Hyperkalemia Treatment Medical Slides

Present the three-pillar simultaneous approach: (1) STABILIZE — calcium gluconate 10% 30 mL IV over 2-3 minutes (or calcium chloride 10 mL via central line) — onset 1-3 minutes, duration 30-60 minutes, antagonizes cardiac membrane effects (does NOT lower K+). (2) SHIFT — regular insulin 10 units IV + D50 25 g (onset 15-30 min, lowers K+ 0.5-1.2 mEq/L, monitor glucose for 4-6 hours), albuterol 10-20 mg nebulized (onset 15-30 min, lowers 0.5-1.0 mEq/L). (3) ELIMINATE — sodium zirconium cyclosilicate (onset 1 hour), loop diuretics (if volume tolerant), hemodialysis (if refractory/severe/renal failure). Emphasize that calcium should be given FIRST if ECG changes present.

Present the hypoglycemia risk: insulin-glucose for hyperkalemia causes hypoglycemia in 10-75% of patients depending on the study and definition. Risk factors: lower baseline glucose, renal failure (impaired insulin clearance), no dextrose given, or insufficient dextrose. Prevention protocol: check baseline glucose, give D50 25 g (or D10 250 mL) with insulin 10 units, recheck glucose every 30 min for 4-6 hours. If baseline glucose >250 mg/dL, insulin can be given without dextrose. Some institutions now use reduced insulin dose (5 units) which may be equally effective with less hypoglycemia (Apel 2014). Always use regular insulin, not analog insulins.

Present the classic progression (noting that correlation with K+ level is imperfect): K+ 5.5-6.0 — peaked (tented) T waves, shortened QT; K+ 6.0-7.0 — PR prolongation, P wave flattening; K+ 7.0-8.0 — QRS widening, loss of P waves; K+ >8.0 — sine wave pattern, ventricular fibrillation/asystole. CRITICAL teaching point: ECG changes do not reliably correlate with absolute K+ level — some patients arrest at K+ 6.5, others tolerate K+ 8.0 with minimal ECG changes. Rate of rise matters more than absolute level. Treat the patient, not the number — any ECG changes warrant immediate calcium administration.