Algorithm
- Confirm with urgent repeat K+ if unexpected; continuous ECG monitoring; stop K+-sparing drugs / supplements / digoxin toxicity review.
- If ECG changes or K+ typically ≥6.5 mmol/L with urgency: protect the heart first — IV calcium (gluconate or chloride per access/protocol).
- Shift K+ intracellularly: insulin–glucose; nebulized salbutamol as adjunct; consider bicarbonate only if severe metabolic acidosis and local protocol supports.
- Remove K+: loop diuretics if urine output; potassium binders when appropriate; urgent dialysis if oliguric AKI, severe/refractory hyperK, or ongoing release (rhabdo/tumor lysis).
- Treat cause (AKI, drugs, acidosis, tissue necrosis); recheck K+ and glucose frequently after insulin.
- If cardiac arrest with suspected hyperK: follow ALS + give calcium; consider insulin–glucose; dialysis when ROSC/feasible — do not delay standard ALS.
Red flags
- • Wide QRS / sine wave / bradycardia — arrest risk
- • Hypoglycemia after insulin
- • PseudohyperK (hemolyzed sample)
- • Concomitant digoxin — caution with calcium
Medications by step
Membrane stabilization
- Calcium gluconate 10% · i.v.
10 mL IV over 2–5 min; repeat if ECG unchanged
Intracellular shift
- Insulin regular + glucose · i.v.
10 U IV insulin with 25 g glucose (e.g. 50 mL D50W); monitor glucose
- Salbutamol · inhaled
10–20 mg nebulized
Elimination
- Furosemide · i.v.
40–80 mg IV if volume/urine allows
- Urgent dialysis · —
If refractory / anuric / severe
References
- • ERC Guidelines 2025 — Special circumstances (electrolytes) (2025)
- • Renal Association / UKKA — Treatment of acute hyperkalaemia in adults (2023)
Updated: Июль 2026