Management of Hyperkalaemia

• Exclude spurious hyperkalaemia (venous blood gas sample in emergency or seek advice from biochemistry) and check for ECG changes.
• Identify and treat underlying cause where possible:
  
  • Potassium supplements, ACE inhibitors, potassium-sparing diuretics and spironolactone should be discontinued.
  • Renal failure - consider referral to renal unit.
  • Hypovolaemia - consider volume expansion with IV sodium chloride 0.9%.
  • Severe acidosis (often associated with renal failure).
  • Hypoaldosteronism e.g. Addison's disease.
• If hyperkalaemia remains unexplained, more specialised investigation may be appropriate.  Advice may be obtained from your local Biochemistry Department.

1.  Confirmed plasma K⁺5.5 - 6.5 mmol/L

Calcium Resonium^R oral 15g three times daily (in water not fruit juice)

• Calcium Resonium will not lower potassium acutely.  It is only licensed for hyperkalaemia due to anuria or oliguria.
• Resonium A can be used if there is a risk of hypercalcaemia.
• Monitor plasma K⁺ < 5.5mmol/L

2.  Confirmed plasma K⁺ > 6.5 mmol/L and/or ECG changes

(Although treatment should not be dleayed, result should be confirmed):

10 ml calcium gluconate 10% - slow IV injection over 5 - 10 minutes given by a doctor (to antagonise the effect of potassium on the heart).

8 units soluble insulin (Actrapid^R) in 100ml IV glucose 20% vial over 30 minutes (to move potassium into the cells).  This may be repeated once and/or followed by an infusion of the same mixture 5 -10 ml/hour.

and/or

5-10mg nebulised salbutamol

• Calcium gluconate may be repeated after 5 minutes if ECG changes persist.
• Check plasma K⁺ and glucose one hour after glucose/insulin infusion.
• Glucose/insulin infusions should be repeated until plasma K⁺ < 6.5 mmol/L.
• Hyperosmolal glucose infusions should not be used in diabetic ketoacidosis.