Fluids, Electrolytes, Acid-Base Disorders, and Nutrition Support

The following regimens are for patients with symptomatic evidence of toxicity from

hyperkalemia such as peaked T waves on ECG or if serum potassium is greater than 5.5 mg/

dL (Mayo Clin Proc. 2021;96(3):744-762):

Stepwise

Approach

Mechanism

Treatment

Description

Step 1 -

Only if ECG

changes

Stabilization of

myocardium

Calcium gluconate 10%, 1–2 g IV

Given as slow intravenous push.

Repeat dose after 5 minutes if

ECG changes persist. Should be

given in addition to other therapies

as calcium does not affect serum

potassium concentration.

Calcium chloride, 0.5–1 g IVa

Step 2

Intracellular

shifting of potas-

sium (temporary

redistribution)

Regular human insulin, 10 units IV

Usually given with 1 ampule of D50

(25 g). Dextrose can be omitted if

the patient has hyperglycemia (BG

> 250 mg/dL).

Sodium bicarbonate, 50–100 mEq IV

Especially useful if patient is

acidemic

Albuterol, 10–20 mg via nebulization

over 10 minutes

Step 3

Elimination of

potassium

Loop diuretics

Sodium zirconium cyclosilicate (SZC)

Dosed as 10 mg orally every 8 h

for up to 48 h, then reassess

Hemodialysis

The most effective and predictable

method for potassium elimination

but also the most invasive.

Reserved for life-threatening

hyperkalemia or for patients

already receiving dialysis.

BG = blood glucose; D50 = dextrose 50% solution; ECG = electrocardiogram.

aAvoid IV push administration of calcium chloride except in cardiac arrest.

ii.

Ensure no exogenous sources of potassium are present (e.g., intravenous fluids, EN, PN); to

reduce intake with EN or PN, use a “renal” (no or low-electrolyte) formulation, if necessary.

iii.

Potassium binding agents may be considered in conjunction with standard of care for treatment

of acute hyperkalemia (Mayo Clin Proc 2021;96:744-62). Compared with other potassium

binders, sodium zirconium cyclosilicate (SZC) has higher selectivity for potassium and the

quickest onset of action at 1 hour, which makes it the most favorable option in the acute setting.

SZC and patiromer are both more palatable and have superior safety profiles compared with

sodium polystyrene sulfate (SPS). The onset of SPS is variable (up to days), as is its efficacy

in the acute setting. Additionally, the risk of rare but significant adverse events with the use of

SPS, including bowel ischemia, bowel necrosis, and increased hospitalizations, limits its utility

as adjunctive therapy for acute hyperkalemia.