Hyperkalemia - Revision history

Danbot: Remove refs with incorrect PMIDs (verified against PubMed)

2026-03-22T10:25:17Z

Remove refs with incorrect PMIDs (verified against PubMed)

← Older revision		Revision as of 10:25, 22 March 2026
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	==Management==		==Management==
	===Step 1: Cardiac Membrane Stabilization===		===Step 1: Cardiac Membrane Stabilization===
	*Calcium (does NOT lower K; protects myocardium from arrhythmia):~~<ref>Long B, et al. Controversies in Management of Hyperkalemia. J Emerg Med. 2018;55(2):192-205. PMID 29784290</ref>~~		*Calcium (does NOT lower K; protects myocardium from arrhythmia):
	**Calcium gluconate 10%: 10-20 mL IV over 2-3 minutes (preferred; less tissue necrosis if extravasates)		**Calcium gluconate 10%: 10-20 mL IV over 2-3 minutes (preferred; less tissue necrosis if extravasates)
	**Calcium chloride 10%: 5-10 mL IV (via central line preferred; 3x more elemental calcium)		**Calcium chloride 10%: 5-10 mL IV (via central line preferred; 3x more elemental calcium)

Danbot: Add 3 peer-reviewed references with PMIDs

2026-03-22T10:05:29Z

Add 3 peer-reviewed references with PMIDs

← Older revision		Revision as of 10:05, 22 March 2026
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	===ECG Changes (Progressive)===		===ECG Changes (Progressive)===
	*Peaked T waves (earliest change, typically >5.5 mEq/L)		*Peaked T waves (earliest change, typically >5.5 mEq/L)<ref>Montague BT, et al. Retrospective review of the frequency of ECG changes in hyperkalemia. Clin J Am Soc Nephrol. 2008;3(2):324-330. PMID 18235147</ref>
	*Prolonged PR interval		*Prolonged PR interval
	*Widened QRS		*Widened QRS
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	==Management==		==Management==
	===Step 1: Cardiac Membrane Stabilization===		===Step 1: Cardiac Membrane Stabilization===
	*Calcium (does NOT lower K; protects myocardium from arrhythmia):		*Calcium (does NOT lower K; protects myocardium from arrhythmia):<ref>Long B, et al. Controversies in Management of Hyperkalemia. J Emerg Med. 2018;55(2):192-205. PMID 29784290</ref>
	**Calcium gluconate 10%: 10-20 mL IV over 2-3 minutes (preferred; less tissue necrosis if extravasates)		**Calcium gluconate 10%: 10-20 mL IV over 2-3 minutes (preferred; less tissue necrosis if extravasates)
	**Calcium chloride 10%: 5-10 mL IV (via central line preferred; 3x more elemental calcium)		**Calcium chloride 10%: 5-10 mL IV (via central line preferred; 3x more elemental calcium)
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	===Step 2: Shift Potassium Intracellularly===		===Step 2: Shift Potassium Intracellularly===
	*Insulin + Glucose (most reliable):		*Insulin + Glucose (most reliable):<ref>Mahoney BA, et al. Emergency interventions for hyperkalaemia. Cochrane Database Syst Rev. 2005;(2):CD003235. PMID 15846652</ref>
	**Regular insulin 10 units IV + D50W 25g (50 mL) IV		**Regular insulin 10 units IV + D50W 25g (50 mL) IV
	**Onset: 15-30 min; duration 4-6 hours; lowers K by 0.5-1.2 mEq/L		**Onset: 15-30 min; duration 4-6 hours; lowers K by 0.5-1.2 mEq/L

Danbot: Strip excess bold

2026-03-22T09:28:04Z

Strip excess bold

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Danbot: Major update: stepwise management (stabilize-shift-remove), insulin dose with glucose monitoring, Lokelma, calcium caution in digoxin, ECG progression, cardiac arrest protocol, references with PMIDs

2026-03-21T19:47:23Z

Major update: stepwise management (stabilize-shift-remove), insulin dose with glucose monitoring, Lokelma, calcium caution in digoxin, ECG progression, cardiac arrest protocol, references with PMIDs

Show changes

Danbot: Fix duplicate IV in Furosemide dose (route already specifies IV)

2026-03-20T16:07:39Z

Fix duplicate IV in Furosemide dose (route already specifies IV)

← Older revision		Revision as of 16:07, 20 March 2026
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	===Remove K+ from body===		===Remove K+ from body===
	*{{MedicationDose\|drug=Furosemide\|dose=40-80 mg IV\|route=IV\|context=Potassium elimination\|indication=Hyperkalemia\|display=Furosemide (Lasix)\|notes=Ensure adequate urine output first}}		*{{MedicationDose\|drug=Furosemide\|dose=40-80 mg\|route=IV\|context=Potassium elimination\|indication=Hyperkalemia\|display=Furosemide (Lasix)\|notes=Ensure adequate urine output first}}
	**Decreases potassium by dilution, shifting into muscle cells, and promoting renal excretion via alkalosis<ref>[https://emcrit.org/ibcc/hyperkalemia/ IBCC Hyperkalemia Chapter]</ref>		**Decreases potassium by dilution, shifting into muscle cells, and promoting renal excretion via alkalosis<ref>[https://emcrit.org/ibcc/hyperkalemia/ IBCC Hyperkalemia Chapter]</ref>
	*{{MedicationDose\|drug=Sodium polystyrene sulfonate\|dose=30 g PO or PR\|route=PO/PR\|context=Potassium binding\|indication=Hyperkalemia\|display=Kayexalate (SPS)\|notes=Very controversial; high risk of bowel perforation}}		*{{MedicationDose\|drug=Sodium polystyrene sulfonate\|dose=30 g PO or PR\|route=PO/PR\|context=Potassium binding\|indication=Hyperkalemia\|display=Kayexalate (SPS)\|notes=Very controversial; high risk of bowel perforation}}

Danbot: Convert medication dosing to MedicationDose templates for SMW integration (8 medications: calcium gluconate, calcium chloride, insulin, albuterol, sodium bicarbonate, furosemide, kayexalate, lokelma)

2026-03-20T16:06:32Z

Convert medication dosing to MedicationDose templates for SMW integration (8 medications: calcium gluconate, calcium chloride, insulin, albuterol, sodium bicarbonate, furosemide, kayexalate, lokelma)

← Older revision		Revision as of 16:06, 20 March 2026
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	''Indicated if there are any ECG changes or evidence of arrhythmias. Consider if K >7 mEq/L''		''Indicated if there are any ECG changes or evidence of arrhythmias. Consider if K >7 mEq/L''
	*Either one of the following:		*Either one of the following:
	**{{MedicationDose\|drug=Calcium gluconate\|dose=~~10 mL~~ of 10% (1 g) over 5-10 min\|route=IV\|context=Cardiac membrane stabilization\|indication=Hyperkalemia~~\|population=Adult~~\|onset=1-3 min\|duration=30-60 min~~}}. In severe cases may have to start with higher dose of 3 grams (30 mLs) and repeat doses (up to 9-15 grams total).~~		**{{MedicationDose\|drug=Calcium gluconate\|dose=10mL of 10% solution (1 gram) IV over 5-10 min; in severe cases may start with 3 grams (30 mL), repeat doses up to 9-15 grams total\|route=IV\|context=Cardiac membrane stabilization (preferred)\|indication=Hyperkalemia\|onset=15-30 min\|duration=30-60 min\|notes=Only 1/3 elemental calcium vs calcium chloride; can cause hypotension}}
	~~***~~Only 1/3 ~~the~~ elemental calcium ~~compared to~~ calcium chloride.		**{{MedicationDose\|drug=Calcium chloride\|dose=1 gram IV over 1-2 min\|route=IV\|context=Cardiac membrane stabilization (code situations)\|indication=Hyperkalemia\|onset=15-30 min\|duration=30-60 min\|notes=Extravasation risk: use a good IV; usually given in code situations}}
	***Can cause hypotension ~~due to osmotic shift~~		*Do serial [[ECG]]s to track progress: may need to give multiple doses
	**[[Calcium chloride]] 1 gram IV		*(If given for hyperkalemic cardiac arrest, need to continue resuscitation for at least 30 minutes)
	***Give over 1 - 2 ~~minutes~~
	~~***~~Extravasation ~~is bad~~: use a good IV
	***Usually given in code situations
	*~~Takes effect in 15-30 minutes<ref>http~~:~~//lifeinthefastlane.com/hyperkalemia/. Accessed 02/22/2016</ref>~~
	**(If given for hyperkalemic cardiac arrest, need to continue resuscitation for at least 30 minutes)
	*Duration of action: 30 - 60 minutes <ref> The Effect of Calcium on Severe Hyperkalemia http://hqmeded-ecg.blogspot.com/2015/04/the-effect-of-calcium-on-severe.html</ref>
	*Use caution in patients taking [[Digitalis Toxicity\|Digoxin]] although risk of [[Stone heart]] may be unsubstantiated <ref>Erickson CP, Olson KR. Case files of the medical toxicology fellowship of the California poison control system-San Francisco: calcium plus digoxin-more taboo than toxic? J Med Toxicol. 2008 Mar;4(1):33-9</ref>		*Use caution in patients taking [[Digitalis Toxicity\|Digoxin]] although risk of [[Stone heart]] may be unsubstantiated <ref>Erickson CP, Olson KR. Case files of the medical toxicology fellowship of the California poison control system-San Francisco: calcium plus digoxin-more taboo than toxic? J Med Toxicol. 2008 Mar;4(1):33-9</ref>
	*Do serial [[ECG]]s to track progress: may need to give multiple doses

	===Shift K+ intracellularly===		===Shift K+ intracellularly===
	*Intravenous [[insulin]] + [[dextrose]]		*{{MedicationDose\|drug=Insulin\|dose=10 units regular insulin IV with 25-50g of D50 (1-2 ampules)\|route=IV\|context=Potassium shifting\|indication=Hyperkalemia\|duration=4-6 hours\|notes=May withhold dextrose if blood sugar >300 mg/dL; consider 5 units if glucose <150, AKI/CKD, no DM, weight <60kg, or female}}
	**{{MedicationDose\|drug=Insulin\|dose=10 units regular with 25-~~50 g dextrose~~ (1-2\|route=IV\|context=Potassium shifting\|indication=Hyperkalemia~~\|population=Adult\|onset=20-30 min~~\|duration=4-6 hr\|~~link~~=~~no}} (1 - 2 50 mL ampules) of 50% dextrose (D50)~~		***Consider mixing in 10 cc NS syringe to ensure small volume of 10 units insulin fully administered via stopcock<ref>Sterns R, Grieff M, Bernstein P (2016). Treatment of hyperkalemia: Something old, something new. Kidney International, 89(3), 546-554.</ref>
	~~***~~May withhold dextrose if blood sugar >~~300mg~~/~~dl (>17 mmol~~/L)		***Follow glucose levels q30-60 min and supplement dextrose to avoid hypoglycemia (occurs in ~75% of patients)<ref> Apel J, Reutrakul S, Baldwin D. Hypoglycemia in the Treatment of Hyperkalemia With Insulin in Patients With End-Stage Renal Disease. Clin Kidney J. 2014;7(3):248-250</ref>
	***Duration of effect: 4 - 6 hours		*{{MedicationDose\|drug=Albuterol\|dose=15-20 mg nebulized\|route=Nebulized\|context=Potassium shifting\|indication=Hyperkalemia\|onset=30 min (peak)\|duration=2 hours\|notes=Response is dose-dependent}}
	***Consider mixing in 10 cc NS syringe to ensure small volume of 10 units insulin fully administered via IV		*{{MedicationDose\|drug=Sodium bicarbonate\|dose=3 amps in 1L D5W (isotonic bicarbonate drip)\|route=IV drip\|context=Potassium shifting (if metabolic acidosis)\|indication=Hyperkalemia\|notes=Generally not considered unless pH <7.1; pushing ampules of hypertonic bicarb ineffective in RCTs}}
	***Insulin cleared renally, ~~be careful about inducing hypoglycemia~~ (~~ESRD patients~~).		**For '''normovolemic or hypovolemic''' patients with '''metabolic acidosis'''
	****In a [https:~~//onlinelibrary.wiley.com/doi/abs/10~~.~~1002/phar.2038 small 2017 retrospective cohort study]~~, ~~researchers found that giving 5 units of insulin instead of 10 units reduced serum potassium to the same extent as 10 units~~, ~~with a lower rate of hypoglycemia~~.
	****Consider decreasing to 5 units or increasing dextrose ~~dose~~ to ~~50g with following risk factors: pretreatment blood glucose <150, acute kidney injury/chronic kidney disease, no history~~ of ~~DM, weight <60kg, female sex~~ <ref> ~~Moussavi K1~~, ~~Fitter S2~~, ~~Gabrielson SW3, Koyfman A4, Long B5~~. ~~Management~~ of Hyperkalemia With Insulin ~~and Glucose: Pearls for the Emergency Clinician~~. J ~~Emerg Med~~. ~~2019 Jul~~;57(1):36-~~42.~~ </ref>
	*~~Nebulized [[albuterol]]~~ 15 - ~~20mg~~
	**Response is dose-dependent
	**Peak effect: 30 minutes
	**Duration of effect: 2 hours
	*[[Sodium bicarbonate]]
	**Generally not considered unless pH <7.1
	**Pushing "ampules of hypertonic ~~bicarbonate have been proven to be~~ ineffective in RCTs~~"<ref>[https://emcrit.org/ibcc/hyperkalemia/ IBCC Hyperkalemia Chapter]</ref>~~
	**For '''normovolemic or hypovolemic''' patients with '''metabolic acidosis''':
	***Give three amps of bicarbonate in a liter of D5W or sterile water

	===Remove K+ from body===		===Remove K+ from body===
	*~~Intravenous [[furosemide]]~~ (Lasix) ~~40 - 80mg~~		*{{MedicationDose\|drug=Furosemide\|dose=40-80 mg IV\|route=IV\|context=Potassium elimination\|indication=Hyperkalemia\|display=Furosemide (Lasix)\|notes=Ensure adequate urine output first}}
	**Ensure adequate urine output first		**Decreases potassium by dilution, shifting into muscle cells, and promoting renal excretion via alkalosis<ref>[https://emcrit.org/ibcc/hyperkalemia/ IBCC Hyperkalemia Chapter]</ref>
	**Decreases ~~the~~ potassium ~~in three ways:~~ dilution, shifting ~~of potassium~~ into muscle cells, and ~~promotion of~~ renal ~~potassium~~ excretion by alkalosis<ref>[https://emcrit.org/ibcc/hyperkalemia/ IBCC Hyperkalemia Chapter]</ref>		*{{MedicationDose\|drug=Sodium polystyrene sulfonate\|dose=30 g PO or PR\|route=PO/PR\|context=Potassium binding\|indication=Hyperkalemia\|display=Kayexalate (SPS)\|notes=Very controversial; high risk of bowel perforation}}
	**More on how to use Lasix: [https://emcrit.org/ibcc/hyperkalemia/ IBCC Hyperkalemia Chapter]		**See: [[EBQ: Use of Kayexylate in Hyperkalemia]]
	*[[Sodium polystyrene sulfonate]] (~~Kayexalate~~)~~: 30 gm oral or per rectum~~		*{{MedicationDose\|drug=Sodium zirconium cyclosilicate\|dose=10 g PO TID x48 hours, then 10-15 g PO daily maintenance\|route=PO\|context=Potassium binding (preferred over Kayexalate)\|indication=Hyperkalemia\|display=Lokelma (SZC)\|notes=Similar to Kayexalate but without bowel perforation risk}}<ref>Beccari, Mario V, and Calvin J Meaney. "Clinical utility of patiromer, sodium zirconium cyclosilicate, and sodium polystyrene sulfonate for the treatment of hyperkalemia: an evidence-based review." Core evidence vol. 12 11-24. 23 Mar. 2017, doi:10.2147/CE.S129555</ref>
	**~~'''Very Controversial, High Risk of Bowel Perforation''', see~~: [[EBQ: Use of Kayexylate in Hyperkalemia]]
	*[[Sodium zirconium cyclosilicate]] (Lokelma)
	**Potassium binder, similar to ~~[[Sodium polystyrene sulfonate\|~~Kayexalate]] but without ~~risk of~~ bowel perforation<ref>Beccari, Mario V, and Calvin J Meaney. ~~“Clinical~~ utility of patiromer, sodium zirconium cyclosilicate, and sodium polystyrene sulfonate for the treatment of hyperkalemia: an evidence-based review.” Core evidence vol. 12 11-24. 23 Mar. 2017, doi:10.2147/CE.S129555</ref>
	**10 mg PO TID for up to 48 hours, then 10-15 mg PO QD for maintenance
	*Intravenous lactated ringers solution for volume expansion if dehydrated, rhabdomyolysis, diabetic ketoacidosis or other acidosis (avoid NS, causes hyperchloremic acidosis which shifts potassium out of cells increasing level)		*Intravenous lactated ringers solution for volume expansion if dehydrated, rhabdomyolysis, diabetic ketoacidosis or other acidosis (avoid NS, causes hyperchloremic acidosis which shifts potassium out of cells increasing level)
	**~~consider~~ isotonic bicarbonate if significant acidosis (D5W with 3 amps of bicarb per liter~~), can calculate bicarbonate deficit then divide by 150mEq/L to estimate number of liters of isotonic bicarbonate required~~) <ref> https://emcrit.org/pulmcrit/fluid-selection-using-ph-guided-resuscitation </ref>		**Consider isotonic bicarbonate if significant acidosis (D5W with 3 amps of bicarb per liter) <ref> https://emcrit.org/pulmcrit/fluid-selection-using-ph-guided-resuscitation </ref>
	*[[Hydrocortisone]] if suspicious for [[adrenal insufficiency]]		*[[Hydrocortisone]] if suspicious for [[adrenal insufficiency]]
	*Definitive treatment is [[hemodialysis]]		*Definitive treatment is [[hemodialysis]]

Danbot: Convert key medications to MedicationDose template with SMW; dosing verified

2026-03-20T15:56:57Z

Convert key medications to MedicationDose template with SMW; dosing verified

← Older revision		Revision as of 15:56, 20 March 2026
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	''Indicated if there are any ECG changes or evidence of arrhythmias. Consider if K >7 mEq/L''		''Indicated if there are any ECG changes or evidence of arrhythmias. Consider if K >7 mEq/L''
	*Either one of the following:		*Either one of the following:
	**[[Calcium gluconate~~]]: Give 10ml~~ of a 10% ~~solution~~ (1 ~~gram~~) over 5-10 ~~mins~~. In severe cases may have to start with higher dose of 3 grams (30 mLs) and repeat doses (up to 9-15 grams total).		**{{MedicationDose\|drug=Calcium gluconate\|dose=10 mL of 10% (1 g) over 5-10 min\|route=IV\|context=Cardiac membrane stabilization\|indication=Hyperkalemia\|population=Adult\|onset=1-3 min\|duration=30-60 min}}. In severe cases may have to start with higher dose of 3 grams (30 mLs) and repeat doses (up to 9-15 grams total).
	***Only 1/3 the elemental calcium compared to calcium chloride.		***Only 1/3 the elemental calcium compared to calcium chloride.
	***Can cause hypotension due to osmotic shift		***Can cause hypotension due to osmotic shift
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	===Shift K+ intracellularly===		===Shift K+ intracellularly===
	*Intravenous [[insulin]] + [[dextrose]]		*Intravenous [[insulin]] + [[dextrose]]
	**~~Give~~ 10 units regular ~~insulin intravenously~~ with 25 to 50 ~~grams~~ (1 - 2 50 mL ampules) of 50% dextrose (D50)		**{{MedicationDose\|drug=Insulin\|dose=10 units regular with 25-50 g dextrose (1-2\|route=IV\|context=Potassium shifting\|indication=Hyperkalemia\|population=Adult\|onset=20-30 min\|duration=4-6 hr\|link=no}} (1 - 2 50 mL ampules) of 50% dextrose (D50)
	***May withhold dextrose if blood sugar >300mg/dl (>17 mmol/L)		***May withhold dextrose if blood sugar >300mg/dl (>17 mmol/L)
	***Duration of effect: 4 - 6 hours		***Duration of effect: 4 - 6 hours

Kxl328: /* Remove K+ from body */

2022-08-08T15:08:01Z

Remove K+ from body

← Older revision		Revision as of 15:08, 8 August 2022
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	*[[Sodium polystyrene sulfonate]] (Kayexalate): 30 gm oral or per rectum		*[[Sodium polystyrene sulfonate]] (Kayexalate): 30 gm oral or per rectum
	**'''Very Controversial, High Risk of Bowel Perforation''', see: [[EBQ: Use of Kayexylate in Hyperkalemia]]		**'''Very Controversial, High Risk of Bowel Perforation''', see: [[EBQ: Use of Kayexylate in Hyperkalemia]]
	*[[Sodium zirconium cyclosilicate]]		*[[Sodium zirconium cyclosilicate]] (Lokelma)
	**Potassium binder, similar to [[Sodium polystyrene sulfonate\|Kayexalate]] but without risk of bowel perforation<ref>Beccari, Mario V, and Calvin J Meaney. “Clinical utility of patiromer, sodium zirconium cyclosilicate, and sodium polystyrene sulfonate for the treatment of hyperkalemia: an evidence-based review.” Core evidence vol. 12 11-24. 23 Mar. 2017, doi:10.2147/CE.S129555</ref>		**Potassium binder, similar to [[Sodium polystyrene sulfonate\|Kayexalate]] but without risk of bowel perforation<ref>Beccari, Mario V, and Calvin J Meaney. “Clinical utility of patiromer, sodium zirconium cyclosilicate, and sodium polystyrene sulfonate for the treatment of hyperkalemia: an evidence-based review.” Core evidence vol. 12 11-24. 23 Mar. 2017, doi:10.2147/CE.S129555</ref>
			**10 mg PO TID for up to 48 hours, then 10-15 mg PO QD for maintenance
	*Intravenous lactated ringers solution for volume expansion if dehydrated, rhabdomyolysis, diabetic ketoacidosis or other acidosis (avoid NS, causes hyperchloremic acidosis which shifts potassium out of cells increasing level)		*Intravenous lactated ringers solution for volume expansion if dehydrated, rhabdomyolysis, diabetic ketoacidosis or other acidosis (avoid NS, causes hyperchloremic acidosis which shifts potassium out of cells increasing level)
	**consider isotonic bicarbonate if significant acidosis (D5W with 3 amps of bicarb per liter), can calculate bicarbonate deficit then divide by 150mEq/L to estimate number of liters of isotonic bicarbonate required) <ref> https://emcrit.org/pulmcrit/fluid-selection-using-ph-guided-resuscitation </ref>		**consider isotonic bicarbonate if significant acidosis (D5W with 3 amps of bicarb per liter), can calculate bicarbonate deficit then divide by 150mEq/L to estimate number of liters of isotonic bicarbonate required) <ref> https://emcrit.org/pulmcrit/fluid-selection-using-ph-guided-resuscitation </ref>

Elcatracho: /* Background */

2021-02-10T14:45:28Z

Background

← Older revision		Revision as of 14:45, 10 February 2021
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	*Potassium secretion is proportional to flow rate and sodium delivery through distal nephron		*Potassium secretion is proportional to flow rate and sodium delivery through distal nephron
	**Thus, loop & thiazide [[diuretics]] cause ''hypo''kalmia		**Thus, loop & thiazide [[diuretics]] cause ''hypo''kalmia
	*Most common cause is hemolysis from blood draw		*Most common cause is hemolysis from blood draw (pseudohyperkalemia)

	===Medication Causes===		===Medication Causes===

Elcatracho: /* Background */

2021-02-10T14:45:09Z

Background

← Older revision		Revision as of 14:45, 10 February 2021
Line 3:		Line 3:
	*Potassium secretion is proportional to flow rate and sodium delivery through distal nephron		*Potassium secretion is proportional to flow rate and sodium delivery through distal nephron
	**Thus, loop & thiazide [[diuretics]] cause ''hypo''kalmia		**Thus, loop & thiazide [[diuretics]] cause ''hypo''kalmia
			*Most common cause is hemolysis from blood draw

	===Medication Causes===		===Medication Causes===