Table 3.
Emergency pharmacological treatment of severe hyperkalemia
| Treatment | Expected decrease in sK | Onset of action | Duration of effect | Side effects/risks |
|---|---|---|---|---|
| 10% calcium gluconate 1 ampule (1 g) by slow (1–2 min) bolus (may be repeated after 5 min) | None | < 3 min | 20–50 min | Caution/avoid if digitalis toxicity strongly suspected |
|
Regular insulin 0.1 IU/Kg BW (up to max 10 IU) by i.v. bolus, preceded by (if serum glucose <250 mg/dL) 50% dextrose 50–100 mL (25–50 g) or |
0.6–1.2 mEq/L after 1 h | 15 min | 4 h | Hypoglycemia (up to 30% in patients with advanced CKD) |
| Regular insulin 20 IU by i.v. infusion over 1 hour together with i.v. infusion of dextrose 60 g | 0.60–0.92 mEq/L after 1 h | Hourly monitoring of serum glucose concentration for at least 3 hours necessary | ||
|
10–20 mg nebulized salbutamol (20 gtt of a 0.5% salbutamol solution repeated up to 8 times in 120 min) or |
0.53–0.98 mEq/L | Within 30 min | Maximum effect at 90 min |
Tremor, tachycardia, palpitations, anxiety More effective if used in conjunction with insulin/dextrose Use with caution in patients with heart disease 12–40% of patients unresponsive, especially if on treatment with betablockers Avoid in patients with ischemic heart disease |
| 0.5–2.5 mg i.v. salbutamol | 0.87–1.4 mEq/L | Maximum effect at 30 min | ||
| 1.4% (1/6M) or 8.4% (1 M) sodium bicarbonate by i.v. infusion, 10–20 mEq/h | Variable (up to 2 mEq/L after 10 mEq/L of increase in serum bicarbonate concentration in acidemic patients with CKD |
Use only in acidemic patients Risk of hypernatremia, volume overload, tetany, and pCO2 increase in patients with respiratory failure |
||
| Furosemide 1 mg/Kg as i.v. bolus (up to 80 mg), followed by 10 mg/h continuous infusion | Unpredictable | 15 min | Duration of infusion |
Use only in hypervolemic patients May be combined with thiazides or thiazide-like diuretics |
| Sodium polystyrene sulphonate 30 g with 100 ml 20% sorbitol orally or by rectal enema | Doubtful efficacy in the acute setting | At least 2 h | 6 h |
Risk of colonic necrosis (low) Bowel obstruction must be ruled out before administration Not recommended as a first-line treatment of emergency hyperkalemia |
BW body weight, CKD chronic kidney disease, pCO2 partial pressure of carbon dioxide, sK serum potassium