Remember: is it a haemolysed blood sample? (you can do an iSTAT)


  • Mild: 5.5-5.9mmol/l – No urgent action required (Dietary & Medication modification & GP F/U)
  • Moderate: 6.0-6.4mmol/l – Follow treatment guide (maybe suitable for discharge)
  • Severe: ≥6.5mmol/l OR ECG changes – Follow treatment guide, must admit


  • Muscle weakness
  • Constipation
  • Arrhythmias

ECG Changes

a.Tented T, b. Prolonged PR, c. Wide QRS

As Potassium (K) rises the arrhythmias can deteriorate

a.  Bradycardia & wide QRS

b. & c. Sine wave

d. VT



Treatment pathway

1. Protect the heart  

  • 6.8mmol Calcium IV is recommended- equivalent to: 10ml Calcium Chloride 10% (6.8mmol Ca) OR 30ml Calcium Gluconate 10% (6.9mmol Ca)
  • In Digoxin toxicity Calcium can theoretically potentiate effects, so consider using; slower infusion (30min) OR Magnesium Sulphate 2g I.V. instead of Calcium

2. Move K into cells

  • Insulin (Actrapid) 10 unit & 25g of Glucose (250ml 10%, OR 50ml 50%) I.V. (30min)
    • Can reduce K by 0.65-1mmol/l
    • Must Monitor Blood Glucose for 6hrs (due to risk of hypoglycaemia)
  • Salbutamol 10-20mg Neb.
    • Can reduce K by 0.62-0.8mmol/l (but can be inconsistent)
    • Caution if Hx of Ischaemic Heart Disease or Arrhythmia
    • β-Blockers and Digoxin can attenuate effect
  • Sodium Bicarbonate 1.4% 500ml I.V. (2hours)
    • Only in Acidosis pH <7.2
    • This is controversial and must only be given on instruction of senior decision maker
    • Never give with Ca (due to risk of precipitation)

3. Remove K from body

  • 0.9% NaCl I.V. – this will dilute and improve renal excretion
  • Dialysis – Likely to be needed if: K >7.5mmol/l, Oliguric, CRF and on dialysis
  • Calcium Resonium – SLOW onset 2-6 hours, Contraindicated in hypercalcaemia

4. Monitor

  • ECG monitoring
  • U&E’s
  • Glucose

5. Prevent recurrence

  • Treat cause: Rhabdomyolysis, Haemolysis, Trauma, Renal disease, Low insulin, Low steroid, etc.
  • Medication Review: Spironolactone, NSAID, ACEi, Ciclosporin, Digoxin etc.
  • Food (see list below)

PDF: full guide from UK renal association (its long)

Searchs: hyperkalemia

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