Hyperkalaemia: Management

Key points

• Severe hyperkalaemia can cause life-threatening arrhythmias. Identify and treat the cause, stop/review potassium-raising drugs where appropriate and obtain an ECG urgently.
• Protect the myocardium: if ECG changes attributable to hyperkalaemia are present, give IV calcium. Current UKKA guidance prefers 10% calcium gluconate for most non-arrest patients and calcium chloride in resuscitation/peri-arrest; calcium stabilises the myocardium but does not lower serum potassium .
• Shift potassium into cells: UKKA recommends 10 units soluble insulin with 25 g glucose IV for severe hyperkalaemia and suggests it for K⁺ 6.0–6.4 mmol/L; nebulised salbutamol 10–20 mg is useful as adjunctive therapy and should not be used alone in severe hyperkalaemia. Monitor closely for hypoglycaemia.
• Remove potassium: sodium zirconium cyclosilicate is recommended for emergency management of severe hyperkalaemia and may be considered in moderate hyperkalaemia; patiromer is an option in selected acute cases. Calcium resonium should no longer be routinely used for acute hyperkalaemia.
• Renal replacement therapy is required when hyperkalaemia is severe/refractory or cannot be controlled medically, particularly in dialysis patients; it should not be delayed when urgent definitive potassium removal is required.
• MRCP emergency sequence: ECG changes → IV calcium; then shift K⁺ with insulin-glucose ± nebulised salbutamol; then remove K⁺ with binder/diuresis/dialysis as appropriate.
• Do not confuse calcium's role: IV calcium protects the myocardium but does not lower serum potassium.

Decision points in this pathway

• AKI with persistent hyperkalaemia?

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