Treating Hypokalemia and Hyperkalemia

Eddie Chen, DO

A review of the treatment of Hypokalemia and Hyperkalemia in an inpatient setting.

Hypokalemia
-Check renal function
-Check magnesium Levels
-Check for acidosis
-Also search for causes

Rule of thumb in patients with normal renal function:
Every 10 meq KCL given will raise the potassium by 0.1 mmol.

If patient can receive PO, then give PO only.

When to give IV potassium?
I've searched many articles, and did not find a guideline, but I noticed that when levels fall below 3.3 then IV was given along with PO. Of course, if patient is NPO, you give IV.

So if K is
3.8-3.9 give 20 meq of KCL
3.6-3.7 give 40 meq of KCL
3.4-3.5 give 60 meq of KCL
3.2-3.3 give 80 meq of KCL
3.0-3.1 give 100 meq of KCL
< >

Hyperkalemia
This is a medical emergency.

Evaluate with ECG, electrolytes, BUN, Cr, and Glucose.

Transfer to Telemetry if K > 6.5 or if ECG abnomalities (Peaked T waves, QRS widening).

If ECG abnormalities present, give one amp of Calcium Gluconate IVP over 3 minutes. It may be repeated in 5 minutes, if ECG does not improve
OR
Calcium Gluconate 10% @ 20mg/kg IV over 5 minutes
OR
Calcium Chloride 10% 10 ml IV over 3 minutes

Be very cautious if patient is on Digoxin, and may have to infuse much slowly over an hour and watch for Digoxin toxicity.

In all patients with K > 5.5:
-Low K diet
-D/C salt substitutes, KCL, K sparing agents, Heparin, Beta blockers, ACEi/ARB, NSAIDS and look for suitable substitutes.

Treat with one or more of the following:
10-15 U of Regular Insulin with one amp of D50 IVP Q2-3 hrs or 10 units of Regular Insulin in 500 ml of D20 infuse over an hour

10-20 mg of albuterol by nebulizer (remember one amp of premixed albuterol is 2.5 mg)

1-2 amps (50-100 mmol NaHCO3) IV over 10-20 minutes (onset in 20 mins, lasts 2 hrs).
Do not give with Calcium, or will precipitate. Give if pt is metabolic acidosis.

Kayexalate (Sodium polystyrene Sulfonate) 20-30 gms PO,
or Retention Enema 50 gms in 200 cc water with 50 gms of Sorbital or 200 ccs of D20. PO works best. Avoid if bowel obstruction. Watch for sodium overload.

Hemodialysis
-Follow up on hyperkalemia
-Repeat K level in 2 hrs and prn
-Repeat therapy if K is still > 6.5