Hyperkalaemia Management


  • Hyperkalaemia is a life-threatening emergency.


  • A, B, C
  • Large bore IV access -> fluid resuscitation (to enhance renal perfusion and elimination)
  • Bloods – FBC, U+E, CK, ABG/ VBG
  • Monitoring – ECG and NIBP



  • 10mL of 10% Ca2+ gluconate or chloride
  • calcium gluconate = 2.2mmol of Ca2+ in 10mL
  • calcium chloride = 6.8mmol of Ca2+ in 10mL
  • antagonises the membrane excitability of heart
  • does not lower serum K+
  • can cause: bradycardia, arrhythmias, tissue necrosis if extravasated


HCO3- infusion

  • 1mmol/kg IV
  • 100mL of 8.4%
  • decreases the concentration of H+ in the extracellular fluid compartment -> increases intracellular Na+ via the Na+/H+ exchanger and facilitates K+ shift into cells via the Na+/K+ ATPase
  • does require a metabolic acidosis
  • doesn’t lower K+ independently but has been shown to be additive with insulin/dextrose and salbutamol
  • don’t administer at same time as Ca2+ -> precipitation
  • can cause: hypernatraemia, pulmonary oedema, tetany in patients with hypocalaemia


  • 10U actrapid, 50mL of 50% glucose
  • insulin increases uptake by stimulating the Na+/K+ ATPase
  • reduces K+ by 0.65-1mmol/L/hr
  • can cause: hypoglycaemia

Salbutamol nebulisers/IV

  • 0.5mg IV or 20mg neb
  • binds to the beta-2-receptor -> stimulated adenylase cyclase converting ATP->cAMP -> stimulation of Na+/K+ ATPase with subsequent increase in intracellular K+
  • IV slightly better than nebulised
  • can cause: tachyarrhythmias, tremor, anxiety and flushing



  • Mannitol, Frusemide
  • theoretically work but no clinical trials to support use in hyperkalaemia


  • IHD = best (can remove 25-40mmol/hr -> 1mmol/L/hr)
  • faster if increase blood flow rate, dialysis flow rate, low K+ concentration in dialysate, high bicarbonate concentration-

Resonium – K+ binders

  • calcium resonium (15-30g PO/PR) or sodium polysterene sulphonate
  •  cation exchange resins
  • negatively charged polymers than exchange the cation for K+ across the intestinal wall
  • give a laxative at the same time
  • caution: slow acting and ineffective -> unsuitable for emergency situations, constipation, intestinal necrosis



  • don’t stop until K+ normalised
  • adrenaline helps drive K+ down
  • Ca2+ chloride
  • Na+ bicarbonate in acidosis
  • @ ROSC start insulin/dextrose
  • dialysis while undergoing CPR has well documented in case reports -> IHD, CVVH, CVVHDF and peritoneal with complete neurological recovery
  • consider ECMO

References and Links



  • Parham WA, Mehdirad AA, Biermann KM, Fredman CS. Hyperkalemia revisited. Tex Heart Inst J. 2006;33(1):40-7. PMC1413606.

CCC 700 6

Critical Care


Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

One comment

  1. To the moderator of this site: This is great (hyperkalaemia).It has been very useful for med students (Aust)and the interns and JMOs doing ward shifts at present. They have all asked, is there a list of what you do when ie what levels of potassium eg 5.5 to 6, to 6.5 to 7 etc as it varies depending on the level.I assume you don’t give calcium gluconate unless there are ecg changes? and when would you do an ecg eg if K over 6? Your LITFL is a great resource for so many doctors /students at many levels and concise and to the point (a lot of medical info isn’t!) thanks for all the efforts you put in. (if you don’t have a list, do you know of a reliable one?)

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.