TCH09:046

Canberra Hospital and Health Services

Clinical Procedure
Hyperkalaemia – Management of Acute Hyperkalaemia in
Adults
Contents

Contents....................................................................................................................................1
Purpose..................................................................................................................................... 2
Diagnostic Parameters..............................................................................................................2
Alerts......................................................................................................................................... 2
Scope........................................................................................................................................ 2
Section 1 – Management..........................................................................................................3
Section 2 – Treatment...............................................................................................................3
Section 3 – Medications that may cause hyperkalaemia..........................................................4
Implementation........................................................................................................................ 4
Related Policies, Procedures, Guidelines and Legislation.........................................................4
Definition of Terms................................................................................................................... 5
Search Terms............................................................................................................................ 5
Attachments..............................................................................................................................5
Attachment 1: Flow Chart: Hyperkalaemia in Adults - Decision Making Tool.......................6

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Purpose

The purpose of this procedure is to guide management of patients with hyperkalaemia

Diagnostic Parameters

Mild hyperkalaemia:
 Serum potassium concentration 5.0-6.0 mmol/L
 Nil or Peaked T wave

Moderate hyperkalaemia:
 Serum potassium concentration 6.1-7.0 mmol/L
 Peaked T Wave, shortened QT interval

Severe hyperkalaemia:
 Serum potassium concentration > 7.0 mmol/L
 Widening of QRS interval.

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Alerts

1. In severe acute renal failure, dialysis should be the first option considered
2. The flow chart attached is a decision making tool. All steps should occur almost
simultaneously unless otherwise stated.

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Scope

This document applies to staff who are working within their scope of practice:
 Medical Officers
 Registered Nurses and Registered Midwives
 Students under direct supervision.

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Section 1 – Management

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1. Hyperkalaemia identified
2. Exclude pseudohyperkalaemia
3. Treat underlying conditions:
3.1. Dehydration: treat with fluids. Isotonic bicarbonate (seek advice) if acidotic pH<7.2
3.2. Digoxin toxic: consider digoxin antibodies (Digibind). Consult toxicologist
3.3. Diabetic ketoacidosis (DKA): treat with insulin and fluids. NOT bicarbonate
3.4. Acidosis: consider bicarbonate IV (seek specialist advice)

Note: To prepare an approximate isotonic bicarbonate solution, first remove 150mL from a
ONE Litre glucose 5% bag. Then add 150mL of 8.4% Sodium Bicarbonate Solution to the ONE
Litre glucose 5% bag.

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Section 2 – Treatment

Mild hyperkalaemia (5.0-6.0mmol/L)

1. Stop offending drugs (see table 1. below for medications that may cause hyperkalaemia)
2. Review after 24 hours
3. Resonium A (sodium polystyrene sulfonate) treatment if no resolution 15-30 g orally or
in 100mL of sorbitol/water as retention enema for one hour.

Note:
Enema will lower potassium more quickly than oral route

4. Referral rather than long term Resonium.

Moderate to Severe hyperkalaemia (>6.0mmol/L)

1. Treat with glucose 50% 50mL over 15 minutes together with regular insulin (e.g.
Actrapid) 10 units intravenously. As an alternative/in addition to the above use
salbutamol 10 mg by nebuliser
2. Sodium polystyrene sulfonate (Resonium A) 30g orally OR in 100mL of sorbitol/water as
retention enema for one hour
3. Are there ECG changes? Treat with calcium gluconate 10% 10mL (2.2 mmol)
intravenously over 3 minutes (with ECG monitoring of response).
Note: The effect of IV calcium gluconate is short-lived and dose may need to be repeated
in 30 to 60 minutes.

 If initial potassium was >7.0 mmol/L recheck in 1 hour

 If initial potassium was between 6.0-7.0 mmol/L recheck in 2 hours
 If remains high, further IV insulin and dextrose
 Consider referral for opinion ± dialysis.

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Section 3 – Medications that may cause hyperkalaemia

 Potassium supplements (IV or oral)

 Potassium-sparing diuretics (e.g. amiloride, triamterene, spironolactone)
 ACE-inhibitors (e.g. captopril, enalapril)
 Angiotensin receptor blockers (e.g. irbesartan, candesartan)
 Acute digoxin toxicity
 Aldosterone antagonists (e.g. spironolactone, eplerenone)
 Nonsteroidal anti-inflammatory agents
 Cyclosporin
 Tacrolimus
 Trimethoprim
 Pentamidine.

Notes
1. In severe acute renal failure, dialysis should be the first option considered
2. The flow chart (Attachment 1) is a decision making tool. All steps should occur almost
simultaneously unless otherwise stated.

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Implementation

This document will be available on the CHHS Policy Register (via Sharepoint). It will be
discussed in existing program of education (orientation, in-service). Emailed to staff and
placed in workrooms.

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Related Policies, Procedures, Guidelines and Legislation

Policies
 CHHS Consent and Treatment
 CHHS Medication handling Policy
 CHHS Patient Identification and Procedure Matching Policy

Procedures
 CHHS Pathology requests and specimens Procedure
 CHHS Patient Identification and Procedure Matching Procedure

Legislation
 Medicines, Poisons and Therapeutic Goods Act 2008
 Medicines, Poisons and Therapeutic Goods Regulation 2008
 Therapeutic Goods Act 1989
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 Therapeutic Goods Regulations 1990

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Definition of Terms

Pseudohyperkalemia: a rise in serum potassium concentration with concurrently normal

plasma potassium concentration

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Search Terms

Hyperkalaemia, Mild hyperkalaemia, Moderate hyperkalaemia, Severe hyperkalaemia, Acute

Hyperkalaemia, potassium k, K+, high

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Attachments

Attachment 1: Flow Chart: Hyperkalaemia in Adults - Decision Making Tool

Disclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services
specifically for its own use. Use of this document and any reliance on the information contained therein by any
third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Policy Team ONLY to complete the following:

Date Amended Section Amended Divisional Approval Final Approval
Minor review and Whole document Girish Talaulikar, ED, Chair, CHHS Policy
extension Medicine Committee

This document supersedes the following:

Document Number Document Name

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Attachment 1: Flow Chart: Hyperkalaemia in Adults - Decision Making Tool

Hyperkalaemia Identified

Confirm potassium level with a

second test, but treat
immediately.

Treat underlying conditions:

Dehydration: treat with fluids. Isotonic
bicarbonate if acidotic pH<7.2
Digoxin toxic: consider Digoxin antibodies
(Digibind). Consult toxicologist
DKA: treat with insulin and fluids. NOT
bicarbonate

Mild Hyperkalaemia 5-6 mmol/L Moderate to severe hyperkalaemia

>6 mmol?L

Stop offending drugs Treat with insulin and dextrose

and/or nebulised sulbutamol

Review after 24 hours Resonium A orally and rectally.

Oral takes 6 hours for effect

Resonium treatment if no
resolution ECG changes? Treat with IV
Referral rather than long term calcium gluconate
Resonium

Potassium 6-7
Potassium >7
recheck in 2
recheck in 1
hours
hour

If remains high, further IV insulin

and dextrose
Consider referral for opinion ±
dialysis

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