CHANGES = EMERGENCY
         1. ◆

            Decision

            Severity Assessment

            Determines urgency

            • MILD: K+ 5.5-6.0
            • MODERATE: K+ 6.0-6.5
            • SEVERE: K+ >6.5 OR ANY ECG changes
            1. ⚠

               Warning

               SEVERE: Emergency Treatment

               K+ >6.5 or ECG changes

               • 1. CALCIUM GLUCONATE 10%:
               • - 1-2 grams (10-20 mL) IV over 2-3 min
               • - Cardiac membrane stabilization
               • - Effect immediate, lasts 30-60 min
               • - Can repeat in 5 min if needed
               • 2. SHIFT K+ INTRACELLULAR (see next)
               • 3. REMOVE K+ from body
               • 4. CARDIOLOGY/NEPHROLOGY stat
               1. ●

                  Action

                  Shift K+ Intracellularly

                  Temporary measures

                  • INSULIN + DEXTROSE:
                  • - Regular insulin 10 units IV
                  • - D50 25g (50 mL) IV push
                  • - Onset 15-30 min, lasts 4-6 hrs
                  • - Monitor glucose closely
                  • ALBUTEROL:
                  • - 10-20 mg nebulized
                  • - Onset 30 min
                  • - Avoid if tachyarrhythmia
                  • SODIUM BICARBONATE:
                  • - Only if metabolic acidosis
                  • - 50-100 mEq IV
                  • - Less effective alone
                  1. ●

                     Action

                     Remove K+ from Body

                     Definitive treatment

                     • DIURETICS (if kidney function):
                     • - Furosemide 40-80 mg IV
                     • - Increases urinary K+ excretion
                     • GI BINDERS:
                     • - Patiromer (Veltassa) 8.4g PO
                     • - SZC (Lokelma) 10g PO x 3
                     • - Onset 1-6 hours
                     • - Kayexalate: Less preferred (GI issues)
                     • DIALYSIS:
                     • - Most effective for severe/refractory
                     • - Removes 25-50 mEq/hr
                     1. ●

                        Action

                        Monitoring

                        Reassess frequently

                        • SEVERE: Check K+ q1-2h
                        • MODERATE: Check K+ q4-6h
                        • MILD: Check K+ q6-12h
                        • Repeat ECG if worsening
                        • Monitor glucose after insulin
                        • Watch for rebound hyperkalemia
                        1. ✓

                           Outcome

                           Outcomes

                           Goals

                           • Target K+ <5.5 mEq/L
                           • Resolution of ECG changes
                           • Address underlying cause
                           • Long-term management plan
                           • Education on K+ restriction
            2. ●

               Action

               Mild-Moderate: Address Causes

               K+ 5.5-6.5, no ECG changes

               • STOP K+ intake:
               • - Hold K+ supplements
               • - Low K+ diet
               • REVIEW MEDICATIONS:
               • - ACEi/ARB
               • - K+-sparing diuretics
               • - NSAIDs
               • - Trimethoprim
               • - Beta-blockers
               • TREAT UNDERLYING:
               • - AKI, metabolic acidosis
               • - Adrenal insufficiency