When potassium is 6.5 mmol/L or above, or there are ECG changes, treat in three steps.
Protect the heart: give intravenous calcium gluconate 10% (30 mL in adults) over 5 to 10 minutes when the ECG shows changes, repeating if they persist. It does not lower potassium.
Shift potassium into cells: give insulin with glucose (10 units soluble insulin with 25 g glucose) and consider nebulised salbutamol. Check glucose hourly for at least six hours, as hypoglycaemia is common, especially in kidney failure.
Remove potassium: dialysis in kidney failure, potassium binders, and treating the cause, including stopping drugs that raise potassium. Recheck potassium within an hour and repeatedly afterwards.
- Give IV calcium gluconate first when the ECG shows hyperkalaemic changes
- Give insulin with glucose and monitor glucose hourly for six hours
- Arrange dialysis early for patients with kidney failure
- Stop potassium-sparing drugs, ACE inhibitors and ARBs during the acute episode
Why it matters
Calcium protects the heart but does nothing to the potassium level, so all three steps are needed.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for nephrology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free